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Greenlee GM, Knott-Willett E, Susarla S, Evans KN, Mancl L, Sheller B. Does Mandibular Distraction Osteogenesis for Robin Sequence Create Altered Craniofacial Morphology and Disrupt Tooth Development? J Oral Maxillofac Surg 2024:S0278-2391(24)00686-4. [PMID: 39182509 DOI: 10.1016/j.joms.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/29/2024] [Accepted: 08/01/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Robin Sequence (RS) infant patients may require mandibular distraction osteogenesis (MDO) to improve airway. The distracted mandible may grow vertically and the developing dentition may be disrupted. PURPOSE The study purpose was to measure the association of MDO on craniofacial morphology and tooth development in RS subjects. STUDY DESIGN, SETTING, SAMPLE This was a retrospective cohort study of RS infants treated with/without MDO. Inclusion criteria were RS diagnosis, complete imaging, and treatment at our pediatric regional hospital. Exclusion criteria were treatment elsewhere and insufficient imaging. EXPOSURE VARIABLE Exposure was airway management; subjects were grouped by use of MDO or not. Subjects were compared to age-matched normal infants presurgically and to age-matched normal controls at follow-up. MAIN OUTCOME VARIABLES Main outcome variables were craniofacial morphology measured using cephalometric gonial angle and ramus height to mandibular body length ratio presurgically (T1), postsurgically (T2), and at the mixed dentition (T3). Disrupted tooth development was assessed by absence/abnormality of teeth on radiographs at T3. COVARIATES Covariates were age, sex, body mass index, comorbidities, and cephalometric measurements. ANALYSES Appropriate univariate, bivariate, and regression models were computed, and significance level was set at P < .05. RESULTS The sample contained 14 RS-MDO subjects with median age of 1.1 months and 10 (71.4%) were female. Presurgery, RS-MDO subjects had significantly more obtuse gonial angles (145° vs 137°, P = .04) and shorter mandibular bodies (32 vs 41 mm, P < .01) than the 37 unaffected controls. Increased ramus height (P < .01) and mandibular body length (P < .01) and forward rotation of the mandible were seen in 12 subjects with post-MDO imaging compared to their presurgical condition. At mixed dentition, 12 post-MDO subjects had more obtuse gonial angles (P < .01) and steeper mandibular planes (P < .01) than 19 non-MDO RS subjects. Both RS groups had different cephalometric values and more vertical measures than matched cephalometric norms. Thirty-one percent of 12 RS-MDO subjects had ≥1 teeth with abnormal development compared to none of 19 RS subjects without MDO (P = .02). CONCLUSION AND RELEVANCE MDO increased mandibular size in infants but can disrupt the developing dentition. Postdistraction growth may result in more vertical mandibular morphology with large gonial angles.
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Affiliation(s)
- Geoffrey M Greenlee
- Dentistry, Seattle Children's Hospital, Seattle, WA; Department of Orthodontics, University of Washington School of Dentistry, Seattle, WA.
| | | | - Srinivas Susarla
- Craniofacial Center, Divisions of Maxillofacial Surgery and Plastic and Craniofacial Surgery, Seattle Children's Hospital, Seattle, WA; Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA; Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine, Seattle, WA
| | - Kelly N Evans
- Craniofacial Center, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Lloyd Mancl
- Department of Oral Health Sciences, University of Washington School of Dentistry, Seattle, WA
| | - Barbara Sheller
- Dentistry, Seattle Children's Hospital, Seattle, WA; Department of Orthodontics, University of Washington School of Dentistry, Seattle, WA; Craniofacial Center, Seattle Children's Hospital, Seattle, WA
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Resnick CM, Rottgers SA, Wright JM, Vyas RM, Goldstein JA, Swanson JW, Padula MA, Coghill CH, Ahmad I, Molter DW, Menezes MD, Naing KW, Cielo CM. Surgical Outcome and Treatment Trends in 1289 Infants with Micrognathia: A Multicenter Cohort. Plast Reconstr Surg 2024; 154:155e-166e. [PMID: 37184511 DOI: 10.1097/prs.0000000000010639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Studies of infants with micrognathia, especially Robin sequence, are limited by its rarity and both phenotypic and diagnostic variability. Most knowledge of this condition is sourced from small, single-institution samples. METHODS This is a cross-sectional study including infants with micrognathia admitted to 38 Children's Hospital Neonatal Consortium centers from 2010 through 2020. Predictor variables included demographic data, birth characteristics, cleft, and syndrome status. Outcome variables included length of stay, death, feeding or respiratory support, and secondary airway operations. RESULTS A total of 1289 infants with micrognathia had surgery to correct upper airway obstruction. Mean age and weight at operation were 34.8 ± 1.8 weeks and 3515.4 ± 42 g, respectively. A syndromic diagnosis was made in 150 (11.6%) patients, with Stickler (5.4%) and Treacher Collins (2.2%) syndromes being the most common. Operations included mandibular distraction osteogenesis (MDO) in 66.3%, tracheostomy in 25.4%, and tongue-lip adhesion (TLA) in 8.3%. Patients receiving a tracheostomy had lower birthweight, head circumference, gestational age, and Apgar scores. Patients undergoing MDO were less likely to need a second airway operation compared with patients undergoing TLA (3.5% versus 17.8%; P < 0.001). The proportion of infants feeding exclusively orally at hospital discharge differed significantly, from most to least: MDO, TLA, and tracheostomy. Hospital length of stay was not statistically different for patients who had MDO or TLA, but was longer for those with primary tracheostomy. The mortality rate was low for all operations (0.5%). CONCLUSIONS In this surgical patient cohort, MDO was associated with shorter hospital stay, improved oral feeding, and lower rates of secondary airway operations. Prospective multicenter studies are necessary to support these conclusions. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Cory M Resnick
- From the Department of Plastic and Oral Surgery, Boston Children's Hospital
| | - S Alex Rottgers
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital
| | - Joshua M Wright
- Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital
| | - Raj M Vyas
- Department of Aesthetic and Plastic Surgery, University of California, Irvine
| | | | | | | | | | - Irfan Ahmad
- Division of Neonatology, Children's Hospital of Orange County
| | - David W Molter
- Department of Otolaryngology, St. Louis Children's Hospital
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Mehta B, Waters K, Fitzgerald D, Badawi N. Clinical characteristics, associated comorbidities and hospital outcomes of neonates with sleep disordered breathing: a retrospective cohort study. BMJ Paediatr Open 2024; 8:e002639. [PMID: 38897623 PMCID: PMC11191764 DOI: 10.1136/bmjpo-2024-002639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/08/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE Awareness of the need for early identification and treatment of sleep disordered breathing (SDB) in neonates is increasing but is challenging. Unrecognised SDB can have negative neurodevelopmental consequences. Our study aims to describe the clinical profile, risk factors, diagnostic modalities and interventions that can be used to manage neonates with SDB to facilitate early recognition and improved management. METHODS A single-centre retrospective study of neonates referred for assessment of suspected SDB to a tertiary newborn intensive care unit in New South Wales Australia over a 2-year period. Electronic records were reviewed. Outcome measures included demographic data, clinical characteristics, comorbidities, reason for referral, polysomnography (PSG) data, interventions targeted to treat SDB and hospital outcome. Descriptive analysis was performed and reported. RESULTS Eighty neonates were included. Increased work of breathing, or apnoea with oxygen desaturation being the most common reasons (46% and 31%, respectively) for referral. Most neonates had significant comorbidities requiring involvement of multiple specialists (mean 3.3) in management. The majority had moderate to severe SDB based on PSG parameters of very high mean apnoea-hypopnoea index (62.5/hour) with a mean obstructive apnoea index (38.7/hour). Ten per cent of patients required airway surgery. The majority of neonates (70%) were discharged home on non-invasive ventilation. CONCLUSION SDB is a serious problem in high-risk neonates and it is associated with significant multisystem comorbidities necessitating a multidisciplinary team approach to optimise management. This study shows that PSG is useful in neonates to diagnose and guide management of SDB.
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Affiliation(s)
- Bhavesh Mehta
- Department of Neonatology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Karen Waters
- Sleep Medicine, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Dominic Fitzgerald
- Respiratory and Sleep Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Nadia Badawi
- Discipline of Child & Adolescent Health, Faculty of Medicine & Health, The University of Sydney, Cerebral Palsy Alliance Research Institute, Camperdown, Sydney, New South Wales, Australia
- Grace Centre for Newborn Care, Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Theologie-Lygidakis N, Kamperos G, Pavli M, Christopoulos P, Tzermpos F, Tsiklakis K, Iatrou I. Mandibular Distraction Osteogenesis in Children and Adolescents: A Clinical and Radiographic Research Using Cone-Beam Computed Tomography. J Craniofac Surg 2024; 35:1163-1169. [PMID: 38376164 DOI: 10.1097/scs.0000000000010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 01/08/2024] [Indexed: 02/21/2024] Open
Abstract
AIM The aim of this cross-sectional study was to evaluate, via cone-beam computed tomography, the long-term postoperative outcome in children treated with mandibular distraction osteogenesis. MATERIALS AND METHODS All young patients treated with mandibular distraction osteogenesis (MDO), during a 16-year period, at the University Department of Oral and Maxillofacial Surgery of a Pediatric Hospital, were recalled, and various clinical and radiographic parameters were recorded. RESULTS Eleven patients were included: 5 with hemifacial microsomia (HFM) and 6 with mandibular micrognathia. In all cases, MDO had been successful in regular follow-up and decannulation, soon after MDO, was achieved in all tracheostomy cases. The long-term result in cases of HFM was found stable, functionally and esthetically accepted, although less satisfactory than in regular follow-up; in micrognathia patients, relapse of different degrees was registered in 4 of 6 cases, without any need for tracheostomy though. Detailed and accurate information was obtained by cone-beam computed tomography (CBCT). The shape of the regenerated bone was irregular in HFM cases and relatively normal in the micrognathia cases. Quality of the regenerated bone was normal in all patients. The irregular shape registered in HFM cases did not compromise a safe orthognathic operation. CONCLUSIONS Distraction osteogenesis remains an early treatment choice in cases of mandibular deformities. Long-term findings showed that there is a degree of relapse with growth, which was more obvious in mandibular micrognathia cases. Computed tomography contributes to detailed evaluation of changes at the distraction site.
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Affiliation(s)
- Nadia Theologie-Lygidakis
- Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens, and "P. & A. Kyriakou" Children's Hospital
| | - Georgios Kamperos
- Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens
| | - Maria Pavli
- Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens
| | - Panos Christopoulos
- Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens
| | - Fotios Tzermpos
- Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens
| | - Kostas Tsiklakis
- Department of Oral Diagnosis and Radiology, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Iatrou
- Department of Oral and Maxillofacial Surgery, School of Dentistry, National and Kapodistrian University of Athens
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Sanford JN, Lam DJ. Management of Obstructive Sleep Apnea in the Infant and Newborn. Otolaryngol Clin North Am 2024; 57:395-405. [PMID: 38523051 DOI: 10.1016/j.otc.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
Obstructive sleep apnea in newborns and infants presents a unique challenge with distinct differences in sleep physiology, etiologies, and management compared to older children. The indications for and interpretation of polysomnography are less well defined in infants. There are also no broadly accepted clinical practice guidelines for treating sleep apnea in this age group. Etiologies include general causes of upper airway obstruction in infants such as laryngomalacia, micrognathia, and nasal obstruction in addition to adenotonsillar hypertrophy. Treatment strategies must be tailored to the specific anatomic features and comorbidities of the specific patients and often require a multidisciplinary approach.
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Affiliation(s)
- Jillian N Sanford
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Derek J Lam
- Pediatric Otolaryngology Division, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
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Goza SD, Brown MI, Hopper SJ, Phillips J, Sink MC, Brown KW, Fernstrum CJ, Friel MT, Humphries LS, Hoppe IC. Mandibular Distraction in Patients With Pierre Robin Sequence: A Multisurgeon Experience. Ann Plast Surg 2024; 92:S382-S386. [PMID: 38725108 DOI: 10.1097/sap.0000000000003949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
OBJECTIVE Mandibular distraction osteogenesis (MDO) is rapidly becoming a standard of care for management of patients with severe Pierre Robin sequence. The tongue is brought forward to alleviate airway obstruction. This study will look at an institutional, multisurgeon experience with MDO over 10 years. DESIGN A retrospective chart review was conducted. SETTING All patients who underwent MDO at the authors' institution from 2012 to 2022 were included. Three craniofacial surgeons performed all interventions. PATIENTS Demographics, preoperative and postoperative respiratory and feeding status, and distraction data were collected for 27 patients meeting inclusion criteria. MAIN OUTCOME MEASURES Primary outcomes were avoidance of a gastrostomy tube, avoidance of a tracheostomy, discharge from hospital on room air, and complications. A significance value of 0.05 was utilized. RESULTS The average age at MDO was 135 days, mean activation phase was 13.6 days, mean distraction length was 14.9 mm, and mean consolidation phase was 64.2 days. A longer activation phase was associated with discharge with a gastrostomy tube and a shorter activation phase was associated with discharge on full oral feeds. The ability to discharge on room air was associated with a shorter latency phase, shorter activation phase, and decreased distance of distraction. CONCLUSIONS The goal of MDO is to achieve full oral feeds with no respiratory support. Several different latency periods were used in this study, and a short latency period was demonstrated to be safe.
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Affiliation(s)
- Shelby D Goza
- From the University of Mississippi Medical Center School of Medicine
| | - Madyson I Brown
- From the University of Mississippi Medical Center School of Medicine
| | - Samuel J Hopper
- From the University of Mississippi Medical Center School of Medicine
| | - John Phillips
- From the University of Mississippi Medical Center School of Medicine
| | - Matthew C Sink
- From the University of Mississippi Medical Center School of Medicine
| | - Kathryn W Brown
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Colton J Fernstrum
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Michael T Friel
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Laura S Humphries
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
| | - Ian C Hoppe
- Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
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7
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Meazzini MC, Piza A, Giorgio N, Sozzi D, de Ponti E, Mazzoleni F. Long-term mandibular growth in patients with airway obstruction treated with mandibular distraction. J Craniomaxillofac Surg 2024; 52:792-797. [PMID: 38644093 DOI: 10.1016/j.jcms.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/30/2024] [Indexed: 04/23/2024] Open
Abstract
Congenital craniofacial malformations play an important role in upper airway obstruction. One of the main causes is mandibular hypoplasia which is present in the pierre robin sequence. Mandibular distraction osteogenesis (MDO) is one of the most commonly used treatments for the resolution of upper airway obstruction in patients that do not respond to a conservative treatment. We performed a long term follow up of syndromic and non-syndromic patients with pierre robin sequence where the lateral xrays were studied before surgery (T1), after MDO (T2) and long-term follow-up (T3, at least 5 years). Possible complications of the surgery were also studied through panoramic x-rays and clinical controls. The results evidenced an increase of mandibular length comparing T1-T2 and a good stability during the long-term follow-up. The Sd patients presented smaller mandible dimensions. We had not found any complications during the follow-up. The scars outcomes are modest, but none of the patients requested a surgical correction. Mandibular distraction osteogenesis is a treatment to be considered in patients with upper airway obstruction that do not respond to conservative treatments. The results of the surgery are stable and the complications in experienced hands are low.
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Affiliation(s)
- Maria Costanza Meazzini
- Department of Maxillofacial Surgery, University of Milano-Bicocca, IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alejandro Piza
- Department of Maxillofacial Surgery, University of Milano-Bicocca, IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Novelli Giorgio
- Department of Maxillofacial Surgery, University of Milano-Bicocca, IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Davide Sozzi
- Department of Maxillofacial Surgery, University of Milano-Bicocca, IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Elena de Ponti
- Department of Medical Physics, University of Milano-Bicocca, IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Fabio Mazzoleni
- Department of Maxillofacial Surgery, University of Milano-Bicocca, IRCCS San Gerardo dei Tintori, Monza, Italy
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de Blacam C, Butler D, Duggan L, Byrne S, Russell J, Javadpour S, White M, Orr DJA. Minimally-invasive airway management and early cleft palate repair in infants born with Robin sequence. J Craniomaxillofac Surg 2024; 52:514-521. [PMID: 38448335 DOI: 10.1016/j.jcms.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/01/2024] [Indexed: 03/08/2024] Open
Abstract
The objective of this study was to report outcomes of early cleft palate repair in infants born with Robin sequence (RS). A retrospective case series in a tertiary referral paediatric hospital was carried out, examining a consecutive series of 69 infants born with RS and cleft palate. A minimally invasive approach was taken to upper airway obstruction, with liberal nasopharyngeal airway (NPA) and non-invasive ventilation (NIV) use, guided by sleep studies. The palate was repaired between 6 and 9 months with a modified Malek technique. The most frequently used airway adjunct (59.4% of patients) was an NPA and the median duration of use was 5.6 months. All patients underwent a modified Malek cleft palate repair at a median of 7 months of age. Overnight oximetry demonstrated higher mean oxygen saturation (SpO2) across the group from initial neonatal admission to discharge (median 96.5% (interquartile range [IQR] 95-98%) vs 97.45% (IQR 96.5-98%) (P = 0.2, N = 34). Of those with a cardiorespiratory polysomnogram, the obstructive apnoea-hypopnea index (OAHI) was significantly lower postoperatively (5.9 vs 2.8, P = 0.028). This study supports the use of non-surgical airway strategies and early cleft palate repair in infants born with RS and cleft palate.
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Affiliation(s)
- Catherine de Blacam
- Dept of Plastic Surgery, Children's Health Ireland at Crumlin, Dublin 12, Ireland; Dublin Cleft Centre, Children's Health Ireland at Crumlin, Dublin 12, Ireland; Dept of Paediatrics, Trinity College Dublin, Dublin 2, Ireland; Royal College of Surgeons in Ireland, Dublin 2, Ireland.
| | - Daryl Butler
- Dept of Paediatric Respiratory Medicine, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Laura Duggan
- Dublin Cleft Centre, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Sandra Byrne
- Dublin Cleft Centre, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - John Russell
- Dept of Paediatric Otolaryngology, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Sheila Javadpour
- Royal College of Surgeons in Ireland, Dublin 2, Ireland; Dept of Paediatric Respiratory Medicine, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Martin White
- Dept of Paediatrics, Trinity College Dublin, Dublin 2, Ireland; Dept of Neonatology, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - David J A Orr
- Dept of Plastic Surgery, Children's Health Ireland at Crumlin, Dublin 12, Ireland; Dublin Cleft Centre, Children's Health Ireland at Crumlin, Dublin 12, Ireland; Dept of Paediatrics, Trinity College Dublin, Dublin 2, Ireland; Dept of Surgery, Trinity College Dublin, Dublin 2, Ireland
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Mao Z, Tian G, Shrivastava M, Zhou J, Ye L. Complications of Mandibular Distraction Osteogenesis in Infants with Isolated Robin Sequence. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1591. [PMID: 37892254 PMCID: PMC10605000 DOI: 10.3390/children10101591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/05/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023]
Abstract
Mandibular Distraction Osteogenesis (MDO) is now the preferred procedure to alleviate airway obstruction in infants with severe Robin Sequence (RS). However, there have been very few studies investigating complications related to MDO surgery performed on patients affected by isolated RS. In this study, age at distraction, weight at distraction, preoperative intubation, repeat MDO and complications associated with MDO were included as variables. Minor, moderate and major problems were evaluated and recorded as surgical site infections (SSI), injuries to the facial nerve, self-extinction hypertrophic scars, temporomandibular joint ankylosis, device failures, early ossification and fibrous non-union. One hundred and fifty one patients with isolated RS were included. At distraction, the mean age was 72 days (12-540 days) and the mean weight was 4.05 kg (2.4-12.2 kg). Only one patient needed tracheostomy after MDO, and none required further distraction. Ultimately, the complication rate was 15.23%, and there was a total of 7.95% minor, 9.27% moderate and 0% major complications. Minor incidents included surgical site infection (SSI) managed with antibiotics taken orally (n = 8), neuropraxia in the VII cranial nerve (CN) (n = 1), and hypertrophic scarring (n = 3). Incidents reported as moderate were SSIs managed with intravenous antibiotics (n = 9), incision and drainage (n = 3) and self-extubation (n = 2). There was no case of TMJ ankylosis. There were no cases of early or premature ossification, fibrous non-union and device fracture. In conclusion, MDO is an effective and appropriate management technique for infants with isolated RS and severe airway obstruction. Infections at the surgery site accounted for the vast majority of the complications. Further investigations may be needed to determine the long-term consequences of MDO.
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Affiliation(s)
- Zhe Mao
- Department of Oral and Maxillofacial Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou 510000, China; (Z.M.)
| | - Gabriel Tian
- Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mayank Shrivastava
- Orofacial Pain, TMD & Dental Sleep Medicine at Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA;
| | - Jiawei Zhou
- Department of Oral and Maxillofacial Surgery, Guangzhou Women and Children’s Medical Center, Guangzhou 510000, China; (Z.M.)
| | - Liang Ye
- Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN 55455, USA
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10
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Motamedian SR, Ahmadi N, Ghaffari S, Niazmand M, Mohaghegh S, Morice A, Khonsari RH. Effects of distraction osteogenesis with Le Fort osteotomies on upper airway volumes: a systematic review and meta-analyses. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023:101553. [PMID: 37422264 DOI: 10.1016/j.jormas.2023.101553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/25/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE Distraction osteogenesis is one of the treatment options in patients with severe maxillomandibular abnormalities to treat morphological and respiratory problems (obstructive sleep apnea syndrome). The study aimed to evaluate the effect of Le Fort I, II and III distraction osteogenesis (DO) on upper airway dimensions and respiratory function. METHODS Electronic search was performed in PubMed, Scopus, Embase, Google Scholar and Cochrane databases. Studies that only involved two dimensional analyses were excluded. Besides, studies that performed DO in conjunction with orthognathic surgery were not considered. NIH quality assessment tool was used to evaluate the risk of bias. Meta-analyses were performed to assess sleep apnea indices and the mean differences in the airway dimensions before and after DO. Gradings of Recommendations, Assessment, Development and Evaluation were used to analyze the evidence level. RESULTS Among the 114 studies that went under full-text analyses, 11 articles met the inclusion criteria. Results of the quantitative analyses showed that maxillary Le Fort III DO significantly increased the amounts of oropharyngeal, pharyngeal and upper airway volumes. However, apnea-hypopnea index (AHI) showed a non-significant improvement after this procedure. Besides, the dimensions of the airways increased with Le Fort I and II DO, according to a qualitative analysis. Considering the design of the included studies, our results had a low level of evidence. CONCLUSION Maxillary Le Fort DO does not significantly impact AHI, while it significantly increases the airway dimensions. Meanwhile, multicentric studies with standardized evaluation are still required to confirm the effects of maxillary Le Fort DO on airway obstruction.
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Affiliation(s)
- Saeed Reza Motamedian
- Dentofacial Deformities Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nima Ahmadi
- Dentofacial Deformities Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samin Ghaffari
- Dentofacial Deformities Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maral Niazmand
- Dentofacial Deformities Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sadra Mohaghegh
- Dentofacial Deformities Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Anne Morice
- Service de Chirurgie Maxillofaciale et Chirurgie Plastique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Faculté de Médecine, Université Paris Cité; Paris, France
| | - Roman Hossein Khonsari
- Service de Chirurgie Maxillofaciale et Chirurgie Plastique, Hôpital Necker - Enfants Malades, Assistance Publique - Hôpitaux de Paris; Faculté de Médecine, Université Paris Cité; Paris, France.
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11
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Tonello C, Dias GB, Nunes RB, Fussuma CY, Sousa LR, Feitosa LB, Flores RL, Alonso N. Mandibular Dysmorphology and Clinical Presentation in Treacher Collins Syndrome. Cleft Palate Craniofac J 2023:10556656231184967. [PMID: 37437901 DOI: 10.1177/10556656231184967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
INTRODUCTION Treacher Collins syndrome is a rare congenital disease characterized by the multiple craniofacial malformations. Although the deformities affecting patients with Treacher Collins syndrome have been well characterized, the effects of these malformations to clinical severity of the syndrome are not well understood. OBJECTIVE To determine the association of specific Treacher Collins mandibular malformations with clinical severity. DESIGN A retrospective radiographic observational study. SETTING Study conducted at a single institution, a quaternary craniofacial care center. PATIENTS 54 patients with Treacher Collins syndrome. INTERVENTIONS Computed tomography (CT), clinical photographs and medical history were included in this analysis. Mandibles were isolated from CT data and reconstructed in three dimensions using Mimics software. Cephalometric measurements were performed on CT data. Clinical severity was determined by Teber and Vincent scores. Association of craniofacial dysmorphology to clinical severity was determined by Spearman rank coefficient. MAIN OUTCOME MEASURES The main results obtained were the measurements of the mandibles and the quantification of the malformations of the evaluated patients. RESULTS Among the most frequent findings in the sample are hypoplasia of the zygomatic complex, descending palpebral cleft and mandibular hypoplasia. Patients with a lower ramus/corpus ratio had a higher (more severe) Teber and Vincent classification. CONCLUSION Patients with the most compromised mandible are also the patients with the highest number of malformations, thus, the most severe patients.
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Affiliation(s)
- C Tonello
- Craniofacial Surgeon of Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, São Paulo, Brazil
| | - G B Dias
- Bauru School Dentistry, University of São Paulo, São Paulo, Brazil
| | - R B Nunes
- Craniofacial Surgeon of Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, São Paulo, Brazil
| | - C Y Fussuma
- Craniofacial Surgeon of Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, São Paulo, Brazil
| | - L R Sousa
- Bauru School Dentistry, University of São Paulo, São Paulo, Brazil
| | - L B Feitosa
- Craniofacial Surgeon of Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, São Paulo, Brazil
| | - R L Flores
- Craniofacial Surgeon of The Hansjörg Department of Plastic Surgery, New York University Langone Health, New York City, NY, USA
| | - N Alonso
- Craniofacial Surgeon of Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, São Paulo, Brazil
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Ma LK, Zhang ZY, Tang XJ, Xu X, Feng S, Zhao SB, Shu KY, Liu BY, Zang TY, Liu W. Respiratory outcome of mandibular distraction osteogenesis on obstructive sleep apnea in craniofacial microsomia: A retrospective study. J Craniomaxillofac Surg 2023:S1010-5182(23)00079-3. [PMID: 37355371 DOI: 10.1016/j.jcms.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/09/2023] [Accepted: 05/21/2023] [Indexed: 06/26/2023] Open
Abstract
This study aimed to evaluate the effect of mandibular distraction osteogenesis (MDO) on respiratory function in CFM patients with obstructive sleep apnea (OSA) according to polysomnography (PSG). This study retrospectively analyzed patients with CFM who underwent PSG before surgery and after completion of mandible distraction. Patients who met the inclusion criteria were selected. The Pediatric Sleep Questionnaire (PSQ) was used to assess patients' signs and symptoms related to OSA. The obstructive apnea-hypopnea index (OAHI) and lowest oxygen saturation (LSaO2) were imported into SPSS version 26.0. The Wilcoxon signed-rank test was used to assess the differences in PSG before and after MDO. Other data were described using descriptive statistics. A P-value less than 0.05 was considered statistically significant. A total of 25 unilateral CFM patients were included in this study. Most patients (72%) had mild OSA; moderate and severe OSA were 12% and 16%, respectively. Snoring (52%) was the most common symptom among these patients. After completion of mandibular distraction, snoring and other OSA-related symptoms were significantly improved. Twelve patients had normalized PSG and the severity of OSA improved significantly in 3 patients. The total effective rate of MDO for OSA was 60%. The statistical results showed that OAHI (P = 0.045) decreased and LSaO2 (P = 0.009) increased significantly compared to preoperative values. MDO can improve OSA-related symptoms in CFM patients. In addition, respiratory function was improved in most patients after MDO, based on PSG. CFM patients, especially those with OSA, can benefit from MDO.
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Affiliation(s)
- Lun-Kun Ma
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Zhi-Yong Zhang
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Xiao-Jun Tang
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Xi Xu
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Shi Feng
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Shan-Baga Zhao
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Kai-Yi Shu
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Bing-Yang Liu
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Tian-Ying Zang
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China
| | - Wei Liu
- Department of Cranio-Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, China.
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Duarte DW, Fleith IJ, Pinheiro RC, Machado MF, Zanin EM, Collares MVM. Mandibular morphology and distraction osteogenesis vectors in patients with Robin sequence. Int J Oral Maxillofac Surg 2023; 52:442-450. [PMID: 35985910 DOI: 10.1016/j.ijom.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 10/15/2022]
Abstract
The aims of this cohort study were to compare the mandibular morphology between patients with Robin sequence (RS) and controls, and to examine the effects of mandibular distraction osteogenesis (MDO) using different vectors. Measurements of the mandibles of 80 patients with RS and 46 controls aged< 90 days were made using computed tomography. The data were compared among isolated RS patients (n = 58), syndromic RS patients (n = 22), and controls. Patients with RS exhibited significantly shorter ramus and body lengths and larger symphyseal angles than controls (all P < 0.001). Patients with isolated RS had shorter body lengths (P < 0.001), while syndromic patients had shorter ramus and body lengths (both P < 0.001) than controls. Seventy RS patients underwent MDO. Pre-MDO (n = 37) and post-MDO (n = 29) mandibular measurements were compared between patients undergoing MDO with a vertical vector and those undergoing MDO with a horizontal vector. Polysomnography data from part of the cohort highlighted the effectiveness of both vectors. MDO with a horizontal vector conferred 11% and 36% increases in ramus and body length, respectively, while these increases were 34% and 27.5%, respectively, with a vertical vector. MDO with a vertical vector was effective in lengthening ramus and body components and should be considered in the presence of ramus hypoplasia.
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Affiliation(s)
- D W Duarte
- Division of Plastic and Craniofacial Surgery, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul Federal University, Porto Alegre, Brazil.
| | - I J Fleith
- Department of Radiology, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul Federal University, Porto Alegre, Brazil
| | - R C Pinheiro
- School of Design, Rio Grande do Sul Federal University, Porto Alegre, Brazil
| | - M F Machado
- School of Medicine, Rio Grande do Sul Federal University, Porto Alegre, Brazil
| | - E M Zanin
- Division of Plastic and Craniofacial Surgery, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul Federal University, Porto Alegre, Brazil
| | - M V M Collares
- Division of Plastic and Craniofacial Surgery, Hospital de Clínicas de Porto Alegre, Rio Grande do Sul Federal University, Porto Alegre, Brazil
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Liu Z, Yang J, Zhou C, Liu Y, Luo E. A bibliometric analysis of research on craniomaxillofacial distraction osteogenesis from 2000 to 2021. Front Surg 2022; 9:932164. [PMID: 35978605 PMCID: PMC9377540 DOI: 10.3389/fsurg.2022.932164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This study collected and summarized publications related to craniomaxillofacial distraction osteogenesis(DO) from 2000 to 2021, investigated trends in related research, and compared publications from different countries, institutions and journals. The aim is showcasing hotspots and frontiers in the field and providing a reference for future research. Background Craniomaxillofacial DO serves to treat different types of craniomaxillofacial dysplasia and bone defects and deformities. DO can significantly reduce surgical trauma, complications, and recurrence rate compared to conventional surgery. However, there is a lack of bibliometric analyses regarding Craniomaxillofacial DO. Methods CiteSpace and VOSviewer were used to analyze and visualize 3,141 articles and reviews searching through the Web of Science Core Collection(WOSCC) to obtain publications on craniomaxillofacial DO from 1 January 2000 to 31 December 2021. Results In the last 21 years, there has been a significant increase in the number of publications. The United States, the People's Republic of China, and Italy produce the vast majority of publications. University of Milan and University of Bologna are the most influential in this field. McCarthy JG is the most influential author. Obstructive sleep apnea, TMJ ankylosis and cleft lip and palate are potential research direction in this field. Conclusion Future research should focus on the precise indications and optimal timing of craniomaxillofacial DO and the evaluation of the long-term outcomes of various modified procedures. This study provides a relatively objective reference for related researchers, medical practitioners, and global health systems.
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Affiliation(s)
- Zhen Liu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jianying Yang
- Department of Outpatient nursing, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Changhan Zhou
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yao Liu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - En Luo
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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15
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Dental outcomes after neonatal mandibular distraction. Curr Opin Otolaryngol Head Neck Surg 2022; 30:254-259. [PMID: 35906978 DOI: 10.1097/moo.0000000000000826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study was to understand dental complications associated with neonatal mandibular distraction and subsequent dental outcomes. RECENT FINDINGS Dental injury is often associated with neonatal mandibular distraction osteogenesis. Newer technology offers safer techniques to minimize this risk. Long-term follow up and dental outcomes in permanent dentition are needed to better understand the actual risk associated with the procedure. SUMMARY Surgeons performing neonatal mandibular distraction osteogenesis need to understand the associated risks to deciduous and permanent dentition as well as techniques to mitigate this risk.
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Chandrasekar I, Tablizo MA, Witmans M, Cruz JM, Cummins M, Estrellado-Cruz W. Obstructive Sleep Apnea in Neonates. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030419. [PMID: 35327791 PMCID: PMC8947507 DOI: 10.3390/children9030419] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/04/2022] [Accepted: 03/05/2022] [Indexed: 12/03/2022]
Abstract
Neonates have distinctive anatomic and physiologic features that predispose them to obstructive sleep apnea (OSA). The overall prevalence of neonatal OSA is unknown, although an increase in prevalence has been reported in neonates with craniofacial malformations, neurological disorders, and airway malformations. If remained unrecognized and untreated, neonatal OSA can lead to impaired growth and development, cardiovascular morbidity, and can even be life threatening. Polysomnography and direct visualization of the airway are essential diagnostic modalities in neonatal OSA. Treatment of neonatal OSA is based on the severity of OSA and associated co-morbidities. This may include medical and surgical interventions individualized for the affected neonate. Based on this, it is expected that infants with OSA have more significant healthcare utilization.
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Affiliation(s)
- Indira Chandrasekar
- Division of Neonatology, Department of Pediatrics, Valley Children’s Hospital, Madera, CA 94305, USA
- Correspondence: (I.C.); (W.E.-C.)
| | - Mary Anne Tablizo
- Division of Pulmonary and Sleep Medicine, Valley Children’s Hospital, Madera, CA 94305, USA; or
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | | | - Jose Maria Cruz
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
| | - Marcus Cummins
- School of Medicine, University of California San Francisco, Fresno, CA 94143, USA;
| | - Wendy Estrellado-Cruz
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO 64108, USA;
- Correspondence: (I.C.); (W.E.-C.)
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Normal Neonatal Sleep Defined: Refining Patient Selection and Interpreting Sleep Outcomes for Mandibular Distraction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4031. [PMID: 35070593 PMCID: PMC8769137 DOI: 10.1097/gox.0000000000004031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022]
Abstract
Background: Although polysomnography is paramount when evaluating neonatal airway obstruction, “normal” published references do not exist. We present normative polysomnography data for newborns age 0–1 month. We compare this reference to pre and postoperative sleep data from infants undergoing mandibular distraction osteogenesis (MDO) at this same age. Methods: Following IRB approval, normative subjects were recruited from our neonatal intensive care unit to undergo nap polysomnography. One blinded sleep physician read all studies. From 2016 to 2019, we prospectively collected sleep data for newborns undergoing MDO. Results: In total, 22 neonates without airway obstruction provided normative sleep data. Median total apnea-hypopnea index (AHI), obstructive apnea-hypopnea index (OAHI), and central apnea index (CAI) were 7.3, 4.9, and 0.7 events/hour. Median O2 nadir was 91%. Polysomnography for 13 neonates before MDO and during consolidation showed median preoperative AHI was 38.3, OAHI was 37.0, CAI was 1.9, and median O2 nadir was 83%. Following MDO, median AHI was 6.1, OAHI was 4.0, CAI was 1.3, and median O2 nadir was 92.5%. Paired t-tests confirmed significant improvements in all indices; when comparing the postoperative group with the normative group, there was no difference in oxygenation nor any respiratory index. Conclusions: “Normal” neonates have more obstructive events and lower oxygenation nadirs than previously appreciated. We provide normative nap polysomnography values for this age group and encourage centers with multidisciplinary MDO teams to utilize this data to calibrate patient selection algorithms, inform treatment discussions, and better understand surgical outcomes. Limitations include a small sample size and single institution study.
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18
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van der Plas PPJM, Joosten KFM, Wolvius EB, Koudstaal MJ, Mathijssen IMJ, van Dooren MF, Pullens B. Mandibular distraction to correct severe non-isolated mandibular hypoplasia: The role of drug-induced sleep endoscopy (DISE) in decision making. Int J Pediatr Otorhinolaryngol 2022; 152:110968. [PMID: 34861552 DOI: 10.1016/j.ijporl.2021.110968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/17/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In patients with mandibular hypoplasia, mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction. Drug-induced sleep endoscopy (DISE) provides a dynamic assessment of the upper airway and visualizes anatomical site and cause of airway obstruction. The aim of this study was to evaluate the effect of MDO on tongue-based airway obstruction found by DISE within a non-isolated patient population with severe upper airway obstruction (UAO). Furthermore, we aimed to assess the additional value of DISE in clinical decision making by correlating DISE findings to functional airway outcomes after MDO. METHODS Findings on DISE in children who underwent MDO were retrospectively gathered and evaluated. According to DISE findings, severity of tongue-based obstruction was scored using a 4-step classification similar to the one that is used by Bravo et al.. Intubation conditions were scored according to the Cormack Lehane score (CLS). Pre-and postoperative DISE findings were compared and correlated with functional airway outcomes following MDO. RESULTS In 19 out of 28 MDO procedures, both a pre-and postoperative DISE was available. Tongue-based obstruction scores improved in 13 procedures, which correlated to a functional improvement in seven. Postoperative tongue-based obstruction differed significantly between patients with successful MDO and patients treated unsuccessfully (2.00 ((Interquartile range (IQR) 1.00-2.00) vs. 3.00 (IQR 2.00-4.00), p = 0.028), whereas this difference was not significant for the CLS (1.00 (IQR 1.00-1.50) vs. 2.00 (IQR 1.00-4.00), p = 0.066). If no improvement of tongue-based obstruction was seen, MDO is very unlikely to be successful on the functional airway. CONCLUSIONS DISE provides information on the site and nature of airway obstruction and can visualize the effect of MDO on the severity of tongue-based airway obstruction. Therefore, it can be of additional value in understanding the differences in functional airway outcomes after MDO and aids in deciding appropriate and targeted treatment. Hence, standardized use of DISE, in addition to the clinical assessment of mandibular position and a polysomnography, during MDO management is highly recommended.
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Affiliation(s)
- Pleun P J M van der Plas
- Department of Oral and Maxillofacial Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Koen F M Joosten
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Eppo B Wolvius
- Department of Oral and Maxillofacial Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Maarten J Koudstaal
- Department of Oral and Maxillofacial Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Irene M J Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Marieke F van Dooren
- Department of Clinical Genetics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Bas Pullens
- Department of Otorhinolaryngology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, the Netherlands.
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Feeding and swallowing outcomes following mandibular distraction osteogenesis: an analysis of 22 non-isolated paediatric cases. Int J Oral Maxillofac Surg 2021; 51:892-899. [PMID: 34952774 DOI: 10.1016/j.ijom.2021.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/02/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022]
Abstract
Patients with mandibular hypoplasia and upper airway obstruction are at an increased risk of feeding and swallowing difficulties. Little has been described regarding these outcomes following mandibular distraction. The aim of this study was to evaluate the effect of mandibular distraction on feeding and swallowing function. A retrospective study was performed on 22 patients with non-isolated mandibular hypoplasia and severe upper airway obstruction treated with mandibular distraction. Median age at first mandibular distraction was 3.1 years (interquartile range 2.3-6.0 years) and the median follow-up time was 3.5 years (interquartile range 2.0-9.4 years). Prior to mandibular distraction, feeding difficulties were present in 18 patients. Swallowing difficulties were present in 20 patients, all of whom had problems in the oral phase of swallowing, while 11 patients had additional problems in the pharyngeal phase. Following mandibular distraction, at the time of follow-up, feeding difficulties persisted in 13 patients. Swallowing difficulties in the oral phase remained present in all 20 patients, while pharyngeal phase problems persisted in seven patients. In conclusion, feeding and swallowing difficulties are highly prevalent in non-isolated patients and often persist following mandibular distraction. Moreover, these can be the reason that decannulation cannot be accomplished. Hence, awareness and close follow-up by a specialized speech therapist is of paramount importance.
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Hadaegh Y, Uludag H, Dederich D, El-Bialy TH. The effect of low intensity pulsed ultrasound on mandibular condylar growth in young adult rats. Bone Rep 2021; 15:101122. [PMID: 34527791 PMCID: PMC8433121 DOI: 10.1016/j.bonr.2021.101122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/19/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022] Open
Abstract
There is a need for more effective methods to enhance mandibular growth in young adults with mandibular deficiency. Previous studies suggest that low intensity pulsed ultrasound (LIPUS) can enhance mandibular growth in growing individuals. This study aimed to evaluate the potential growth changes of the mandible following 4-week LIPUS application in young adult rats. Nineteen ≈120-day-old female rats were allocated to experimental (n = 10) and control (n = 9) groups. The animals in the experimental group were treated with LIPUS to their temporomandibular joints (TMJs) bilaterally, 20 min each day for 28 consecutive days. Animals were then euthanized; gross morphological evaluation was performed on 2D photographs and 3D virtual models of hemi-mandibles, and microstructural assessment was done for the mandibular condyle (MC). Evaluation of mineralization and microarchitecture properties of subchondral cancellous bone was performed by micro-computed tomography (μCT) scanning. Qualitative and histomorphometric analysis was done on condylar cartilage and subchondral bone following Alcian Blue/PAS and Goldner's Trichrome staining. Vital flourochrome (calcein green) labeling was also utilized to determine the amount of endochondral bone growth. Gross morphological evaluations showed a slight statistically non-significant increase especially in the main condylar growth direction in the LIPUS group. Moreover, 3D evaluation depicted an enhanced periosteal bone apposition at the site of LIPUS application. Microstructural analysis revealed that LIPUS stimulates both chondrogenesis and osteogenesis and enhances endochondral bone formation in young adult rat MC. Furthermore, the effect of LIPUS on osteogenic cells of subchondral cancellous bone was notable. To conclude, LIPUS can enhance young adult rats' MC residual growth potential.
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Affiliation(s)
- Yasamin Hadaegh
- School of Dentistry, University of Alberta, Edmonton, Canada
| | - Hasan Uludag
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, Canada
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Orthognathic surgery for juvenile idiopathic arthritis of the temporomandibular joint: a critical reappraisal based on surgical experience. Int J Oral Maxillofac Surg 2021; 51:799-805. [PMID: 34815166 DOI: 10.1016/j.ijom.2021.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 10/26/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022]
Abstract
Juvenile idiopathic arthritis (JIA) involving the temporomandibular joint (TMJ) can result in significant dentofacial deformities that may require orthognathic surgical correction. The aim of this study was to assess the functional and aesthetic results relative to stability after bimaxillary surgery with counterclockwise rotation of the occlusal plane in patients with JIA. A retrospective chart review was conducted of all patients affected by JIA who underwent orthognathic surgery between January 2000 and December 2019 at the Face Surgery Centre (Parma, Italy). Patient records were evaluated for surgical indications, complications, and outcomes. The final study sample included 13 patients (12 female, one male). The mean age of the patients was 18.6 years (range 17-26 years) at the time of surgery; 12 patients had bilateral TMJ disease. At the 1-year follow-up, all patients except one had a stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. The 1-year postoperative cone beam computed tomography (CBCT) scan revealed complete ossification at all osteotomy sites. Bilateral sagittal split osteotomy with mandibular advancement is an effective procedure with a low rate of complications for patients with JIA with stable disease confirmed by preoperative CBCT or magnetic resonance imaging.
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Postoperative Changes in the Upper Airway Following Mandibular Distraction Osteogenesis in Pediatric Hemifacial Microsomia. J Craniofac Surg 2021; 33:534-538. [PMID: 34723918 DOI: 10.1097/scs.0000000000008327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients with hemifacial microsomia (HFM) may undergo unilateral mandibular distraction osteogenesis (MDO) before skeletal maturity in an effort to improve facial symmetry. Mandibular distraction osteogenesis's effect on airway volumes have been studied in the past, though to our knowledge, none have accounted for the effect of head and neck posture on airway morphology. This study aimed to tackle this shortcoming, using imaging to analyze the upper airway of patients with HFM before and after surgical intervention with MDO. METHODS/DESCRIPTION The authors retrospectively reviewed patients with a diagnosis of unilateral HFM whom underwent unilateral MDO with an oblique vector at age 4 to 14 years at a single institution from 2004 to 2019. Patients with pre- and post-MDO three-dimensional computed tomography scans of the upper airway within 12 months of distractor placement and removal, respectively, were included. Head and neck postures were determined by craniocervical, pitch, roll, and yaw angles. Pre- and post-operative pharyngeal airway volumes, pharyngeal surface area, minimum retropalatal cross-sectional areas (RP CSA) and retroglossal (RG) CSA and associated anteroposterior distances were measured using Mimics 22.0 (Materialise; Leuven, Belgium). Comparison was done using Kruskal-Wallis tests and linear mixed-effects models controlling for head and neck postures. RESULTS Ten patients met inclusion criteria. Mean age at pre-distractor placement computed tomography scan was 99 ± 35 months, and mean duration between pre- and post-surgery scans was 220 ± 90 days. Head and neck posture were found to be significant predictors of all airway dimensions. After controlling for significant factors with fixed effects linear modeling, surface area was found to be significantly smaller in patients after MDO by 189.48 mm2 (F[10.8] = -3.47, P = 0.0053), compared to their preoperative measurements. Surgery was not a significant predictor of changes in airway volume (F[11.6] = 0.52, P = 0.61), minimum RP CSA (F[12.2] = -0.64, P = 0.53), minimum RG CSA (F[12.6] = -1.64, P = 0.13), RP anteroposterior distance (F[14.0] = 0.30, P = 0.77), or RG anteroposterior distance (F[20.0] = -0.04, P = 0.97). CONCLUSIONS Oblique vector MDO in patients with HFM is associated only with statistically significant changes in the surface area of the upper airway, and is not associated with statistically significant changes in dimensions like volume, CSA, or anteroposterior dimension. This is an important finding, as it may guide discussions surrounding risk/benefit ratio for MDO in childhood.
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Vertical mandibular bone augmentation by the osteodistraction of the transplanted fibula free flap: A case series with long-term follow-up. J Craniomaxillofac Surg 2021; 49:1044-1053. [PMID: 34215493 DOI: 10.1016/j.jcms.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 06/06/2021] [Accepted: 06/20/2021] [Indexed: 11/22/2022] Open
Abstract
Vertical augmentation of the mandible to prepare dental implant therapy is still a challenge, especially with large mandible defects. Reconstruction with fibula free flap is a regularly applied approach in such cases, but it does not always yield optimal results: the resulting crestal height might differ significantly from the crestal height of the patient's intact bone, which makes esthetic and functional rehabilitation difficult. Osteodistraction of the integrated flap is a known but rarely discussed approach where the already integrated flap undergoes additional distraction. Through the four cases reported here, we would like to demonstrate that the osteodistraction of the transplanted fibula free flap is a useful and efficient method of secondary augmentation for cases where the flap itself fails to produce the desired crestal height, and no other method is applicable. The cases show that the method allows outcomes that are highly satisfactory, both in the functional and esthetic sense.
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Marston AP, Patel T, Pecha PP, Nguyen SA, Discolo CM. Impact of Hospital Characteristics on Mandibular Distraction Osteogenesis Outcomes Among Patients With Pierre Robin Sequence Utilizing a National Inpatient Database. Cleft Palate Craniofac J 2021; 59:622-628. [PMID: 33977781 DOI: 10.1177/10556656211015007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study collected national inpatient data to investigate the impact of hospital specialty and size on patient outcomes following mandibular distraction osteogenesis (MDO). DESIGN Kids' Inpatient Database was used to identify patients less than 12 months of age with Pierre Robin sequence (PRS) who underwent MDO in one of the following years: 2006, 2009, and 2012. SETTING Inpatient database from the United States. PARTICIPANTS Two hundred seventy-six patients with PRS underwent MDO with 134 (48.6%) identified as nonsyndromic and 142 (51.4%) as syndromic. INTERVENTIONS Mandibular distraction osteogenesis. MAIN OUTCOME MEASURES Length of hospital stay, adjunct airway and nutritional interventions and disposition. RESULTS The average length of stay was 24 and 30 days for patients with nonsyndromic and syndromic PRS, respectively (P = .066). Patients with a syndromic as compared to nonsyndromic diagnosis had a higher incidence of gastrostomy tube placement (21.8 vs 12.7%, P = .045). Univariate analysis showed that a lower proportion of patients at children's hospitals as compared to non-children's hospitals necessitated 1 or more airway or nutrition-related intervention (19/148 [12.8%] vs 31/127 [24.4%]; P = .012) and had a lower incidence of a nonroutine discharge (transfer or patient death; 7.4% vs 40.0% nonroutine; P < .001). Multivariable analysis additionally revealed that patients at children's hospitals were less likely to discharge nonroutine (OR = 0.07, 95% CI: 0.02-0.32). CONCLUSIONS Results from this national cohort demonstrated that at children-specific hospitals patients with PRS were less likely to require additional airway and nutritional procedures and more likely to discharge to home.
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Affiliation(s)
- Alexander P Marston
- Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine, Boston, MA, USA
| | - Terral Patel
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Phayvanh P Pecha
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christopher M Discolo
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Avinoam S, Shetye PR. Craniofacial Distraction: Orthodontic Considerations. Clin Plast Surg 2021; 48:531-541. [PMID: 34051904 DOI: 10.1016/j.cps.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A combined surgical and orthodontic approach to midface and mandibular distraction optimizes stability and outcomes. Orthodontic considerations include proper planning of the distraction vector, appropriate device use, and thorough follow-up through the consolidation and postoperative period. The dental occlusion must be managed throughout treatment in order to achieve ideal results.
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Affiliation(s)
- Shayna Avinoam
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY 10017, USA
| | - Pradip R Shetye
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY 10017, USA.
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Wiechers C, Thjen T, Koos B, Reinert S, Poets CF. Treatment of infants with craniofacial malformations. Arch Dis Child Fetal Neonatal Ed 2021; 106:104-109. [PMID: 32409560 DOI: 10.1136/archdischild-2019-317890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/29/2020] [Indexed: 11/04/2022]
Abstract
Infants with craniofacial malformations (CFMs) are at increased risk of various clinical problems, including respiratory and feeding disorders, the result of which may be long-lasting. An improvement in clinical care can be achieved by prenatal diagnosis and interdisciplinary birth preparation. Feeding problems may particularly be stressful for the family and require a team approach involving nursing staff, speech therapists and nutritional specialists to anticipate, avoid and treat sequelae such as failure to thrive or recurrent aspirations. Special techniques (eg, optimisation of breast feeding, alternative feeding methods or manual orofacial therapy) may be used individually to improve feeding competence; supplemental nutrition via a nasogastric or gastrostomy tube may be temporarily necessary to ensure adequate weight gain. The high prevalence of respiratory disorders in infants with craniofacial abnormalities requires anticipation and screening to prevent growth failure and neurological deficits. Treatment of upper airway obstruction varies widely, strategies can be divided into non-surgical and surgical, and in those aimed at widening the pharyngeal space (eg, prone position, palatal plates, craniofacial surgery) and those bridging the narrow upper airway (eg, nasopharyngeal airway, modified palatal plate, pneumatic airway stenting, tracheostomy). The complex management of an infant with CFM should be performed by a multidisciplinary team to offer specialised support and care for affected families.
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Affiliation(s)
- Cornelia Wiechers
- Department of Neonatology, Tuebingen University Hospital, Tuebingen, Germany.,Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany
| | - Tabea Thjen
- Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany.,Physical Therapy Centre, Tuebingen University Hospital, Tuebingen, Germany
| | - Bernd Koos
- Department of Orthodontics, University of Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Siegmar Reinert
- Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany.,Department of Craniofacial Surgery, Tuebingen University Hospital, Tuebingen, Germany
| | - Christian F Poets
- Interdisciplinary Centre for Cleft Palate and Craniofacial Malformations, Tuebingen University Hospital, Tuebingen, Germany .,Department of Neonatology, University of Tuebingen, Tuebingen, Germany
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Shah HN, Jones RE, Borrelli MR, Robertson K, Salhotra A, Wan DC, Longaker MT. Craniofacial and Long Bone Development in the Context of Distraction Osteogenesis. Plast Reconstr Surg 2021; 147:54e-65e. [PMID: 33370054 PMCID: PMC7773036 DOI: 10.1097/prs.0000000000007451] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bone retains regenerative potential into adulthood, and surgeons harness this plasticity during distraction osteogenesis. The underlying biology governing bone development, repair, and regeneration is divergent between the craniofacial and appendicular skeleton. Each type of bone formation is characterized by unique molecular signaling and cellular behavior. Recent discoveries have elucidated the cellular and genetic processes underlying skeletal development and regeneration, providing an opportunity to couple biological and clinical knowledge to improve patient care. METHODS A comprehensive literature review of basic and clinical literature regarding craniofacial and long bone development, regeneration, and distraction osteogenesis was performed. RESULTS The current understanding in craniofacial and long bone development and regeneration is discussed, and clinical considerations for the respective distraction osteogenesis procedures are presented. CONCLUSIONS Distraction osteogenesis is a powerful tool to regenerate bone and thus address a number of craniofacial and appendicular skeletal deficiencies. The molecular mechanisms underlying bone regeneration, however, remain elusive. Recent work has determined that embryologic morphogen gradients constitute important signals during regeneration. In addition, striking discoveries have illuminated the cellular processes underlying mandibular regeneration during distraction osteogenesis, showing that skeletal stem cells reactivate embryologic neural crest transcriptomic processes to carry out bone formation during regeneration. Furthermore, innovative adjuvant therapies to complement distraction osteogenesis use biological processes active in embryogenesis and regeneration. Additional research is needed to further characterize the underlying cellular mechanisms responsible for improved bone formation through adjuvant therapies and the role skeletal stem cells play during regeneration.
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Affiliation(s)
- Harsh N. Shah
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ruth E. Jones
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mimi R. Borrelli
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kiana Robertson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Ankit Salhotra
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Derrick C. Wan
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael T. Longaker
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Dynamic orthognathic surgical procedure (DOSP) in asymmetric maxillomandibular dysmorphism secondary to unilateral micrognathia: Outcomes of 12 consecutive cases. J Craniomaxillofac Surg 2020; 49:75-83. [PMID: 33358117 DOI: 10.1016/j.jcms.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/18/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
This study aimed to evaluate the outcomes following a dynamic orthognathic surgical procedure performed at the end of growth to treat asymmetric maxillomandibular deformities linked to unilateral micrognathia when conventional orthognathic surgery was not feasible. The dynamic orthognathic surgical procedure (DOSP) combined concomitant mandibular distraction osteogenesis with contralateral poorly stabilized sagittal split osteotomy and Le Fort I osteotomy. Cephalometric studies were retrospectively conducted on pre- and postoperative lateral and frontal cephalographs, and maxillomandibular movements were calculated. Outcome scores were computed by both experts and laypersons based on photographic analyses. There was a significant postoperative increase in height of the micrognathic ramus in all patients (n = 12; p = 0.002). The angle between the occlusal cant and horizontal reference plane decreased significantly in all of the patients, as did the angle between the midline sagittal plane and mandibular tilt (p < 0.001). Postoperative outcome scores showed significant improvements in all cases, according to both expert and layperson groups. This procedure allows correction of maxillomandibular asymmetries linked to micrognathia. However, it cannot resolve all the factors participating in facial asymmetry, such as those originating in the oculo-auriculo-ventricular spectrum or complex tumor sequelae, and second-step procedures may be required.
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29
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Resnick CM, Caprio R, Evans F, Park R. Is Intensive Care Unit Admission Necessary After Removal of Mandibular Distraction Devices in Infants With Robin Sequence? Cleft Palate Craniofac J 2020; 58:306-312. [PMID: 32806928 DOI: 10.1177/1055665620949430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Intensive care unit (ICU) care is routinely required after the operation to initiate mandibular distraction osteogenesis (MDO) in infants with Robin sequence (RS). Many patients are also managed in the ICU after subsequent device removal. It is uncertain if ICU care, which is expensive and limited, is necessary after this second operation. The objective of this study was to evaluate the incidence of respiratory events following device removal. We hypothesized that respiratory events would be infrequent and non-ICU inpatient monitoring would be adequate. DESIGN This is a retrospective study of patients with RS from 2013 to 2018. PATIENTS Patients were included if they had MDO and distractor removal during the first year of life. Patients were excluded if they had a tracheostomy or remained intubated after distractor removal. MAIN OUTCOME MEASURE Postoperative respiratory events. RESULTS Twenty-five (60% male) patients were included. Mean age and weight at distractor removal were 142 ± 79 days of life and 5.5 ± 1.1 kg. Mean apnea-hypopnea index after completion of distraction was 1.1 ± 1.5 events/hour. Two (8%) patients experienced postoperative respiratory events that required intervention. In 1 (4% of sample) of these, the event was deemed to have benefited from ICU-level care. Two variables were significantly associated with these events: congenital heart disease (P = .020) and concomitant procedure performed during the same operation (P = .020). CONCLUSIONS Intensive care unit-level care is rarely needed after distractor removal in infants with RS. Intensive care unit admission should be considered in patients with congenital cardiac disease and when having multiple operations during the same anesthetic.
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Affiliation(s)
- Cory M Resnick
- Harvard School of Dental Medicine and Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Oral and Maxillofacial Surgeon, Boston Children's Hospital, Boston, MA, USA
| | | | - Faye Evans
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Raymond Park
- Harvard Medical School, Boston, MA, USA.,Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA
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Mandibular Distraction in Robin Sequence With Multi-Level Airway Disease: Always Contraindicated? J Craniofac Surg 2020; 31:1883-1887. [DOI: 10.1097/scs.0000000000006620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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31
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Kamath AT, Kudva A, Singh A. Bilateral temporomandibular joint reconstructions with stock alloplastic prostheses on a distracted mandible - A case report. Cranio 2020; 40:365-372. [PMID: 32407250 DOI: 10.1080/08869634.2020.1765600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: The management of patients with a triad of temporomandibular joint (TMJ) ankylosis, retrognathia, and obstructive sleep apnea (OSA) has long been a matter of debate. Even though consensus favors distraction osteogenesis (DO) in the 1st phase of treatment to relieve the OSA, various treatment approaches for TMJ reconstruction after ankylosis release have been put forth. Most of the reconstructive modality has been focused on autogenous materials or customized TMJ prostheses after mandibular distraction.Case Presentation: The authors present a case of a patient with the triad of TMJ ankylosis, retrognathia, and OSA who underwent DO for correction of his OSA. This was followed by bilateral TMJ reconstruction with stock alloplastic prostheses on the distracted mandible, along with genioplasty to correct retrogenia.Conclusion: In this case, stock TMJ total joint prostheses were used successfully to treat bilateral TMJ ankylosis following previous surgery for mandibular distraction.
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Affiliation(s)
- Abhay T Kamath
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Adarsh Kudva
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
| | - Anupam Singh
- Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education (MAHE), Manipal, India
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Leveling the Maxillary Occlusal Plane Without Orthodontic Appliances in Patients With Hemifacial Microsomia Using Unilateral Vertical Mandibular Distraction Osteogenesis. J Craniofac Surg 2020; 31:927-930. [PMID: 32310863 DOI: 10.1097/scs.0000000000006153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess maxillary occlusal plane correction in patients with hemifacial microsomia (HFM) after vertical vector mandibular distraction osteogenesis (vMDO) without orthodontic appliances. METHODS A retrospective study was performed on consecutive patients with HFM and Kaban-Pruzansky type-II mandibular deformities who underwent unilateral vMDO by a single surgeon over an 18-month period. Patients with 12-months minimum clinical follow-up and postero-anterior (PA) cephalograms taken preoperatively and at a minimum of 3 months post-consolidation were included. RESULTS Five patients met inclusion criteria, 3 were female, median age was 13 years, median distraction length was 21.3 mm. Median radiographic follow-up was 5 months (range 3-38) post-consolidation. Median correction of the ramus height differential (difference between non-diseased and diseased side) was 97.3%. Median maxillary height differential correction was 72.2%. Median maxillary occlusal plane angle correction (towards zero) was 84.2%. Relative and absolute maxillary bone growth was greater on the diseased side (median 7.4%, 3.5 mm versus 2.8%, 1.4 mm). Dentoalveolar height decreased bilaterally in 4 of the 5 patients. Median chin point correction (towards midline) was 31.4%. CONCLUSION Unilateral vMDO without orthodontic appliances effectively corrected mandibular ramus height, leveled the maxillary occlusal plane, and preferentially increased maxillary bone growth on the diseased side in patients with HFM.
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Temporomandibular Joint Ankylosis Following Mandibular Distraction Osteogenesis. J Craniofac Surg 2020; 31:222-225. [DOI: 10.1097/scs.0000000000005911] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hopkins B, Dean K, Appachi S, Drake AF. Craniofacial Interventions in Children. Otolaryngol Clin North Am 2019; 52:903-922. [PMID: 31353139 DOI: 10.1016/j.otc.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Craniofacial interventions are common and the surgical options continue to grow. The issues encountered include micrognathia, macroglossia, midface hypoplasia, hearing loss, facial nerve palsy, hemifacial microsomia, and microtia. In addition, a unifying theme is complex upper airway obstruction. Throughout a child's life the focus of interventions may change from airway management to speech, hearing, and language optimization, and finally to decannulation and procedures aimed at social integration and self-esteem. Otolaryngologists play an important role is this arena and provide high-quality care while continuing to expand what can be done for our patients.
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Affiliation(s)
- Brandon Hopkins
- Pediatric Otolaryngology, Pediatric Center for Airway Voice and Swallowing, Cleveland Clinic, 9500 Euclid Avenue, 7th Floor Crile Building, Cleveland, OH 44195, USA.
| | - Kelly Dean
- Department of Otolaryngology/Head and Neck Surgery, UNC Hospitals, University of North Carolina, 170 Manning Drive, CB# 7070, Chapel Hill, NC 27599-7070, USA
| | - Swathi Appachi
- Cleveland Clinic Head and Neck Institute, Cleveland Clinic, 9500 Euclid Avenue, 7th Floor Crile Building, Cleveland, OH 44195, USA
| | - Amelia F Drake
- Department of Otolaryngology/Head and Neck Surgery, UNC Hospitals, Craniofacial Center, University of North Carolina, 170 Manning Drive, CB# 7070, Chapel Hill, NC 27599-7070, USA
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Kurian C, Ehsan Z. Sleep and respiratory outcomes in neonates with Pierre Robin sequence: a concise review. Sleep Breath 2019; 24:1-5. [DOI: 10.1007/s11325-019-01876-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/15/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
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Risk Factors for Perioperative Respiratory Failure following Mandibular Distraction Osteogenesis for Micrognathia. Plast Reconstr Surg 2019; 143:1725-1736. [DOI: 10.1097/prs.0000000000005651] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Denadai R, Raposo-Amaral CA, Raposo-Amaral CE. Fat Grafting in Managing Craniofacial Deformities. Plast Reconstr Surg 2019; 143:1447-1455. [PMID: 31033827 DOI: 10.1097/prs.0000000000005555] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The successful correction of craniofacial contour deformities remains a major challenge in plastic surgery. This article reviews important concepts and strategies for craniofacial fat grafting and presents a SOBRAPAR Hospital algorithm focused on achieving craniofacial contour symmetry as early as possible without compromising function. METHODS Principle-based methods (i.e., anatomical facial fat compartments, fluid accommodation model, multistage site-specific craniofacial fat grafting, and structural fat-grafting technique) were itemized into an algorithm to aid in planning and selecting the best surgical approach (i.e., bone and/or soft tissue procedures) in order to obtain craniofacial contour symmetry. RESULTS The treatment plan and choice of surgical technique implemented to address bone and/or or soft tissue deformities were determined by specific diagnosis, patient age at presentation, and functional status. Bony reconstruction in skeletally immature patients is reserved solely for those patients with functional issues. CONCLUSION By adopting principle-based methods and fat compartment theory, we are able to achieve craniofacial contour symmetry and aesthetically pleasing outcomes without compromising function.
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Affiliation(s)
- Rafael Denadai
- From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital
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Frid P, Resnick C, Abramowicz S, Stoustrup P, Nørholt SE. Surgical correction of dentofacial deformities in juvenile idiopathic arthritis: a systematic literature review. Int J Oral Maxillofac Surg 2019; 48:1032-1042. [PMID: 30704836 DOI: 10.1016/j.ijom.2019.01.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/19/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
The aim of this study was to assess current evidence for the surgical correction of dentofacial deformities in patients with temporomandibular joint (TMJ) involvement from juvenile idiopathic arthritis (JIA). A systematic literature review, according to the PRISMA guidelines, was conducted. Meta-analyses, randomized controlled trials, cohort studies, observational studies, and case reports were eligible for inclusion. Exclusion criteria were no JIA diagnosis, no clearly defined outcomes, dual publications (except meta-analyses), non peer-reviewed studies, non English language publications, and animal studies. The outcome measures assessed were TMJ function, skeletal alignment, and morbidity. The database search identified 255 citations, of which 28 met the eligibility criteria. Of these, 24 were case reports or case series with a low level of evidence that did not allow for meta-analysis. Extrapolated evidence supports orthognathic surgery in skeletally mature patients with controlled or quiescent JIA and a stable dentofacial deformity. Distraction osteogenesis was recommended for severe deformities. Some authors demonstrated unpredictable postoperative mandibular growth with costochondral grafts. Alloplastic TMJ reconstruction was efficacious, but should be used cautiously in skeletally immature patients. TMJ function and skeletal alignment was improved with reconstruction by any technique and morbidity was low. The surgical correction of arthritis-induced dentofacial deformities is indicated but the level of evidence is low. Prospective multicenter studies are needed.
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Affiliation(s)
- P Frid
- Department of Otorhinolaryngology, Division of Oral and Maxillofacial Surgery, University Hospital North Norway and Public Dental Service Competence Centre of North Norway and Department of Clinical Medicine, Faculty of Health Sciences, The Arctic University of Norway, Tromsø, Norway.
| | - C Resnick
- Harvard School of Dental Medicine and Harvard Medical School, Boston, MS, USA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MS, USA
| | - S Abramowicz
- Division of Oral and Maxillofacial Surgery, Department of Surgery, Emory University School of Medicine, and Section of Dentistry/Oral and Maxillofacial Surgery, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - P Stoustrup
- Section of Orthodontics, Department of Dentistry and Oral Health, Aarhus University, Aarhus, Denmark
| | - S E Nørholt
- Department of Oral and Maxillofacial Surgery, Aarhus University Hospital and Section of Oral Surgery and Oral Pathology, Aarhus University, Aarhus, Denmark
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Surgical Management and Outcomes of Pierre Robin Sequence: A Comparison of Mandibular Distraction Osteogenesis and Tongue-Lip Adhesion. Plast Reconstr Surg 2019; 142:480-509. [PMID: 29870511 DOI: 10.1097/prs.0000000000004581] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion achieved full oral feeds at latest follow-up. The incidence of second intervention for recurrent obstruction ranged from 4 to 6 percent in mandibular distraction osteogenesis studies, compared to a range of 22 to 45 percent in tongue-lip adhesion studies. Variability of patient selection, surgical techniques, outcomes measurement methods, and follow-up length across studies precluded meta-analysis of the data. Both mandibular distraction osteogenesis and tongue-lip adhesion are effective alternatives to tracheostomy for patients who fail conservative management and improve feeding. Mandibular distraction osteogenesis may be superior to tongue-lip adhesion in long-term resolution of airway obstruction and avoidance of gastrostomy, but is associated with notable complications.
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Resnick CM, LeVine J, Calabrese CE, Padwa BL, Hansen A, Katwa U. Early Management of Infants With Robin Sequence: An International Survey and Algorithm. J Oral Maxillofac Surg 2019; 77:136-156. [DOI: 10.1016/j.joms.2018.05.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 10/14/2022]
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Early Mandibular Distraction in Craniofacial Microsomia and Need for Orthognathic Correction at Skeletal Maturity. Plast Reconstr Surg 2018; 142:1285-1293. [DOI: 10.1097/prs.0000000000004842] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
BACKGROUND The purposes of this study were to report autologous free fat grafting as the workhorse procedure to augment the facial soft-tissue envelope and restore facial contour symmetry of patients with asymmetric facial malformations; to detail the SOBRAPAR Hospital algorithm for soft-tissue reconstruction of patients with facial contour asymmetry; and to assess facial symmetry after fat grafting. METHODS A retrospective analysis of consecutive patients (n = 178) who underwent fat grafting to restore the facial contour symmetry according to the SOBRAPAR Hospital algorithm between 2009 and 2016 was conducted. Computerized photogrammetric quantitative and qualitative facial symmetry analyses were performed. RESULTS There were significant (all P < 0.05) postoperative quantitative facial symmetry enhancement and an overall qualitative facial symmetry enhancement, with a mean fat graft procedures per patient of 1.6 ± 0.7, ranging of 1 to 3. CONCLUSION A significant improvement of facial contour symmetry was obtained in a subset of patients using fat grafting according to the SOBRAPAR Hospital algorithm.
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Hammoudeh JA, Fahradyan A, Brady C, Tsuha M, Azadgoli B, Ward S, Urata MM. Predictors of Failure in Infant Mandibular Distraction Osteogenesis. J Oral Maxillofac Surg 2018; 76:1955-1965. [DOI: 10.1016/j.joms.2018.03.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/19/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022]
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Leung YY, Lai KKY. Management of obstructive sleep apnoea: an update on the role of distraction osteogenesis. Curr Opin Otolaryngol Head Neck Surg 2018; 26:214-220. [DOI: 10.1097/moo.0000000000000465] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Peacock ZS, Salcines A, Troulis MJ, Kaban LB. Long-Term Effects of Distraction Osteogenesis of the Mandible. J Oral Maxillofac Surg 2018; 76:1512-1523. [DOI: 10.1016/j.joms.2017.12.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 11/26/2022]
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Bi RY, Luo XT, Jiang N, Zhu SS, Li YF. Change in the posterior airway after mandibular distraction osteogenesis in patients with ankylosis of the temporomandibular joint: a retrospective study. Br J Oral Maxillofac Surg 2018; 56:525-530. [PMID: 29887252 DOI: 10.1016/j.bjoms.2018.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/17/2018] [Indexed: 02/05/2023]
Abstract
Mandibular distraction osteogenesis (DO) has been shown to lead to considerable improvement in obstruction of the posterior airway space in patients with ankylosis of the temporomandibular joint (TMJ), and our objective was to find out if we could confirm these findings. Seventeen patients had spiral computed tomographic (CT) scans before and after DO. After treatment, the overall posterior airway space was enlarged in all three sections of the airway (oropharyngeal, glossopharyngeal, and laryngeal). We then compared rates of change in the airway among the sections using 2-dimensional and 3-dimensional assessments, and found that the rate of change in 3-dimensional assessment of volume was significantly higher than that in the 2-dimensional (62% compared with 34%). We also found that the higher 3-dimensional rate of change came from changes in the oropharyngeal and glossopharyngeal sections, while there was no significant difference between the 2- and 3-dimensional rates of change in the laryngeal section. Because the laryngeal section had the most robust enlargement after DO in both the overall area of the posterior airway space (increased by 54%) and volume (increased by 73%), we concluded that 3-dimensional assessments were more sensitive to smaller changes in the airway space during the operation. This suggests that 3-dimensional assessments are preferable in the prediction and evaluation of the effects of DO on the posterior airway space.
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Affiliation(s)
- R Y Bi
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
| | - X T Luo
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
| | - N Jiang
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
| | - S S Zhu
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
| | - Y F Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Oral & Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China.
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Abstract
Kniest dysplasia is an extremely rare form of type II collagenopathy associated with cleft palate, micrognathia, shortened trunk, arms and legs, and club foot. The authors present a case of an infant with this disorder who also had micrognathia and respiratory distress for which mandibular distraction was performed. Although abnormal collagen and impaired endochondral ossification is noted with Kniest dysplasia, adequate bone formation was observed across the distraction gap. Nonetheless, despite stable mandibular advancement, failure to consider concomitant restrictive lung disease resulted in tracheostomy dependence. The authors demonstrate that while successful bone regeneration can be achieved through distraction of intramembranous facial bones, discretion must still be employed in patients with collagenopathies.
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da Costa AL, Manica D, Schweiger C, Kuhl G, Sekine L, Fagondes SC, Collares MV, Cauduro Marostica PJ. The effect of mandibular distraction osteogenesis on airway obstruction and polysomnographic parameters in children with Robin sequence. J Craniomaxillofac Surg 2018; 46:1343-1347. [PMID: 29861406 DOI: 10.1016/j.jcms.2018.05.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 04/16/2018] [Accepted: 05/11/2018] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION The optimal surgical technique for the management of patients with Robin Sequence (RS) has not been established. One of the most commonly used surgical techniques, mandibular distraction osteogenesis (MDO), is still controversial because of its potential risks and the lack of clear evidence of its efficacy. OBJECTIVES To assess variations in airway patency, clinical symptoms, and polysomnographic parameters in children with RS who underwent MDO. METHODS In this prospective cohort study, 38 patients with RS were evaluated before and after MDO. Symptom severity was classified using a grading scale for RS clinical manifestations. Patients underwent flexible fiberoptic laryngoscopy, and the images were classified by a blinded examiner using two validated grading scales for airway obstruction. Patients not requiring ventilatory support underwent a polysomnography. RESULTS Patients' symptoms significantly improved after MDO, as shown by a decreased score in the grading scale for RS clinical manifestations (preoperative score of 2.20 vs. postoperative score of 0.81; P < 0.001). The two endoscopic grading scales also showed a statistically significant postoperative improvement in airway obstruction (first scale: preoperative score of 1.56 vs. postoperative score of 0.92; second scale: preoperative score of 2.19 vs. postoperative score of 1.16; P < 0.001 for both). Moreover, there was a statistically significant variation in the following polysomnographic parameters evaluated pre- and postoperatively: apnea-hypopnea index, total sleep time, oxygen desaturation nadir, and oxygen desaturation index (P < 0.05). CONCLUSIONS MDO seems to be an effective surgical option for children, as shown by postoperative improvements in clinical symptoms, endoscopic grading scales, and polysomnographic parameters.
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Affiliation(s)
- Amanda Lucas da Costa
- Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, 90035-003, Porto Alegre, RS, Brazil; Otolaryngology Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, 90035-903, Porto Alegre, RS, Brazil.
| | - Denise Manica
- Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, 90035-003, Porto Alegre, RS, Brazil; Otolaryngology Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, 90035-903, Porto Alegre, RS, Brazil.
| | - Cláudia Schweiger
- Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, 90035-003, Porto Alegre, RS, Brazil; Otolaryngology Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, 90035-903, Porto Alegre, RS, Brazil.
| | - Gabriel Kuhl
- Otolaryngology Unit, Hospital de Clínicas de Porto Alegre (HCPA), Rua Ramiro Barcelos, 2350, 90035-903, Porto Alegre, RS, Brazil; Department of Ophthalmology and Otolaryngology, UFRGS, Rua Ramiro Barcelos, 2400, 90035-903, Porto Alegre, RS, Brazil.
| | - Leo Sekine
- Programa de Pós-Graduação em Epidemiologia, UFRGS, Rua Ramiro Barcelos, 2400, 90035-003, Porto Alegre, RS, Brazil.
| | | | | | - Paulo Jose Cauduro Marostica
- Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Universidade Federal do Rio Grande do Sul (UFRGS), Rua Ramiro Barcelos, 2400, 90035-003, Porto Alegre, RS, Brazil; Pediatric Pulmonology Unit, HCPA, Rua Ramiro Barcelos, 2350, 90035-903, Porto Alegre, RS, Brazil.
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Paediatric obstructive sleep apnoea: can our identification of surgical candidates be evidence-based? The Journal of Laryngology & Otology 2018; 132:284-292. [PMID: 29439747 DOI: 10.1017/s0022215118000208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Paediatric obstructive sleep apnoea is a common clinical condition managed by most ENT clinicians. However, despite the plethora of publications on the subject, there is wide variability, in the literature and in practice, on key aspects such as diagnostic criteria, the impact of co-morbidities and the indications for surgical correction. METHODS A systematic review is presented, addressing four key questions from the available literature: (1) what is the evidence base for any definition of paediatric obstructive sleep apnoea?; (2) does it cause serious systemic illness?; (3) what co-morbidities influence the severity of paediatric obstructive sleep apnoea?; and (4) is there a medical answer? RESULTS AND CONCLUSION There is a considerable lack of evidence regarding most of these fundamental questions. Notably, screening measures show low specificity and can be insensitive to mild obstructive sleep apnoea. There is a surprising lack of clarity in the definition (let alone estimate of severity) of sleep-disordered breathing, relying on what may be arbitrary test thresholds. Areas of potential research might include investigation of the mechanisms through which obstructive sleep apnoea causes co-morbidities, whether neurocognitive, behavioural, metabolic or cardiovascular, and the role of non-surgical management.
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