Meta-analysis of mandibular distraction osteogenesis: clinical applications and functional outcomes

ERS statement on obstructive sleep disordered breathing in 1- to 23-month-old children

The present statement was produced by a European Respiratory Society Task Force to summarise the evidence and current practice on the diagnosis and management of obstructive sleep disordered breathing (SDB) in children aged 1-23 months. A systematic literature search was completed and 159 articles were summarised to answer clinically relevant questions. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are identified. Morbidity (pulmonary hypertension, growth delay, behavioural problems) and coexisting conditions (feeding difficulties, recurrent otitis media) may be present. SDB severity is measured objectively, preferably by polysomnography, or alternatively polygraphy or nocturnal oximetry. Children with apparent upper airway obstruction during wakefulness, those with abnormal sleep study in combination with SDB symptoms (e.g. snoring) and/or conditions predisposing to SDB (e.g. mandibular hypoplasia) as well as children with SDB and complex conditions (e.g. Down syndrome, Prader-Willi syndrome) will benefit from treatment. Adenotonsillectomy and continuous positive airway pressure are the most frequently used treatment measures along with interventions targeting specific conditions (e.g. supraglottoplasty for laryngomalacia or nasopharyngeal airway for mandibular hypoplasia). Hence, obstructive SDB in children aged 1-23 months is a multifactorial disorder that requires objective assessment and treatment of all underlying abnormalities that contribute to upper airway obstruction during sleep.

Pediatric Obstructive Sleep Apnea: Consensus, Controversy, and Craniofacial Considerations

Pediatric obstructive sleep apnea, characterized by partial or complete obstruction of the upper airway during sleep, is associated with multiple adverse neurodevelopmental and cardiometabolic consequences. It is common in healthy children and occurs with a higher incidence among infants and children with craniofacial anomalies. Although soft-tissue hypertrophy is the most common cause, interplay between soft tissue and bone structure in children with craniofacial differences may also contribute to upper airway obstruction. Snoring and work of breathing are poor predictors of obstructive sleep apnea, and the gold standard for diagnosis is overnight polysomnography. Most healthy children respond favorably to adenotonsillectomy as first-line treatment, but 20 percent of children have obstructive sleep apnea refractory to adenotonsillectomy and may benefit from positive airway pressure, medical therapy, orthodontics, craniofacial surgery, or combined interventions. For children with impairment of facial skeletal growth or craniofacial anomalies, rapid maxillary expansion, midface distraction, and mandibular distraction have all been demonstrated to have therapeutic value and may significantly improve a child's respiratory status. This Special Topic article reviews current theories regarding the underlying pathophysiology of pediatric sleep apnea, summarizes standards for diagnosis and management, and discusses treatments in need of further investigation, including orthodontic and craniofacial interventions. To provide an overview of the spectrum of disease and treatment options available, a deliberately broad approach is taken that incorporates data for both healthy children and children with craniofacial anomalies.

Obstructive sleep apnoea in craniofacial microsomia: analysis of 755 patients

A retrospective cohort study was set up to analyse the prevalence and treatment of obstructive sleep apnoea (OSA) in relation to the severity of the deformity in patients with craniofacial microsomia (CFM). This study included a population of 755 patients with CFM from three craniofacial centres. Medical charts were reviewed for severity of the deformity, types of breathing difficulty, age at which breathing difficulty first presented, treatment for OSA, and treatment outcome. In total, 133 patients (17.6%) were diagnosed with OSA. Patients with Pruzansky IIB/III classification or bilateral craniofacial microsomia were significantly more often diagnosed with OSA than unilaterally affected patients of Pruzansky I/IIA classification. The initial treatment of OSA consisted of adenotonsillectomy, tracheotomy, or non-invasive positive pressure ventilation. Thirty-seven patients received more than one treatment (range 1-3). In this study, the prevalence of OSA in patients with CFM was higher than the prevalence in the healthy population described in the literature. Although several treatment modalities are available for the treatment of OSA in patients with CFM, treatment should be individualized and based on clinical symptoms, the severity of the deformity, and comorbidities.

Simultaneous maxillomandibular distraction osteogenesis in hemifacial microsomia: Report of 7 cases

INTRODUCTION

The goal in treating Hemifacial microsomia (HFM) is to improve facial symmetry, allow functional jaw movement, obtain stable occlusion, and achieve patient satisfaction. This study was planned with an aim to assess the outcome of simultaneous maxillomandibular distraction osteogenesis in hemifacial microsomia.

MATERIAL & METHODS

Seven patients with hemifacial microsomia were included in this study and demographic data was obtained. Simultaneous maxillo-mandibular distraction was planned for correction of maxillary cant, vertical ramal lengthening and midline, by performing unilateral mandibular osteotomy in ramus and distractor fixation, a Le Fort I osteotomy, with fixation at contralateral zygomatic buttress and intermaxillary elastics. Derriford Appearance Scale was used to measure individual responses to address problems of appearance.

RESULTS

6 males and 1 female, with age range 18-26 years, mean 22.14 were included in the study. Maxillary occlusal cant varied from 4-16°, mean 9.85° and distraction achieved ranged from 12-19 mm, mean 15.57. Preoperatively DAS score ranged from 42-61, mean 51.7 and improved to 10-27, mean 18.4. 100% success was achieved in 5 cases, while other two showed 96% and 99% success.

CONCLUSION

Simultaneous maxillomandibular distraction osteogenesis improves facial esthetics and obviates the need for postoperative orthodontics, minimizing the treatment period.

Robin sequence: what the multidisciplinary approach can do

Robin sequence (RS) is a commonly encountered triad of micrognathia, glossoptosis, and airway obstruction, with or without a cleft palate. The management of airway obstruction is of paramount importance, and multiple reviews and retrospective series outline the diagnosis and treatment of RS. This article focuses on the multidisciplinary nature of RS and the specialists’ contributions and thought processes regarding the management of the RS child from birth to skeletal maturity. This review demonstrates that the care of these children extends far beyond the acute airway obstruction and that thorough monitoring and appropriate intervention are required to help them achieve optimal outcomes.

The role of curvilinear distraction system in pediatric obstructive sleep apnea: A case report

OBJECTIVE

The authors present a case of obstructive sleep apnea associated with severe mandibular micrognathia treated by mandibular bone distraction with curvilinear system planned under computer assistance.

CLINICAL PRESENTATION

A 15-year-old child with limited compliance to continuous positive airway therapy was referred to the authors' department. Observation revealed severe mandibular micrognathia as the major cause for obstructive sleep apnea syndrome. The first polysomnography study revealed 14 obstructive apneas, 16 obstructive hypopneas, and 4.6/h apnea-hypopnea index.

CONCLUSION

Mandibular distraction osteogenesis can be a successful technique in alleviating upper airway obstruction secondary to micrognathia, while also improving the patient's appearance. Surgical planning under computer assistance is a useful tool to predict bone movements, and curvilinear distraction could be considered valuable in mandibular distraction.

Neonatal Micrognathia: National Trends in Early Mandibular Surgery

BACKGROUND

Micrognathia is a congenital anomaly that may pose breathing and feeding limitations in newborns, sometimes necessitating invasive management. The present study aims to identify the complications associated with receiving mandibular surgery during the birth stay in order to better predict which patients may benefit from early surgical intervention.

METHODS

A retrospective cohort study was performed using the 2000 to 2012 kids' inpatient databases. We included all live newborn infants born in the hospital through vaginal delivery or caesarean section. We used multivariate logistic regression to investigate the demographic and clinical factors associated with receiving mandibular surgery for micrognathia during the birth stay.

RESULTS

Of 19,638,453 births, 999 were diagnosed with micrognathia (0.005%). Forty (4%) patients with micrognathia underwent mandibular surgery during the initial admission. On univariate analysis in newborns with micrognathia, mandibular surgery during birth stay was associated with cleft palate, apnea, intubation, tracheostomy, obstructive sleep apnea (OSA), and long mechanical ventilation. Multivariate analysis supported the association between mandibular surgery during the initial admission and long mechanical ventilation (odds ratio [OR], 24.6; 95% confidence interval [CI], 7.7-78.5), OSA (OR, 24.9; 95% CI, 2.5-261.8), apnea (OR, 4.2; 95% CI, 1.5-11.3), and cleft palate (OR, 4.6; 95% CI, 2.0-10.6). However, intubation and tracheostomy were not found to be associated with early mandibular surgery during the birth stay.

CONCLUSIONS

The present study identified long mechanical ventilation, apnea, cleft palate, and OSA as factors indicating patients who may benefit from early mandibular surgery, such as mandibular distraction osteogenesis. These findings may bring the clinician closer to standardizing the indications for early mandibular distraction osteogenesis.

Isolated Autologous Free Fat Grafting for Management of Facial Contour Asymmetry in a Subset of Growing Patients With Craniofacial Microsomia

BACKGROUND

To report autologous free fat grafting as an isolated procedure to manage facial contour asymmetry of a subset of growing patients with craniofacial microsomia (CFM).

METHODS

A retrospective analysis of CFM patients (n = 11) with low socioeconomic and intellectual status, poor oral hygiene, living far from our center, Pruzansky-Kaban I/II mandibles, without functional concerns, and with no craniofacial skeletal surgery who underwent isolated free fat grafting between 2012 and 2013 was conducted. Surgeon and parent/patient satisfaction were elicited. Computerized photogrammetric quantitative and qualitative facial symmetry analyses were performed.

RESULTS

All patients underwent isolated autologous free fat grafting to restore the facial contour symmetry. Surgeon and patient/parent were mostly satisfied. There were significant (all P < 0.05) postoperative quantitative facial symmetry enhancement and an overall qualitative facial symmetry enhancement.

CONCLUSIONS

A significant improvement of facial symmetry was obtained in this subset of growing CFM patients using only isolated free fat grafting.

Infant Mandibular Distraction for Upper Airway Obstruction: A Clinical Audit

Background:

Mandibular distraction osteogenesis (MDO) is an effective method of treating upper airway obstruction (UAO) in micrognathic infants. The short-term outcomes include relief of UAO, avoidance of tracheostomy, and prompt discharge from hospital. However, it is a significant surgical procedure with potential associated morbidities. This study describes a cohort of infants managed using MDO over a twelve-year period.

Methods:

A retrospective chart review was undertaken for children who had MDO before the age of 5 years between 2000 and 2012. This was followed by a clinical review of the same cohort specifically looking for dental anomalies, nerve injuries, and scar cosmesis.

Results:

Seventy-three children underwent MDO at a mean age of 2 months [interquartile range (IQR), 1.7–4.2] for nonsyndromic infants and 3.3 months (IQR, 2.1–7.4) for those with syndromes. Infants were discharged from hospital, on average, 15 days after procedure. After MDO, of the 9 who were previously tracheostomy dependent, 5 (56%) were decannulated within 12 months and none of the nontracheostomy-dependent children required further airway assistance. The majority of children required supplemental feeding preoperatively but, 12 months postoperatively, 97% of the nonsyndromic infants fed orally. Thirty-nine children (53%) were reviewed clinically [median age, 5.1 y (IQR, 3.9–6.5)] with 18 being syndromic. Many of the mandibular first permanent and second primary molars had developmental defects, but there was a low rate of neurosensory deficit and good scar cosmesis.

Conclusions:

This study contributes further to the evidence base underpinning the management of micrognathic infants with UAO.

Glossoptosis

Glossoptosis causes varying degrees of airway obstruction and feeding difficulties. It can occur as a consequence of micrognathia in Robin Sequence, but can also occur in children with hypotonia. Despite several attempts to classify severity in Robin Sequence patients, taking into account symptoms, presence of concomitant syndromes or malformations, and even endoscopic findings, there is still no general consensus. Furthermore, several management recommendations have been reported without an agreement about indications, efficacy, or risks of each treatment option. The present article provides an overview of clinical presentation, diagnosis, management, and prognosis of patients with glossoptosis.

Craniofacial syndromes and sleep-related breathing disorders

Children with craniofacial syndromes are at risk of sleep disordered breathing, the most common being obstructive sleep apnea. Midface hypoplasia in children with craniosynostosis and glossoptosis in children with Pierre Robin syndrome are well recognized risk factors, but the etiology is often multifactorial and many children have multilevel airway obstruction. We examine the published evidence and explore the current management strategies in these complex patients. Some treatment modalities are similar to those used in otherwise healthy children such as adenotonsillectomy, positive pressure ventilation and in the refractory cases, tracheostomy. However, there are some distinct approaches such as nasopharyngeal airways, tongue lip adhesion, mandibular distraction osteogenesis in children with Pierre Robin sequence, and midface advancement in children with craniosynostoses. Clinicians should have a low threshold for referral for evaluation of sleep-disordered-breathing in these patients.

Mandibular distraction osteogenesis for the treatment of neonatal tongue-based airway obstruction

Early postnatal tracheostomy for airway compromise is associated with high morbidity and cost. In certain patients with tongue-base airway obstruction (TBAO), mandibular distraction osteogenesis may be preferred. We present a comprehensive analysis of surgical, airway, and cephalometric outcomes in a large series of neonatal patients with TBAO. A retrospective review was performed of patients with laryngoscopically proven TBAO who underwent mandibular distraction osteogenesis before 1 year of age at our institution. Demographic, operative, postoperative, polysomnographic, and radiographic data were analyzed with the appropriate statistical test. Between 2010 and 2013, 28 patients younger than 1 year underwent mandibular distraction for TBAO. Distraction was performed for documented TBAO and failure to thrive at an average age of 58 days (range, 11-312) days with distractor removal after an average of 90 days. Preoperative polysomnograms were obtained on 20 patients with an average apnea-hypopnea index of 39.3 ± 22.0/h; the apnea-hypopnea index on postoperative polysomnograms obtained after distraction completion was significantly reduced in all 14 patients in whom it was measured (mean, 3.0 ± 1.5/h; P < 0.0001). Twenty patients transitioned to oral feeding, and cephalometric and airway diameters were improved (P < 0.0001). Distraction was successful in all but 4 patients including all patients with GILLS scores of 2 or less and 66% of patients with GILLS scores of 3 or greater. Neonatal mandibular distraction is a powerful tool to treat critical obstructive apnea in patients with TBAO. Appropriate patient selection remains a challenge; however, mandibular distraction represents a compelling treatment modality.

Imaging neonates and children with Pierre Robin sequence before and after mandibular distraction osteogenesis: what the craniofacial surgeon wants to know

Pierre Robin sequence is characterized by micrognathia and glossoptosis causing upper airway obstruction. Mandibular distraction osteogenesis is a mandibular lengthening procedure performed in neonates and children with Pierre Robin sequence to alleviate airway compromise. This pictorial review demonstrates the role of imaging in the preoperative and postoperative assessment of these children. It is important for pediatric radiologists to know what information about the mandible and airway the craniofacial surgeon needs from preoperative imaging and to identify any complications these children may encounter after surgery.

Effectiveness of Tongue-lip Adhesion for Obstructive Sleep Apnea in Infants With Robin Sequence Measured by Polysomnography

OBJECTIVE

Tongue-lip adhesion (TLA) is commonly used to relieve obstructive sleep apnea (OSA) in infants with Robin sequence (RS), but few studies have evaluated its efficacy with objective measures. The purpose of this study was to measure TLA outcomes using polysomnography. Our hypothesis was that TLA relieves OSA in most infants.

METHODS

This is a retrospective study of infants with RS who underwent TLA from 2011 to 2014 and had at least a postoperative polysomnogram. Predictor variables included demographic and birth characteristics, surgeon, syndromic diagnosis, GILLS score, preoperative OSA severity, and clinical course. A successful outcome was defined as minimal OSA (apnea-hypopnea index score < 5) on postoperative polysomnogram and no need for additional airway intervention. Descriptive, bivariate, and regression statistics were computed, and statistical significance was set at P < .05.

RESULTS

Eighteen subjects who had TLA at a mean age of 28 ± 4.7 days were included. Thirteen (72.2%) had a confirmed or suspected syndrome, and the mean GILLS score was 3 ± 0.3. All parameters trended toward improvement from the preoperative to postoperative polysomnograms, and improvement in OSA severity, oxygen saturation nadir, and arousals per hour was statistically significant (P < .02). This effect was significant across categories of surgeon, syndrome, and GILLS score. Nine subjects (50%) met the criteria for a successful outcome. Bivariate and regression analyses did not demonstrate a significant relationship between success and any predictor variable.

CONCLUSIONS

TLA improved airway obstruction in all infants with RS but resolved OSA in only nine patients, and success was unpredictable.

Dental treatment for paediatric obstructive sleep apnea

Paediatric obstructive sleep apnea (OSA) is common and its prevalence is expected to increase due to the rise in childhood obesity. Recent research has shown that many children, both syndromic and non-syndromic, who exhibit mouth breathing as a result of upper airway obstruction, may also exhibit dentofacial anomalies. Although adenotonsillectomy and continuous positive airway pressure have been classically proposed as the primary treatment modalities for paediatric OSA, there are significant limitations to both therapies. Therefore newer treatment modalities are needed. Current research has focused on emerging dental treatment options for paediatric OSA, such as rapid maxillary expansion, oral appliances and distraction osteogenesis. However, there are few randomized trials assessing the effectiveness of these novel dental therapies for paediatric OSA, and hence further research is required to advance the field.

Effect of unilateral mandibular distraction osteogenesis on mandibular morphology in rabbits with antigen-induced temporomandibular joint arthritis

Aim was to evaluate effect of unilateral distraction osteogenesis (DO) on mandibular morphology in rabbits with antigen-induced arthritis in the temporomandibular joint (TMJ). Forty 8-week-old rabbits were divided into four groups. In groups A,C, arthritis was induced in the right TMJ. Groups A,B underwent DO. Group D served as control group. Cephalometric analysis of mandibular angle, mandibular ramus height, mandibular collum height, and total posterior mandibular height was done on CT-scans preoperatively (T0), after distraction (T1), and at euthanasia (T2). Two-factor ANOVA evaluated the effect of DO and antigen-induced arthritis. No effect of DO or arthritis was observed on mandibular angle or mandibular collum height. For T0-T1, DO increased mandibular ramus height 12.3% (95% CI 5.2-19.4%) in group B (P=0.001) and total posterior mandibular height 6.2% (95% CI 0.3-12.1%) in group A (P=0.04) and 10.0% (95% CI 4.3-15.7%) in group B (P=0.001). For T1-T2, no significant changes occurred in arthritic rabbits (group A). In conclusion, DO increased total posterior mandibular height in rabbits with arthritis. Postoperatively, no significant effect of DO was observed in rabbits with arthritis. Mandibular DO could be a viable treatment modality in patients with TMJ-arthritis.

Mandibular volumetric increase following distraction osteogenesis

INTRODUCTION

Mandibular distraction osteogenesis (MDO) for the treatment of Pierre Robin sequence (PRS) enables mandibular lengthening and improves airway and feeding function. It remains unknown how the post-distracted mandibular volume compares to a normal control population. The aim of this study was to analyze mandibular volume and symmetry following bilateral MDO and compare post-distraction measurements to a non-distracted, normal age- and sex-matched control cohort.

METHODS

Demographic information and three dimensional-computed tomographic (CT) images were obtained from normal control and distracted PRS patients. Mandibular volume and symmetry indices were calculated and results statistically analyzed. P values ≤0.05 were considered statistically significant.

RESULTS

24 CT scans and 48 hemimandibles were analyzed (8 control patients: mean age = 5.6 months, 3 females; 8 distracted patients: mean age pre-distraction = 1.8 months, mean age post-distraction = 5.3 months, 3 females). No complications were encountered in the distracted group. The mean pre- and post-distraction volume in the MDO group measured 7238.1 mm(3) and 15,360.6 mm(3), respectively (P = 0.0003) and the mean percent increase in mandibular volume following distraction was 113.3%. The mean symmetry index increased after distraction from 0.91 to 0.95 (P = 0.31). Matched normal control mandibles measured 13,488.6 mm(3) versus post-distraction mandibles at 15,360.6 mm(3) (P = 0.40). Normal control and post-distraction symmetry indices were 0.99 and 0.95, respectively (P = 0.68).

CONCLUSION

Distraction resulted in a significantly increased mandibular volume and an observed preservation in mandibular symmetry. Post-distraction volume was increased compared to normal controls but remained less symmetrical.

The effectiveness of mandibular distraction in improving airway obstruction in the pediatric population

BACKGROUND

Distraction osteogenesis is an effective technique for elongating the deficient mandible. The authors specifically evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia.

METHOD

A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included. Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, predistraction and postdistraction airway status, and complications.

RESULTS

Seventy-four articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1 months. The most common diagnoses were isolated Pierre Robin sequence (52.9 percent), syndromic Pierre Robin sequence (7 percent), and Treacher Collins syndrome (6.8 percent). Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 percent of cases. Success was defined as either decannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea symptoms. One hundred seventy-one (84.2 percent) of the 203 tracheostomy-dependent patients were successfully decannulated. Among the 181 patients with obstructive sleep apnea, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 percent. A 23.8 percent overall complication rate was noted. The mean follow-up time was 28.7 months.

CONCLUSION

In addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.

Neonatal mandibular distraction osteogenesis: converting virtual surgical planning into an operative reality

Mandibular distraction osteogenesis (DO) has become an accepted method to manage severe cases of micrognathia-induced airway obstruction in neonates. Current imaging used to plan these procedures aids in surgical planning, but offers only a rough guide for the operating room. To our knowledge the following report offers the first description of virtual surgery used to guide DO in the mandible of a neonate. The plan provided a valuable link between the simulated procedure and the actual operative steps. Such technology can serve an important role in DO and offers objective guidance in device selection, vector planning and operative guide positioning.

Pediatric sleep surgery

Adenotonsillectomy is the most common surgery performed for sleep disordered breathing with good outcomes. Children with obesity, craniofacial disorders, and neurologic impairment are at risk for persistent sleep apnea after adenotonsillectomy. Techniques exist to address obstructive lesions of the palate, tongue base, or craniofacial skeleton in children with persistent sleep apnea. Children with obstructive sleep apnea have a higher rate of peri-operative complications.

Tracheostomy versus mandibular distraction osteogenesis in infants with Robin sequence: a comparative cost analysis

Many treatments have been described for infants with Robin sequence and severe respiratory distress, but there have not been many comparative studies of outcome and cost-effectiveness. The aim of this study was to compare the cost and complications of two common interventions - mandibular distraction osteogenesis and tracheostomy. Nine patients with isolated Robin sequence (mandibular distraction osteogenesis, n=5, and tracheostomy, n=4) were included in the analyses. Predetermined costs and complications were obtained retrospectively from medical records and by questionnaires to the parents over a 12-month period. Overall direct costs (admission to hospital, diagnostics, surgery, and homecare) were 3 times higher for tracheostomy (€105.523 compared with €33.482, p=0.02). Overall indirect costs (absence from work) were almost 5 times higher (€2.543 compared with €543, p=0.02). There was a threefold increase in overall total cost/patient (both direct and indirect) for tracheostomy (€108.057 compared with 34.016, p=0.02) and 4 times more complications were encountered. This study shows that mandibular distraction osteogenesis in infants diagnosed with Robin sequence costs significantly less and results in fewer complications than tracheostomy, and this contributes to our current knowledge about the ideal approach for infants with Robin sequence and might provide a basis for institutional protocols in the future.

Incidence of concomitant airway anomalies when using the university of California, Los Angeles, protocol for neonatal mandibular distraction

BACKGROUND

In newborns with micrognathia and severe upper airway obstruction, understanding potential airway lesions is important for determining appropriate treatment: observation, mandibular distraction, or tracheostomy. When concomitant airway anomalies are present, mandibular distraction is often unsuccessful at alleviating causes of obstruction, mandating the need for tracheostomy. The first part of this study evaluates 10-year results using the University of California, Los Angeles, algorithm for surgical candidacy to identify patients who will benefit from neonatal mandibular distraction. The second part describes the concomitant airway abnormalities found at the time of diagnostic laryngoscopy/bronchoscopy and how these anomalies affect neonatal distraction candidacy of these patients.

METHODS

Newborns admitted to the neonatal intensive care unit with micrognathia and upper airway obstruction (n = 133) were subjected to a decision tree model protocol formulated by a multidisciplinary team at the University of California, Los Angeles, to decide on appropriate treatment. Concomitant airway abnormalities were recorded and outcomes were documented for the first 5 years of life.

RESULTS

Fifty-five percent of patients underwent internal mandibular distraction with 97 percent success. Home observation with a nasopharyngeal tube was chosen in 11 percent of patients, and 34 percent had tracheostomies. On endoscopic examination, 51.7 percent of the nondistracted patients had concomitant airway anomalies: laryngomalacia (53.3 percent), tracheal web (20.0 percent), vocal cord paralysis (13.3 percent), epiglottal collapse (6.7 percent), and infraglottal narrowing (6.7 percent).

CONCLUSIONS

For the management of neonatal upper airway obstruction with micrognathia, a decision tree algorithm is useful to determine candidates for mandibular distraction. Diagnostic laryngoscopy/bronchoscopy is an important component of this algorithm because a multitude of airway anomalies may be present.

CLINICAL QUESTION/LEVEL OF EVIDENCE

: Therapeutic, IV.

Mandibular distraction osteogenesis in the micrognathic neonate: a review for neonatologists and pediatricians

In the past, severe neonatal upper airway obstruction secondary to micrognathia was managed with a tracheostomy. Although effective, tracheostomy can cause many short-term and long-term complications. More recently, mandibular distraction osteogenesis (MDO) has become a well-accepted surgical option in treating micrognathic newborns. Overall, MDO has been reported to be an effective intervention in alleviating the micrognathia-associated airway compromise. Furthermore, it seems to be well tolerated and has supplanted the need for tracheostomy in many patients. Neonatologists and pediatricians commonly care for these children, and therefore an up-to-date clinical narrative review regarding MDO is presented to increase the awareness of this relatively new surgical option.

Impact of mandibular distraction osteogenesis on the oropharyngeal airway in adult patients with obstructive sleep apnea secondary to retroglossal airway obstruction

AIM

To evaluate the impact of mandibular advancement by distraction osteogenesis on the oropharyngeal airway in adult patients with retroglossal airway obstruction using two different techniques of mandibular distraction.

MATERIALS AND METHODS

13 adult patients with mandibular hypoplasia secondary to TMJ ankylosis with OSAS and radiographic, CT and polysomnographic evidence of OSAS were included in the study. MDO was performed (corpus distraction in 8 cases and morphometric distraction in 5 patients). Post-operatively the patients were followed up by radiographs, CT and polysomnography after 1 month and 6 months.

RESULTS

There was an increase in the linear dimension of mandible by 11.07 mm, the volume by 19.3% and a decrease in AHI from 44.8 to 13.2.

CONCLUSION

Mandibular distraction (corpus and orthomorphic-equivocal results) is an effective method of relieving the retroglossal airway obstruction in adult patients with OSAS.

Regenerative strategies for craniofacial disorders

Craniofacial disorders present markedly complicated problems in reconstruction because of the complex interactions of the multiple, simultaneously affected tissues. Regenerative medicine holds promise for new strategies to improve treatment of these disorders. This review addresses current areas of unmet need in craniofacial reconstruction and emphasizes how craniofacial tissues differ from their analogs elsewhere in the body. We present a problem-based approach to illustrate current treatment strategies for various craniofacial disorders, to highlight areas of need, and to suggest regenerative strategies for craniofacial bone, fat, muscle, nerve, and skin. For some tissues, current approaches offer excellent reconstructive solutions using autologous tissue or prosthetic materials. Thus, new “regenerative” approaches would need to offer major advantages in order to be adopted. In other tissues, the unmet need is great, and we suggest the greatest regenerative need is for muscle, skin, and nerve. The advent of composite facial tissue transplantation and the development of regenerative medicine are each likely to add important new paradigms to our treatment of craniofacial disorders.

Functional changes following distraction osteogenesis treatment of asymmetric mandibular growth deviation in unilateral juvenile idiopathic arthritis: a prospective study with long-term follow-up

In juvenile idiopathic arthritis (JIA), temporomandibular joint involvement is a frequent complication leading to deficient mandibular growth. Occurring unilaterally this will give rise to mandibular and maxillary asymmetry that will affect the soft tissue and the muscles and result in complex dentofacial anomaly. In the case of severe dentofacial malformation, orthognathic surgery is the only treatment option. Vertical osseodistraction of the mandibular ramus has been suggested as a means of rectifying the mandibular growth deviation and soft-tissue problems. Whether such treatment introduces dysfunctional side effects of the temporomandibular joint and muscles has been debated and concern has been raised that treatment impairs the patient's mouth opening capacity and mandibular movement. The present study prospectively evaluated 23 patients with JIA and mandibular asymmetry caused by unilateral temporomandibular joint arthritis. The authors found a clinical effect on the asymmetry with only minor subjective complaints and limited objective changes in functional parameters.

Mandibular distraction osteogenesis in children with Pierre Robin sequence: impact on health-related quality of life

BACKGROUND

Upper airway obstruction in children with Pierre Robin sequence (PRS) may be severe enough to require surgical intervention. Although many studies have demonstrated the effectiveness of mandibular distraction osteogenesis (MDO) in relieving airway obstruction, no study has reported health-related quality of life (QOL) outcomes. The objective of the present study was to conduct the first health-related QOL assessment post-MDO.

METHODS

The Glasgow Children's Benefit Inventory (GCBI) questionnaire was distributed in a retrospective manner to the caregivers of all children who had undergone MDO at the authors' institutions between January 2007 and December 2010. Patients who had other major surgical procedures were excluded.

RESULTS

The response rate was 84% (21 of 25 questionnaires completed). The total mean GCBI score was +54 (SD, 19.5), which demonstrated a subjective overall benefit in health-related QOL post-MDO. All of the domains within the GCBI also scored in the positive range, indicating domain specific improvements in health-related QOL. There were no significant differences in the GCBI scores between syndromic-PRS patients and isolated PRS patients; similar results were observed between tracheostomy patients and no tracheostomy patients.

SUMMARY

In treating children with PRS and severe upper airway obstruction, MDO resulted in a subjective overall benefit in health-related QOL in our study population.

Feeding and mandibular distraction osteogenesis in children with Pierre Robin sequence: a case series of functional outcomes

INTRODUCTION

In addition to upper airway obstruction, many patients with micrognathia and Pierre Robin sequence also have swallowing abnormalities and reflux. Many studies have demonstrated the effectiveness in alleviating the airway symptoms with mandibular distraction osteogenesis, but very few studies have focused on feeding and reflux outcomes.

METHODS

A retrospective chart review was performed to identify patients with Pierre Robin sequence who underwent mandibular distraction osteogenesis with completed pre- and post-operative upper gastroesophageal series and videofluoroscopic swallow assessments.

RESULTS

All six children in our series demonstrated significant improvements in both airway obstructive symptoms and feeding abnormalities. More specifically, all patients showed clinical and objective improvements in reflux and swallowing function after distraction surgery.

CONCLUSION

Objective and symptomatic improvements in swallowing function and reflux disease can be seen after mandibular distraction osteogenesis in children with Pierre Robin sequence.

Mandibular distraction osteogenesis: at what age to proceed

OBJECTIVE

To evaluate if there is a difference in mandibular distraction osteogenesis (MDO) treatment success rates and adverse outcomes in newborns, early infants, and older pediatric patients.

DESIGN

Retrospective medical review spanning a nine-year period. Ten newborn (≤ 35 days old), five early infant (36 days-5 months) and eight older pediatric (> 5 months) patients underwent MDO for treatment of micrognathia with a severe tongue-based obstruction. Success was defined as avoidance of tracheostomy or CPAP, and decannulation of patients with tracheotomies. Postoperative complications were grouped into minor and major.

RESULTS

MDO successfully treated 90% of newborns, 100% of early infants and 100% of older pediatric patients. There was no difference in the rates of success (p=0.48), minor (p=1.00) and major (p=1.00) postoperative complications between newborns and early infants. Older pediatric patients had no treatment failures, tended to have fewer minor (p=0.18) and significantly fewer major (p= 0.04) postoperative complications compared to younger patients. The distractor pin mobility (9%) and scar revisions (13%) were uncommon.

CONCLUSIONS

Mandibular distraction osteogenesis is a reliable method for relieving severe tongue-based obstructions in pediatric patients. When comparing newborns and early infant patients, treatment success rates and the occurrence of complications were not found to be different. Older pediatric patients had no treatment failures, and tended to have fewer postoperative complications compared to younger patients.