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

Bioresorbable distraction device for the treatment of airway problems for infants with Robin sequence

Pierre Robin sequence is a well known craniofacial entity. There are numerous ways to treat the respiratory insufficiency, but sometimes surgical intervention is needed. Tracheotomy could be associated with morbidity, and distraction osteogenesis has been established as a stable method to obtain a safe airway. Distraction osteogenesis has traditionally been performed with an external device. In this manuscript we describe the feasibility of an internal bioresorbable device. Retrospective descriptive study was performed in a tertiary academic children’s hospital. After multidisciplinary team consultation, 12 consecutive patients with Robin sequence were treated with this internal distraction device. The mean age at surgery was 32 days, and the average amount of mandibular distraction was 18 mm. All patients were extubated after an average of 7.5 days after the surgery. The average length of stay in the hospital was 17 days after surgery. There were no major surgical complications. A tracheotomy was prevented in all our patients, and complications were limited. Long-term studies are needed to evaluate the influence that internal distraction has on the growth of the mandible and teeth. The internal distraction system seems safe for infants with micrognathia and has certain benefits when compared to the external distractor.

A clinical narrative review of mandibular distraction osteogenesis in neonates with Pierre Robin sequence

INTRODUCTION

Neonatal upper airway obstruction secondary to micrognathia can be managed with conservative or surgical interventions. Traditionally, severe upper airway obstruction was managed with a tracheostomy. Although tracheostomy may be life saving, it is associated with high rates of complications and can lead to developmental problems. More recently, mandibular distraction osteogenesis has been utilized to relieve micrognathia associated airway obstruction.

METHODS

A clinical narrative review of the current literature was performed to evaluate the efficacy of mandibular distraction osteogenesis in neonates with Pierre Robin sequence.

OBJECTIVES

(1) To evaluate whether mandibular distraction osteogenesis can relieve the upper airway obstruction in micrognathic neonates and (2) to discuss and increase the awareness of various issues surrounding neonatal mandibular distraction procedures including preoperative workup, distraction protocols, and complications.

RESULTS

Mandibular distraction osteogenesis can be a safe and effective intervention in neonates diagnosed with Pierre Robin sequence with severe micrognathia and airway obstruction. Interestingly, in patients with additional complex syndromes, the airway obstruction was not consistently alleviated.

CONCLUSION

When conservative measures fail, mandibular distraction osteogenesis should be considered to obviate the need for a tracheostomy in newborns with micrognathia associated upper airway obstruction.

Treatment of childhood obstructive sleep apnea

OPINION STATEMENT

An array of surgical, medical and orthodontic treatments is available for treating childhood obstructive sleep apnea. Adenotonsillectomy remains the first choice in treatment, with a need for subsequent clinical and polysomnographic reassessment in selected cases to determine residual sleep-disordered breathing. Residual obstructive sleep apnea is more likely in patients with craniofacial abnormalities or obesity. It may require the use of a positive airway pressure breathing device. Topical corticosteroids, leukotriene antagonists, weight reduction, and positional therapy also play a role in ameliorating childhood obstructive sleep apnea. The published evidence for the efficacy of various treatment modalities consists largely of case-controlled studies and case reports.

Robin sequence: from diagnosis to development of an effective management plan

The triad of micrognathia, glossoptosis, and resultant airway obstruction is known as Robin sequence (RS). Although RS is a well-recognized clinical entity, there is wide variability in the diagnosis and care of children born with RS. Systematic evaluations of treatments and clinical outcomes for children with RS are lacking despite the advances in clinical care over the past 20 years. We explore the pathogenesis, developmental and genetic models, morphology, and syndromes and malformations associated with RS. Current classification systems for RS do not account for the heterogeneity among infants with RS, and they do not allow for prediction of the optimal management course for an individual child. Although upper airway obstruction for some infants with RS can be treated adequately with positioning, other children may require a tracheostomy. Care must be customized for each patient with RS, and health care providers must understand the anatomy and mechanism of airway obstruction to develop an individualized treatment plan to improve breathing and achieve optimal growth and development. In this article we provide a comprehensive overview of evaluation strategies and therapeutic options for children born with RS. We also propose a conceptual treatment protocol to guide the provider who is caring for a child with RS.

Mandibular distraction using bone morphogenic protein and rapid distraction in neonates with Pierre Robin syndrome

INTRODUCTION

Mandibular distraction is recognized as a treatment of respiratory distress in neonates with microretrognathia as seen in the Pierre Robin syndrome. However, mandibular distraction is a complex and lengthy treatment involving 2 to 4 weeks of distraction and another 4 to 12 weeks for bone consolidation. This study was performed to establish the safety and effectiveness of rapid protocol distraction osteogenesis with recombinant human bone morphogenetic protein 2 (rhBMP-2) in neonates with the Pierre Robin syndrome.

METHODS

A retrospective review of all patients treated in our department between February 2003 and February 2008 was performed. Three patients with the Pierre Robin syndrome who underwent distraction osteogenesis with rhBMP-2 were identified. Inpatient and outpatient charts were reviewed for time to completion of distraction, age at distraction, need for tracheostomy, and complications of the mandibular distraction.

RESULTS

Three patients (6 hemimandibles) with Pierre Robin syndrome underwent rapid protocol distraction with rhBMP-2. Mean age at initial distraction was 17.3 days. Mean time from device placement to removal was 89.3 days. The complication rate was 16%, with 1 case of nonunion that required subsequent operative intervention. No patient required tracheostomy.

CONCLUSIONS

Rapid protocol distraction with rhBMP-2 allows distraction of the hypoplastic mandible to class III occlusion during the initial operation and avoids the latency and distraction phases of standard mandibular distraction. This case series demonstrates the safety and effectiveness of rapid distraction in neonates with Pierre Robin syndrome. Larger studies and long-term follow-up are necessary; however, this study suggests that rapid protocol distraction with rhBMP-2 is effective in neonates with Pierre Robin syndrome.

Distraction osteogenesis of the mandible for airway obstruction in children: Long-term results

Objective: To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia.

Study Design: Case series with chart review.

Setting: Tertiary care children's hospital.

Subjects and Methods: The records of a pediatric otolaryngology practice and tertiary children's hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified.

Results: Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure.

Conclusion: Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.

Airway analysis: with bilateral distraction of the infant mandible

BACKGROUND

Mandibular distraction was proven to be a valuable tool for lengthening the hypoplastic mandible and relieving airway obstruction in infants. However, analysis of presurgical and postsurgical three-dimensional computed tomography and polysomnogram studies is lacking. The aim of this study was to describe the effect of distraction on the airway by evaluating the clinical, three-dimensional radiographic and polysomnogram studies before and after distraction.

METHODS

Seventeen infants with micrognathia who underwent internal curvilinear mandibular distraction from April 2005 through April 2008 at Lucile Packard Children's Hospital were included. Preoperative and postoperative computed tomography, polysomnograms, and feeding evaluations were obtained and compared after distraction.

RESULTS

The mean patient age before surgery was 105 days. All patients tolerated the distraction process with a mean mandibular advancement of 18.1 mm. One patient experienced a temporary marginal mandibular nerve palsy that resolved, and 1 postoperative wound infection was encountered. Preoperatively, the mean retroglossal oropharyngeal cross-sectional area was 41.53 mm. This was associated with a mean preoperative apnea-hypopnea index (AHI) of 10.57 and a minimum oxygen desaturation of 83%. After distraction, the mean airway increased to 127.77 mm. All patients had clinical improvement of their respiratory status; the mean postoperative AHI was 2.21, and the minimum oxygen desaturation was 90%. The result was a 209% cross-sectional airway increase. All patients progressed to oral feeds by 3.5 months postoperatively.

CONCLUSIONS

Mandibular distraction is effective at relieving anatomic airway obstruction in infants with micrognathia and obstructive sleep apnea while avoiding some previously reported associated complications.

No evidence for long-term effectiveness of early osteodistraction in hemifacial microsomia

BACKGROUND

The authors performed a critical literature review to find evidence of the long-term stability after early distraction osteogenesis of the mandible in patients with hemifacial microsomia.

METHODS

The PubMed, Cochrane, MEDLINE, EMBASE, CENTRAL, and CINAHL databases were searched systematically for studies performed between 2002 and 2008. Abstracts from the 89 relevant articles were reviewed for evidence.

RESULTS

Thirteen articles met the inclusion criteria. Data were tabulated with respect to the length of follow-up, number of patients, age group, Pruzansky-Kaban classification of the patients, methods of analysis and validation, and level of evidence. Methods for long-term follow-up studies were not standardized, and no objective studies have been published on stability after growth cessation.

CONCLUSIONS

Thus far, no randomized controlled trials on early distraction osteogenesis in hemifacial microsomia patients have been published. The authors conclude that there is a lack of statistical evidence to support the use of early distraction osteogenesis for correcting hemifacial microsomia as a single treatment modality. The results call into question its rationale.

Current practice of distraction osteogenesis for craniofacial anomalies in Europe: a web based survey

Aim of the study was to get more insight into the opinion of European surgeons and orthodontists on the use of distraction osteogenesis (DO) for patients with different diagnoses and treatment protocols. A web based survey was set up, showing records of four patients with different conditions: hemifacial microsomia (case 1), bilateral mandibular deficiency (case 2), cleft lip and palate (case 3) and Crouzon syndrome (case 4). Respondents from 181 Eurocleft centres were asked to fill out a questionnaire for each patient. Most of the respondents considered case 1 (80%), case 3 (81%) and case 4 (86%) suitable for DO, while only 31% were considering case 2 for DO. There was lack of consensus among the respondents about many aspects of DO. Out of six different treatment parameters, an acceptable degree of agreement was only seen in two: a latency period of 3-7 days and a distraction rate of 1mm per day. Furthermore, there was noticeable disagreement on the ideal age for treatment, surgical technique, distraction device, and retention period. Our results showed that there is a wide variety in treatment approaches for craniofacial anomalies in Europe. There is disagreement on essential steps in the distraction procedures.

Treatment alternatives for sleep-disordered breathing in the pediatric population

PURPOSE FOR REVIEW: Childhood sleep-disordered breathing (SDB) is associated with a myriad of health problems that underscore the need for early diagnosis and treatment. Children with SDB present with behavior problems, deficits of general intelligence, learning and memory deficits, evidence of brain neuronal injury, increased cardiovascular risk, and poor quality of life. Children are in a rapid state of cognitive development; therefore, alterations of health and brain function associated with SDB could permanently alter a child's social and economic potential, especially if the disorder is not recognized early in life or is treated inadequately.

RECENT FINDINGS

There is evidence that the majority of the problems associated with SDB improve with treatment. Treatment strategies are now being aimed at mechanisms underlying the disorder. There are multiple treatment options available to children; some are novel, with pending treatments on the horizon that may replace age-old therapies such as adenotonsillectomy or nasal positive pressure.

SUMMARY

It is imperative that healthcare workers actively seek out signs and symptoms of SDB in patients to improve early detection and treatment for prevention of long-term morbidity.