Necessity of latency period in craniofacial distraction: Investigations with in vitro microdistractor and clinical outcomes

Mandibular Distraction in Patients With Pierre Robin Sequence: A Multisurgeon Experience

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.

Latency phase in mandibular distraction osteogenesis: a systematic review in animal models

The aim of the present study was to perform a systematic review of the need for the latency period in distraction osteogenesis to obtain adequate bone formation. Searches were performed in the Web of Science, Pubmed/MEDLINE, Scopus, and Cochrane electronic databases. Nine articles were selected for qualitative analysis. Quality assessment was performed using the 10-item SYRCLE tool. Clinical stability was evaluated in two articles, histology was analysed in seven, histomorphometry was analysed in three, and mechanical testing was used in two. The results favoured the five-day latency group in two studies and the seven-day latency group in one. No differences were found between latency and no-latency groups in six studies. A latency period greater than seven days did not provide any additional benefit. Important risks of bias were found in all articles. Some of the results were influenced by uncontrolled intervening factors, such as consolidation time. The need for a latency period for distraction osteogenesis in animal models is not yet clear. Caution must be exercised when extrapolating the results of animal protocols to applications with humans in the clinical setting.

Current Trends in Surgical Airway Management of Neonates with Robin Sequence

Background

Robin sequence is defined by the clinical triad of micrognathia, glossoptosis, and upper airway obstruction, and is frequently associated with cleft palate and failure to thrive. Though the efficacy of certain surgical interventions to relieve airway obstruction has been well established, algorithms dictating decision making and perioperative protocols are poorly defined.

Methods

A 22-question survey was sent via e-mail to members of the American Cleft Palate-Craniofacial Association and International Society of Craniofacial Surgeons. Questions were related to surgeon experience in treating neonates with Robin sequence, and specific perioperative protocols.

Results

One hundred fifty-one responses were collected. Most respondents were surgeons practicing in North America(82.8%), in a university hospital setting (81.5%) and had completed a fellowship in pediatric plastic surgery or craniofacial surgery (76.2%). Preoperative protocols varied widely by years in training and location of practice. Although 78.8% of respondents always performed direct laryngoscopy, only 49.7% of respondents routinely obtained preoperative polysomnography. Mandibular distraction osteogenesis was the most common primary surgical airway intervention reported by 74.2%, with only 12.6% primarily utilizing tongue-lip adhesion. Slightly less than half of respondents ever performed tongue-lip adhesion. Operative selection was influenced by surgeon experience, with 80% of those in practice 0-5 years primarily utilizing mandibular distraction, compared with 56% of respondents in practice >15 years.

Conclusions

This study documents wide variations in preoperative, operative, and postoperative protocols for the surgical airway management of neonates with severe Robin sequence. These results underscore the need to acquire more objective data, to compare different protocols and outcome measures.