Complications of mandibular distraction osteogenesis for developmental deformities: a systematic review of the literature

Distraction Osteotomy Combined With Orthodontics: An Effective Way to Decrease Short-term Recurrence in Treating Child Craniofacial Microsomia

BACKGROUND

This study aims to investigate strategies for reducing early relapse following mandibular distraction osteotomy (MDO) in craniofacial microsomia (CFM) patients.

METHODS

Forty CFM patients were divided into 2 groups: 20 underwent MDO alone, while 20 received MDO combined with orthodontic treatment (MDO-O). Preoperative, prefixation, and postfixation CT data in DICOM format were collected and reconstructed using Proplan software. Spatial geometric analysis was conducted to assess the inclination angle of the occlusal plane (OP), and OP deviation was directly measured using the software.

RESULTS

Patients in the MDO-O group demonstrated a statistically significant improvement in OP inclination at the end of the fixation period compared with those who underwent MDO alone (P=0.003).

CONCLUSIONS

Combining MDO with a bite plate and bite glue sticks in CFM patients during the mixed dentition period enhances OP outcomes, effectively reducing short-term recurrence.

Airway Management May Not Improve in Adult Patients With Pierre Robin Sequence: A Case Report

Infants with Pierre Robin sequence present with difficult airways due to their triad of micrognathia, glossoptosis, and cleft palate. This creates a difficult airway to intubate and ventilate. Typically, with various interventions and the growth of the mandible with age, the airway gets easier to manage into adulthood. Surgeries, such as coronoidectomy, have been found to ease the difficulty of intubation in pediatric patients, but the results are not always permanent. We present an adult with Pierre Robin sequence who continued to have a difficult airway, suggesting that airway management does not necessarily improve with age.

Helical distraction is superior to linear and circular distraction in mandibular distraction osteogenesis: an in silico study

Helical mandibular distraction is theoretically better than linear or circular distraction. However, it is not known whether this more complex treatment will result in unquestionably better outcomes. Therefore, the best attainable outcomes of mandibular distraction osteogenesis were evaluated in silico, given the constraints of linear, circular, and helical motion. This cross-sectional kinematic study included 30 patients with mandibular hypoplasia who had been treated with distraction, or to whom this treatment had been recommended. Demographic information and the computed tomography (CT) scans showing the baseline deformity were collected. The CT scans of each patient were segmented and three-dimensional models of the face created. Then, the ideal distraction outcomes were simulated. Next, the most favorable helical, circular, and linear distraction movements were calculated. Finally, errors were measured: misalignment of key mandibular landmarks, misalignment of the occlusion, and changes in intercondylar distance. Helical distraction produced trivial errors. In contrast, circular and linear distractions resulted in errors that were statistically and clinically significant. Helical distraction also preserved the planned intercondylar distance, while circular and linear distractions led to unwanted changes in the intercondylar distance. It is now evident that helical distraction offers a new strategy to improve the outcomes of mandibular distraction osteogenesis.

Comprehensive Long-Term Outcomes Following Mandibular Distraction Osteogenesis

OBJECTIVE

To describe long-term outcomes and complications following mandibular distraction osteogenesis (MDO) in a diverse patient cohort.

DESIGN

Cross-sectional study.

SETTING

Single tertiary-care pediatric center.

PATIENTS

Forty-eight patients previously undergoing MDO with minimum 4-year follow-up.

MAIN OUTCOME MEASURES

Respiratory outcomes, feeding patterns, dental development, motor/sensory nerve function, temporo-mandibular joint function, and postsurgical scarring.

RESULTS

Forty-six patients with a median age of 7 years were evaluated. Of 20 nonsyndromic patients, none required additional airway procedures, none required continuous positive airway pressure (CPAP) during sleep, and 19 (95%) fed exclusively by mouth. Among 26 syndromic patients, 7 (27%) required CPAP and 8 (31%) were tube fed. Permanent first molar differences were seen in the majority of subjects; patterns of damage interfering with function were more common in syndromic (13/28, 46%) compared to nonsyndromic (5/24, 21%; P = .014) subjects. MDO prior to age two was associated with more frequent and worse dental damage (P = .001). Inferior alveolar nerve and marginal mandibular nerve function were fully intact in 37 (80%) and 39 (85%) of patients, respectively. Three patients (6%), all with associated genetic syndromes, demonstrated severe nerve impairment. By the Vancouver scar scale, ≥ 80% of surgical scars were rated in the most favorable category for each quality assessed. Temporomandibular joint dysfunction was rare.

CONCLUSIONS

MDO shows highly favorable long-term respiratory, feeding, nerve, and scar outcomes in nonsyndromic patients, although permanent molar changes not precluding tooth viability are commonly seen. Patients with associated syndromes demonstrate respiratory and feeding benefits, but higher rates of dental and nerve abnormalities.

Orthognathic Surgery and Relapse: A Systematic Review

BACKGROUND

This review aimed to analyze the relapse in orthognathic surgery.

METHODS

PubMed, Scopus, and Web of Science databases were used to find papers that matched our topic dating from 1 January 2012 up to November 2022. Inclusion criteria were (1) human studies, (2) open access studies, (3) studies concerning the correlation between orthognathic surgery and relapse. Exclusion criteria were: (1) in vitro or animal studies, (2) off-topic studies, (3) reviews, (4) other languages than English.

RESULTS

A total of 482 results were obtained resulting in 323 publications after duplicate removal (158). After screening and eligibility phases 247 records were excluded: 47 reviews, 5 in animals, 35 in vitro, 180 off-topic. The authors successfully retrieved the remaining 78 papers and evaluated their eligibility. A total of 14 studies from these were ultimately included in the review.

CONCLUSION

Using cephalometric examinations and digital study models, these studies reveal that the relapse after orthognathic surgery is an event that occurs in most of the cases. The limitation of our research is that most of the studies are retrospective and use small sample sizes. A future research goal should be to conduct long-term clinical trials with larger numbers of samples.

Modified internal curvilinear distraction device with a pre-embedding guide rail, drive screw, and universal joint for curvilinear lengthening of the mandible: A finite element analysis and animal experiment

OBJECTIVES

The semiburied design of the traditional internal distractor has a relatively high risk of infection and aesthetic problems. To reduce these potential risks, a modified internal distractor with design of pre-embedding curvilinear rail, drive screw, and universal joint was invented. Its stress distribution characteristics and the effect on curvilinear distraction osteogenesis (DO) in vivo were further tested.

MATERIALS AND METHODS

Finite element analysis (FEA) was performed on a model of the human mandible and distraction device to measure the stress distribution during curvilinear DO. Six beagles underwent curvilinear DO and consolidation using the new device. Radiological and histological examinations were performed on the new bone.

RESULTS

On FEA, the stress was concentrated in the condyle (128.6 MPa) and curved guide rails (324.8 MPa). Four of the six animals completed the DO period and were consolidated for 12 weeks. Secondary infections were not observed. Radiography showed that a new fan-shaped bone-15.5 ± 5.5 mm in length and 4.6 ± 1.6 mm in height-was formed in the bone gap. Micro-computed tomography and histological examinations of specimens indicated that the structure of the new bone was similar to that of the normal bone.

CONCLUSIONS

The modified internal curvilinear distraction device meets the mechanical strength requirement and achieve curvilinear DO in animal experiments.

Treatment of severe mandibular deficiency following TMJ ankyloses by distraction osteogenesis and orthodontic treatment with microimplants

Severe mandibular deficiency caused by temporomandibular joint (TMJ) ankyloses produces functional and aesthetic problems that require complicated long-term treatment. In this case report, we describe the benefits of using microimplant mechanics for controlling the direction of distraction during distraction osteogenesis and for performing the movement of teeth. We also present its remarkable results and long-term stability. A 20-year-old girl presented with a convex profile due to severe mandibular retrognathia after a history of several TMJ surgeries for bilateral TMJ ankyloses. Mandibular distraction osteogenesis (MDO) was performed, and elastics were placed between the microimplants to control the direction of distraction. Subsequently, after retraction of the maxillary anterior teeth and distalisation of the whole mandibular dentition, the facial profile was markedly improved, and good interdigitation was obtained. The six-year follow-up retention and overall stability were satisfactory with good interdigitation and jaw function.

Device Malfunction Associated With Mandibular Distraction for Infants With Robin Sequence

INTRODUCTION

Mandibular distraction osteogenesis (MDO) effectively treats upper airway obstruction (UAO) in young patients with Robin sequence (RS). The most commonly used MDO devices have internal and external components that require manual activation. Although complications associated with MDO in infants with RS have been well documented, hardware/device malfunction has not been precisely described. The present study reports the authors' recent experiences with such problems, in an effort to shed light on these complications and identify potential steps to mitigate future related issues.

DESIGN

The authors reviewed a prospectively gathered database to identify all young children under the age of 3 years who underwent MDO using buried internal devices for UAO associated with grade 3 RS from March 2007 to September 2019. We specifically focused on complications attributable to the hardware itself.

RESULTS

Nineteen patients with 40 devices met inclusion criteria. The median age at MDO was 2.3 months (interquartile range 1.4-6.3 months). Intraoperative activation of all devices under direct vision resulted in satisfactory distraction. Four devices (10.5%) developed postoperative complications directly related to the device, including break down of component parts (N = 3) and failure to maintain distraction distance (N = 1). Two patients required surgical replacement of one device each, whereas the remaining complications occurred during the consolidation phase and did not require intervention.

CONCLUSIONS

This report documents a series of device/hardware malfunction in infants and young children undergoing MDO for severe UAO associated with RS. Despite rigorous testing and development, these devices may fail, resulting in patient morbidity.

[Dental complications of the mandibular distraction osteogenesis]

THE AIM OF THE STUDY

Was to reveal the prevalence of dental abnormalities in children after mandibular distraction osteogenesis (MDO).

MATERIALS AND METHODS

The study comprised 75 children aged 5-16 years (42 boys and 33 girls, mean age 9.8±4.2 years) who underwent MDO because of mandible underdevelopment associated with hemifacial microsomia (n=42), Robin syndrome (n=6), Treacher Collins syndrome (n=6), Hallermann-Streiff syndrome (n=1) or acquired conditions (n=16). The mean age at MDO was 6.3±4.4 years. Controls involved 25 children with mandibular underdevelopment (19 with hemifacial microsomis, 4 - with Robin syndrome and 2 with Treacher Collins syndrome, mean age 6.7±3.6 years) receiving orthodontic treatment and with no history of MDO.

RESULTS

In the study group abnormalities of lower molars were revealed in 42 children from 75. The prevalence of the affected first and second molars was 24.7% and 20.5%, respectively. Every tenth child (9.6%) had disorders of both molars. The risks for the first molar developmental defects after MDO was 12 times higher than in controls (OR=12.4; CI=95%). In 21 children delayed eruption or impaction of the first molars was observed. Second molars abnormalities more often included germs displacement and follicular cyst formation (OR=10.4). The age at MDO was significantly higher in children with no dental abnormalities (p<0.01).

CONCLUSION

MDO is associated with significant risk of molars disorders. The younger a child is at MDO the more probable and prominent are the dental complications.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study

OBJECTIVE

Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO.

DESIGN

Retrospective cohort analysis.

SETTING

Three tertiary care institutions.

PATIENTS

Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019.

MAIN OUTCOME MEASURES

The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events.

RESULTS

Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002).

CONCLUSION

Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Obliteration of the pulp canal caused by mandibular distraction: a case report

We present a 16-year-old boy with a history of ankylosis of the temporomandibular joint (TMJ) who had been treated with a costochondral graft and mandibular distraction. The distraction seems to have caused pulp canal obliteration of the lower right second premolar and lower right first molar on radiographic examination. To our knowledge this is the only reported instance of such damage related to mandibular distraction. We aim to highlight the risks of this complication and the importance of discussing it with patients as part of the process of informed consent.

Mandibular Midline Distraction Osteogenesis with a Bone-borne, Tooth-borne or Hybrid Distraction Appliance: a Systematic Review

Objectives

The objective of the present systematic review was to assess the transverse skeletal and dental arch expansion and relapse after mandibular midline distraction osteogenesis with a bone-borne, tooth-borne or hybrid distraction appliance.

Material and Methods

A MEDLINE (PubMed), Embase and Cochrane library search in combination with a hand-search of relevant journals was conducted. Human studies published in English until the 3^rd of July, 2018 were included.

Results

Two comparative and seven non-comparative studies characterized by high risk of bias fulfilled the inclusion criteria. Transverse mandibular widening was achieved with the different types of distraction appliance displaying a horizontal V-shaped opening with larger anterior transverse expansion declining progressively towards the posterior part of the mandible. Bone-borne and hybrid appliance facilitate more skeletal expansion compared with tooth-borne appliance, whereas comparable dental arch expansion was achieved with the different types of distraction appliance. Skeletal and dental arch relapse with the different type of appliance was limited and comparable. However, frequency of complications was higher with bone-borne appliance compared with tooth-borne or hybrid appliance.

Conclusions

Mandibular midline distraction osteogenesis with bone-borne, tooth-borne or hybrid distraction appliance is an effective treatment modality to correct severe transverse mandibular discrepancies, although the skeletal and dental arch expansion pattern was dissimilar with the different types of appliance. However, dissimilar evaluation methods, different outcome measures, various methodological confounding factors posed serious restrictions reviewing the literature in a quantitative systematic manner. Hence, well-designed long-term randomized controlled trials applying three-dimensional technology, patient-related outcome measures and an economic perspective are needed before definite conclusions can be provided.

Pre-arthroplastic and simultaneous mandibular distraction for correction of facial deformity in temporomandibular joint ankylosis

INTRODUCTION

In cases of temporomandibular joint (TMJ) ankylosis, interposition arthroplasty allows return of functional jaw movements. In order to improve the facial appearance, distraction osteogenesis is the treatment of choice, and may be timed either as a pre-arthroplastic, simultaneous or post-arthroplastic procedure. This study was planned to compare the treatment outcomes of pre-arthroplastic distraction (PAD) and simultaneous arthroplastic distraction (SAD) to establish the better treatment modality in terms of improvement in function and aesthetics.

MATERIALS AND METHODS

This prospective randomized experimental study included 20 children and adolescents suffering from facial deformity due to long standing unilateral TMJ ankylosis. They were randomly allocated to the two surgical groups with ten in each group.

RESULT

Both groups resulted in good facial symmetry and aesthetics. Initially, during the distraction period, mouth opening of SAD group scored less than that of PAD group but became comparable in 30 days. More pain at the distraction site and over the normal TMJ was observed in PAD group. The excursive movements were almost comparable in both the groups.

CONCLUSION

We conclude that both procedures are effective in correcting the post-ankylotic deformity and improving function. Although PAD has better control over movement of the distracting segment, the contralateral TMJ may experience pain. SAD requires a shorter management period but is associated with a temporary decrease in function. Also, control of distraction may be difficult and chances of reankylosis are always there.

Bone Replacement Materials and Techniques Used for Achieving Vertical Alveolar Bone Augmentation

Alveolar bone augmentation in vertical dimension remains the holy grail of periodontal tissue engineering. Successful dental implant placement for restoration of edentulous sites depends on the quality and quantity of alveolar bone available in all spatial dimensions. There are several surgical techniques used alone or in combination with natural or synthetic graft materials to achieve vertical alveolar bone augmentation. While continuously improving surgical techniques combined with the use of auto- or allografts provide the most predictable clinical outcomes, their success often depends on the status of recipient tissues. The morbidity associated with donor sites for auto-grafts makes these techniques less appealing to both patients and clinicians. New developments in material sciences offer a range of synthetic replacements for natural grafts to address the shortcoming of a second surgical site and relatively high resorption rates. This narrative review focuses on existing techniques, natural tissues and synthetic biomaterials commonly used to achieve vertical bone height gain in order to successfully restore edentulous ridges with implant-supported prostheses.