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Cephalometric x-rays: (A) during forward mandibular distraction with external device and (B) following distraction.
Source publication
Obstructive sleep apnea is often associated with congenital craniofacial malformations due to hypoplastic mandible and decreased pharyngeal airway. In this study, we will compare external and internal distraction devices for mandibular lengthening in terms of effectiveness, results, patient comfort, and complications.
Thirty-seven patients were tre...
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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 stu...
Citations
... A bidirectional distractor is mandatory. -Due to the exiguous dimension of facial structures in infant patients, external distractors must be chosen, specifically bidirectional external devices [16]. -For a proper tridimensional stabilization of mandibular segments during external distraction, it is important to place two pins in each segment. ...
Background
Severe microretrognathia with the absence of ascending mandibular ramus is a challenging deformity and treatment must aim to avoid tracheostomy or remove it as soon as possible. Although it is not often reported, mandibular distraction osteogenesis represents a valid treatment option in infants affected by hypoplastic mandible Pruzansky-Kaban type IIb and III.
Case presentation
The authors describe 3 cases of infants affected by severe respiratory insufficiency due to congenital mandibular hypoplasia, with follow up ranging from 4 to 8 years. Clinical and technical considerations on treatment choices and outcomes are discussed starting from review of the literature and direct clinical experience.
Conclusion
Early mandibular distraction, specifically bidirectional distraction, is an effective and repeatable technique that leads to mandible lengthening with counterclockwise rotation, pogonion projection increase, anteropositioning of the tongue base, and expansion of oropharyngeal volume with positive effect on the respiratory problems of the infant. Even in Treacher Collins patients, known to have a low decannulation rate, all of these elements are essential for effective speech and swallowing therapy and for a subsequent attempt of decannulation.
... 41,42 However, the use of external distractors for the mandible has become unpopular due to different problems and complications, such as dental injuries, facial scars, a less predictable distraction vector (affecting elongation accuracy), stability problems, pin-tract infection, neural injury, and uncontrollable external forces. 41,[43][44][45] As the distraction rate was not homogeneous, no direct comparisons between the different groups can be made. Moreover, since the studies were performed in animals, the pain and discomfort related to latency, type of distractor, distraction length and rate could not be analysed in the present systematic review. ...
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, hstomorphometry 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.
... De forma geral, a terapêutica da SAHOS varia de acordo com a sua gravidade entre seguimento clínico, tratamento medicamentoso (corticosteróide), cirúrgico (adenoidectomia-tonsilectomia) ou mecânico (ventilação por pressão positiva do ar -CPAP) (PATER et al., 2014;RACHMIEL et al., 2014;MITCHELL et al., 2015). ...
... Após 12 meses consecutivos do uso dos dispositivos de avanço mandibular, por meio de polissonografia, confirmouse que houve diminuição significativa no Índice de Apneia e Hipopneia por hora de sono (AIH/h) em comparação com o grupo controle. Rachmiel et al. (2014) estudaram dispositivos externos para distração osteogênica no tratamento da SAHOS em pacientes com anomalias craniofaciais, comparando os dispositivos externos e internos de distração para alongamento mandibular. Foram tratados 37 pacientes por distração osteogênica mandibular bilateral para SAHOS: 20 com dispositivos externos e 17 com dispositivos internos. ...
A Síndrome da Apneia e Hipopneia Obstrutiva do Sono (SAHOS) é caracterizada por uma interrupção na respiração durante o sono, reduzindo assim a quantidade de oxigênio no sangue. Os sintomas característicos da apneia na infância são respiração bucal, ronco noturno, movimentação intensa durante o sono, enurese/sudorese noturna, alterações cognitivas e comportamentais como déficit de atenção e hiperatividade, que podem gerar prejuízo do aprendizado e baixo rendimento escolar. Visando compreender melhor seus fatores etiológicos e os tratamentos mais indicados, o presente estudo teve como objetivo revisar a literatura publicada nos últimos 20 anos a respeito da SAHOS infantil. Os artigos revisados mostraram que a etiologia da SAHOS é considerada de caráter multifatorial e está associada principalmente com hipertrofia adenotonsilar, embora fatores anatômicos e funcionais predisponham à SAHOS na infância. A terapêutica da SAHOS pode variar de acordo com a sua gravidade, entre seguimento clínico, tratamento medicamentoso ou cirúrgico. No caso da SAHOS infantil, a adenotonsilectomia é considerada como padrão ouro no tratamento, promovendo melhora significativa em 80% dos casos, uma vez que soluciona problemas obstrutivos presentes na maioria das crianças portadoras de SAHOS. Em casos menos graves, o uso de corticosteróide tópico por tempo prolongado (superior à 6 semanas) pode melhorar consideravelmente os sintomas da SAHOS pela redução da hipertrofia das tonsilas. O cirurgião dentista, em especial o ortodontista e o odontopediatra, são fundamentais na identificação precoce de sítios obstrutivos faríngeos, na avaliação e tratamento ortopédico das desarmonias maxilomandibulares decorrentes da SAHOS.
... Indeed, it is well known that the possible dislodgement is one of the disadvantages of using external distractors, as well as lower precision, greater relapse after 1 year, reduced comfort, buccal scarring, and more pin tract infection. 47 However, among the advantages, the external device is simpler to insert and remove, allows for greater freedom in the management of the distraction's vectors and greater ...
... The Journal of Craniofacial Surgery Volume 00, Number 00, Month 2020 distraction length, and has a lower risk to damage the facial nerve tract. 47 Although the use of internal distractors could prevent such a complication from occurring, its use is not without disadvantages. 47 Analyzing the results, the data obtained show an overall correction of the structure of the jaw, its relationship with the skull and a global regain of symmetry. ...
... 47 Although the use of internal distractors could prevent such a complication from occurring, its use is not without disadvantages. 47 Analyzing the results, the data obtained show an overall correction of the structure of the jaw, its relationship with the skull and a global regain of symmetry. These findings allow us to theorize that the continuous stimulus given by both the movement of the mandible and the anatomical constraints allows a certain degree of self-correction in infants with failed osteodistraction. ...
After a failed mandibular osteodistraction, the wrong positioned mandible of a few patients with Pierre Robin sequence returned in the most functional position and regained a proper symmetry, without external intervention. The study aims to explain this self-adjustment and introduce the floating bone phenomenon.
The inclusion criteria were severe micrognathia, Fast and Early Mandibular Distraction Osteogenesis protocol, postoperative mandibular wrong positioning, presurgery, immediate postsurgery, and long-term computed tomography scan. Five patients were included. The considered parameters were the distance between mandibular dental centerline and midsagittal facial axis, the rotation of the mandibular body, the magnitude of elongation, and the lowering of the mandibular body.
Three patients went from a decentralization >4 mm in the activation phase to a normalization of the said value in the follow-up. In the same period, the interincisal point of 2 patients moved respectively from 0.5 mm on the left and 0.8 mm on the right to 1.2 mm and 1.6 mm on the right, respectively. The rotation of the mandibular body was meanly 25.6° among all patients. The mean value of the distraction was 14.1 mm. A difference of about 4.4 mm between the left and the right side was measured. The lowering of the mandible varied between 2.8 and 12.6 mm.
All patients improved their symmetry. Four of them improved in all the measured parameters, while 1 patient presented a worsening in the decentralization of the interincisal point.
The floating bone phenomenon could break new grounds in the management of patients with Pierre Robin sequence.
... All currently available distractors have some external component that protrudes through the skin or mucous membrane to allow for turning of the distractor. This external component predisposes to complications such as soft-tissue infection [14,31,33], patient/parent noncompliance [29,30], patient discomfort/increased analgesic use throughout the distraction period [2], and scarring [25,33]. No studies have yet examined how these various limitations are perceived by physicians and patients. ...
Purpose:
There is a paucity of literature on how limitations of distraction osteogenesis (DO) are perceived by physicians and parents of pediatric patients. Specifically understanding which features of DO are most concerning to these two groups may better inform parent education, as well as direct improvements in distraction protocols and devices.
Method:
Parents/guardians of patients (between January 2016 and October 2017) being treated with craniofacial distraction were recruited to complete a survey regarding level of stress (1 = not stressful, 9 = maximally stressful) associated with eight features of DO. Craniofacial surgeons completed a survey asking them to report (1) their personal level of stress and (2) their perceptions of parental stress regarding these same eight features of DO.
Results:
Thirty-five parents and 15 craniofacial surgeons completed the survey. The risk of the device getting infected was perceived as most stressful by parents (5.5 ± 2.3) followed by the device sticking through the skin (4.9 ± 2.6) and the second operation for removal (4.7 ± 2.3). These same three features also elicited the highest level of stress among surgeons. Surgeon-perceived parental stress regarding turning of the distractor (5.8 ± 1.5) was significantly higher than parent self-reported stress (4.2 ± 2.8, p = 0.042).
Conclusions:
Both parents and surgeons perceive risk of device-associated infection, the protrusion of the device through the skin, and the requirement of a second operation for removal as the most stressful drawbacks of distraction. Infection reduction protocols, less obtrusive devices, and devices that do not require removal are potential targets for stress reduction.
... Inaccuracy in the procedure results malocclusion (Behnia et al., 2013;Şençimen et al., 2014). Imprecise placement of pins results: tooth injury, damage to adjacent vital structures, inappropriate distraction vector and pin loosening (Neelakandan and Bhargava, 2012;Rachmiel et al., 2014). Conventional methods of the EDI placement are often not suitable for many patients, especially when technical difficulties like a thin ramus or relapse has occurred or the large advancement is needed . ...
Purpose
The purpose of this paper is to develop a workflow for design and fabrication of customized surgical guides (CSGs) for placement of the bidirectional extraoral distraction instruments (EDIs) in bilateral mandibular distraction osteogenesis (MDO) surgery to treat the bilateral temporomandibular joint ankylosis with zero mouth opening.
Design/methodology/approach
The comprehensive workflow consists of six steps: medical imaging; virtual surgical planning (VSP); computer aided design; rapid prototyping (RP); functional testing of CSGs and mock surgery; and clinical application. Fused deposition modeling, an RP process was used to fabricate CSGs in acrylonitrile butadiene styrene material. Finally, mandibular reconstruction with MDO was performed successfully using RP-assisted CSGs.
Findings
Design and development of CSGs prior to the actual MDO surgery improves accuracy, reduces operation time and decreases patient morbidity, hence improving the quality of surgery. Manufacturing of CSG is easy using RP to transfer VSP into the actual surgery.
Originality/value
This study describes an RP-assisted CSGs fabrication for exact finding of both; osteotomy site and drilling location to fix EDI’s pins accurately in the mandible; for accurate osteotomy and placement of the bidirectional EDIs in MDO surgery to achieve accurate distraction.
... Bilateral mandibular distraction osteogenesis for obstructive sleep apnea is used in 37 patients (34). Of them, 20 subjects are treated with external and 17 ones with internal distraction devices. ...
Le syndrome de Goldenhar est une maladie rare qui affecte la croissance de la moitié de la face. Les principaux symptômes sont la microsomie hémifaciale, les dermoïdes du limbe et les microties mais on retrouve aussi de manière plus occasionnelle des atteintes systémiques cardiaques ou encore rénales. Son étiologie est mal connue mais serait majoritairement sporadique. C’est l’hémorragie de l’artère stapédienne à la cinquième semaine qui serait responsable des malformations. Il en résulterait un défaut de croissance asymétrique d’importance variable en fonction des cas. Le déficit de croissance doit être dépisté au plus tôt et être quantifié afin de proposer un plan de traitement adapté. La prise en charge est bien souvent chirurgicale et précoce pour permettre à l’enfant de s’accepter, même si une seconde chirurgie en fin de croissance est nécessaire dans la majorité des cas. Un cas clinique présentant une atteinte sévère, traité avec plusieurs chirurgies, et un cas frustre, traité avec une prise en charge principalement fonctionnelle, sont détaillés.
Internal distraction devices are commonly used in congenital micrognathia. The eventual need for device and screw removal can be challenging, requiring extensive dissection and disturbance of bone regenerate. Bioabsorbable poly-L-lactide (PLLA) screws, compared to traditional titanium screws, simplify device removal. Previous in vivo studies have found that the maximal compressive force generated by mandibular distraction is 69.4N. We hypothesized that PLLA screws could support these compressive/distraction forces. Ten mandibles were obtained from 5 canine cadavers. Paired mandibles from the same cadaver were each fixated to a mandibular distractor with eight screws (either titanium or PLLA). Devices were each set to 15 and 30 mm of distraction distance. Compression force of 80 N was then generated parallel to the axis of the distraction device. Distractor displacement was measured to detect any mechanical failure during this pre-set load. Finally, if no failure was observed at 80 N, a load-to-failure compression test was done in the PLLA group to determine the mechanical failure point. All distractors in both the titanium and PLLA screw groups withstood 80 N of compression without failure. When the load-to-failure test was performed in the PLLA group, the average device failure point was 172.8 N (range 148-196 N). Review of high-frame-rate video demonstrated that all failures occurred due to the PLLA screws breaking or falling out. Bioabsorbable PLLA screws can withstand compressive forces more than double that of the maximal in vivo forces needed during mandibular distraction. These screws may be an acceptable alternative for the fixation of internal mandibular distractors.
Objectives/hypothesis:
Mandibular distraction osteogenesis (MDO) is a safe and effective surgery to address respiratory and feeding issues due to micrognathia in patients with Robin Sequence (RS). Previous studies examining postoperative complications in neonates receiving MDO have considered 4 kg as the cut-off for low weight; however, an increasing number of MDO interventions are performed in infants <4 kg. To determine if a weight <3 kg at time of MDO is a risk factor for postoperative complications or need for subsequent tracheostomy or gastrostomy tube (G-tube).
Study design:
Retrospective chart review.
Methods:
A retrospective review of all infants <6 months of age undergoing MDO at two tertiary pediatric hospitals from 2008 to 2018. Demographic data, syndromic status, weight, and age at time of surgery, length of postoperative hospital stay, and postoperative outcomes were recorded including tracheostomy placement, G-tube placement, hardware infection, reintubation, facial/marginal mandibular nerve damage, and need for revision MDO.
Results:
Sixty-nine patients with RS were included. The mean age at MDO was 25 ± 20 days and mean weight was 3.32 ± 0.44 kg. There was no statistically significant correlation between weight (P = .699) or age (P = .422) and unfavorable postoperative outcomes. No patients (0%) underwent tracheostomy pre-MDO. Two patients (2.9%) required tracheostomy postsurgery; neither was <3 kg. Eight patients (11.6%) required a G-tube postoperatively.
Conclusion:
Newborns <3 kg who undergo MDO experience the same rates of success and complication as larger infants, suggesting that MDO is a safe and efficacious procedure in infants less than 3 kg. Laryngoscope, 2021.
