Distraction Osteogenesis for Tracheostomy Dependent Children With Severe Micrognathia

Department of Oral and Maxillofacial Surgery, Rambam Medical Center, Haifa, Israel.
The Journal of craniofacial surgery (Impact Factor: 0.68). 03/2012; 23(2):459-63. DOI: 10.1097/SCS.0b013e3182413db8
Source: PubMed

ABSTRACT Obstructive sleep apnea (OSA) in pediatric populations is often associated with congenital craniofacial malformations resulting in decreased pharyngeal airway, which in severe cases leads to tracheostomy dependence. The purpose of this study was to use distraction osteogenesis to improve the airway and decannulate the tracheostomy. This study involved 11 OSA tracheostomy-dependent patients (age range, 4 months to 6 years) who underwent bilateral distraction in the mandibular body using extraoral distraction devices. Following a latency period of 4 days, gradual distraction at a rate of 1 mm/d was performed followed by a consolidation period of 10 weeks. Three-dimensional computed tomography reconstruction of the face and neck before and after the mandibular lengthening aided in quantitative volumetric evaluation of mandibular volume and airway volume. The results demonstrated mandibular elongation of a mean of 30 mm on each side, an increase in mandibular volume by an average of 29.19%, and increase in pharyngeal airway by an average of 70.53%. Two to 3 months following the last lengthening, all 11 patients were decannulated with improvement of signs and symptoms of OSA and elimination of oxygen requirement. Mean follow-up was 2.0 years. The oxygen saturation level rose to more than 95%, and the apnea index respiratory disturbance index was less than 2 episodes per hour for all patients. Bilateral mandibular distraction is a useful method in younger children to decannulate permanent tracheostomy expanding the hypoplastic mandible and concomitantly advance the base of tongue and hyoid bone increasing the pharyngeal airway.

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    ABSTRACT: 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 treated by bilateral mandibular distraction osteogenesis for obstructive sleep apnea: 20 with external and 17 with internal distraction devices. Lengthening of the mandible and increase of the pharyngeal airway were obtained in all patients. Using the external devices, the average mandibular elongation was 30 mm versus 22 mm with the internal devices; however, after 1 year, the results were more stable with internal devices. External devices carried greater risk for pin tract infection than the internal devices (27.5% vs 5.88%). In addition, pin loosening in 22.5% required pin replacement or led to reduced retention period. Internal devices had a precise and predictable vector of lengthening and left less visible scars at the submandibular area but carried the disadvantage of requiring a second operation for device removal. In very young children with severe micrognathia, it was impossible to place internal devices, and external devices were used. Internal devices should be the first choice because they are more comfortable to the patients, more predictable vector of lengthening, are less vulnerable to dislodgement, and leave reduced scarring, with the great disadvantage of second operation for removal. However, external devices still should be considered mainly in severely hypoplastic cases, and the surgeon should be prepared for both options.
    07/2014; 2(7):e188. DOI:10.1097/GOX.0000000000000147
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    ABSTRACT: A systematic review of English and non-English language articles on the complications of mandibular distraction osteogenesis (MDO) for patients with congenital deformities was performed, in accordance with the PRISMA statement. Search terms expressing distraction osteogenesis were used in ‘AND’ combination with search terms comprising ‘mandible’ and terms for complication, failure, and morbidity. A search using PubMed (National Library of Medicine, NCBI), EMBASE, and the Cochrane Central Register of Controlled Trials yielded 644 articles published between 1966 and mid October 2013. Clinical articles that reported complications related to MDO were included. Finally 81 articles on MDO in congenital deformities were eligible and were screened in detail. Complications including minor infection (6.0%), device-related problems (7.3%), skeletal open bite (2.4%), hypertrophic scar formation (2.1%), facial nerve palsy (1.8%), neurosensory disturbances of the inferior alveolar nerve (1.9%), and (fibrous) non-union (0.7%) were seen. A new index for more detailed classification of complications in MDO is proposed based on six categories that indicate the impact of the complication and its further treatment or final results. The proposed complication index may be a useful tool to classify complications related to MDO.
    International Journal of Oral and Maxillofacial Surgery 08/2014; DOI:10.1016/j.ijom.2014.07.009 · 1.36 Impact Factor
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    ABSTRACT: Gradual bone lengthening using distraction osteogenesis principles is the gold standard for the treatment of hypoplastic facial bones. However, the long treatment time is a major disadvantage of the lengthening procedures. The aim of this study is to review the current literature and summarize the cellular and molecular events occurring during membranous craniofacial distraction osteogenesis. Mechanical stimulation by distraction induces biological responses of skeletal regeneration that is accomplished by a cascade of biological processes that may include differentiation of pluripotential tissue, angiogenesis, osteogenesis, mineralization, and remodeling. There are complex interactions between bone-forming osteoblasts and other cells present within the bone microenvironment, particularly vascular endothelial cells that may be pivotal members of a complex interactive communication network in bone. Studies have implicated number of cytokines that are intimately involved in the regulation of bone synthesis and turnover. The gene regulation of numerous cytokines (transforming growth factor-β, bone morphogenetic proteins, insulin-like growth factor-1, and fibroblast growth factor-2) and extracellular matrix proteins (osteonectin, osteopontin) during distraction osteogenesis has been best characterized and discussed. Understanding the biomolecular mechanisms that mediate membranous distraction osteogenesis may guide the development of targeted strategies designed to improve distraction osteogenesis and accelerate bone regeneration that may lead to shorten the treatment duration.
    01/2014; 2(1):e98. DOI:10.1097/GOX.0000000000000043