Mandibular distraction in neonates: indications, technique, results

Enrico Sesenna, Alice S Magri, Cinzia Magnani, Bruno C Brevi, Marilena L Anghinoni, Enrico Sesenna, Alice S Magri, Cinzia Magnani, Bruno C Brevi, Marilena L Anghinoni

Abstract

Background: The Pierre Robin Sequence features were first described by Robin in 1923 and include micrognathia, glossoptosis and respiratory distress with an incidence estimated as 1:8,500 to 1:20,000 newborns. Upper airway obstruction and feeding difficulties are the main concerns related to the pathology. Mandibular distraction should be considered a treatment option (when other treatments result inadequate). PATIANTS AND METHODS: Ten patients between the ages of 1 month and 2 years with severe micrognathia and airway obstruction were treated with Mandibular Distraction Osteogenesis (MDO).All patients underwent fibroscopic examination of the upper airway and a radiographic imaging and/or computed tomography scans to detect malformations and to confirm that the obstruction was caused by posterior tongue displacement. All patients were evaluated by a multidisciplinary team. Indications for surgery included frequent apneic episodes with severe desaturation (70%). Gavage therapy was employed in all patients since oral feeding was not possible. The two tracheotomy patients were 5 months and 2 years old respectively, and the distraction procedure was performed to remove the tracheotomy tube. All patients were treated with bilateral mandibular distraction: two cases with an external multivector distraction device, six cases with an internal non-resorbable device and two cases with an internal resorbable device. In one case, the patient with Goldenhar's Syndrome, the procedure was repeated.

Results: The resolution of symptoms was obtained in all patients, and, when present, tracheotomy was removed without complications. Of the two patients with pre-existing tracheotomies, in the younger patient (5 months old) the tracheotomy was removed 7 days postoperatively. In the Goldenhar's syndrome case (2 years old) a Montgomery device was necessary for 6 months due to the presence of tracheotomy-inducted tracheomalacia. Patients were discharged when the endpoint was obtained: symptoms and signs of airway obstruction were resolved, PAS and maxillomandibular relationship improved, and tracheotomy, when present, removed. During the follow-up, no injury to the inferior alveolar nerve was noted and scarring was significant in only the two cases treated with external devices.

Conclusion: Mandibular Distraction Osteogenesis is a good solution in solving respiratory distress when other procedures are failed in paediatric patients with severe micrognatia.

Figures

Figure 1
Figure 1
Preoperative frontal and lateral views of an infant with Pierre Robin sequence.
Figure 2
Figure 2
Frontal view during distraction period with an extraoral distractor.
Figure 3
Figure 3
Postoperative frontal and lateral views of the infant after mandibular distraction with external devices.
Figure 4
Figure 4
Intraoperative view after placement of internal metal device.
Figure 5
Figure 5
Preoperative frontal and lateral views of an infant with Pierre Robin sequence.
Figure 6
Figure 6
Three-dimensional CT scan taken previously and during the distraction period.
Figure 7
Figure 7
Postoperative frontal and lateral views of the infant after mandibular distraction with internal device (note the inconspicuous scars).
Figure 8
Figure 8
Intraoperative view: mandibular resorbable distraction device in place.

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