Distraction Osteogenesis in the Pediatric Population

OBJECTIVES: Distraction osteogenesis has been described routinely in the mandible for the advancement of bony segments. Complications, though infrequent, may include postoperative infection, implant extrusion, nonunion of the bony segments, device malfunction, cranial nerve paresis, and premature consolidation.

METHODS: Seventy-eight distractions of the mandible were performed over 10 years. The technique in placement of these internal microdistraction devices involves making intraoral and extraoral incisions and beginning distraction after a latency period of 3 days. Following this latency period, distraction occurs at 1 mm/day.

RESULTS: In this series of patients, distraction was accomplished successfully. There was a 2.6% rate of wound infection in this series; 2.6% also had bony nonunion; 3.8% had premature bony consolidation; and 3.8% had facial nerve complications. In the three patients with facial nerve paresis, we followed the facial nerve clinically and each paresis resolved within 6 months.

CONCLUSIONS: Distraction of the mandible may be accomplished in the pediatric population. As with any intervention, inherent perioperative complications may still arise.

The Osseous Genioplasty

Despite its existence for nearly half a century and its versatility in solving a complex range of chin deformities, osseous genioplasty through an intraoral approach remains a rusty tool in many surgeons' armamentarium. The osseous genioplasty is not solely within the domain of the maxillofacial or craniofacial surgeon; it is well within the reach of any surgeon whose practice involves facial aesthetics. The surgeon who masters this relatively simple procedure can solve a broad range of chin deformities that an implant cannot solve: a chin that is too long, too short, or asymmetric.

Distraction osteogenesis in a severe mandibular deficiency

OBJECTIVE

Distraction osteogenesis is an alternative treatment method for the correction of mandibular hypoplasia. In this case report, distraction with a multidirectional extraoral device was performed to gradually lengthen the corpus and ramus of a patient who had a severe hypoplastic mandible.

MATERIALS AND METHODS

The patient underwent bilateral extraoral ramus and corpus distraction osteogenesis. After seven days of latency period, distraction was performed 0.5 mm twice a day. Subsequent consolidation period was 12 weeks.

RESULTS

The patient's mandible was elongated successfully. Cephalometric analysis revealed that ANB angle decreased from 13 degrees to 6 degrees , overjet of 15 mm decreased to 4 mm, corpus length increased from 49 mm to 67 mm, and ramus length increased from 41 mm to 43 mm. Posterior airway space (PAS) also increased due to advancement of the mandible. In stereolithographic model evaluation it was determined that the distances from condylion to gonion and from gonion to pogonion increased.

CONCLUSION

Satisfactory results from both aesthetic and functional standpoints were obtained by distraction osteogenesis of the ramus and corpus.

Distraction Rate and Latency: Factors in the Outcome of Pediatric Mandibular Distraction

BACKGROUND

Distraction osteogenesis was initially devised as a way to lengthen the lower extremity. All the basic tenets of the technique were developed based on this use. This includes both the supposed need for a latency period before distraction begins (3 to 5 days) and the ideal rate of distraction (1 mm/day). There is no evidence that these values apply to craniofacial distraction osteogenesis, particularly in children. Indeed, with the markedly improved blood supply in the face when compared with the lower extremity and the use of the technique in children versus adults, one might assume that a shorter latency period and a more rapid rate of distraction are possible.

METHODS

This study is a retrospective review of 22 pediatric patients with mandibular hypoplasia undergoing mandibular distraction osteogenesis. All patients were operated on by a team consisting of an oral surgeon and a plastic surgeon. All the distraction devices used were external. All patients had a latency period, before activation, of less than 24 hours and a distraction rate of 2 mm/day.

RESULTS

Two patients developed cellulitis at the pin sites, one patient developed premature healing, one patient developed a nonunion that required further surgery. This was the only patient in the series who had distraction of a previous bone graft. No patient undergoing distraction of native mandible developed a nonunion.

CONCLUSIONS

Eliminating the latency period and rapidly distracting the mandible in pediatric cases has an acceptably low complication rate. This benefits the patient in terms of an overall reduction in the amount of time that the child needs to remain in the distraction device. The patient spends less time with the distraction device, thus reducing the potential morbidity and increased cost of the treatment. Potential explanations for why this variation in distraction technique is successful include the improved blood supply in the face of children and the failure of external devices to translate all the distracted movements to the bone interface. Some of this force is translated into both bending of the pins and migration of the pins through bone. Although a latency period might be necessary in the distraction of the lower extremities, the application of this concept to the craniofacial skeleton in children is erroneous.

Syngnathia and Van der Woude syndrome: a case report and literature review

OBJECTIVE

Syngnathia is a rare anomaly involving soft tissue or bony adhesions between the maxilla and mandible. We review the literature and present a case of syngnathia associated with Van der Woude syndrome. Syngnathia can have very different etiologies, but this has rarely been reported in Van der Woude syndrome. Treatment of this condition is rarely discussed in the literature because of a paucity of case reports.

RESULTS

Oral adhesion (syngnathia) in our patient was caused by a mandibular to maxillary fibrous band. Surgical treatment was successful. Clinical implications and review of literature for the treatment of this rare association of syngnathia and Van der Woude syndrome are discussed.

Tuberous sclerosis: clinicopathologic features and review of the literature

INTRODUCTION

Tuberous sclerosis is a hamartoneoplastic syndrome, which may involve multiple organ systems. Oral hard tissue manifestations of the syndrome have been described in the literature only as recently as 1955. Patients who presented with clinical manifestations of tuberous sclerosis did not routinely undergo oral surveys to rule out 'lesions', and consequently data on 'lesions' in the maxillofacial complex is scant. Ten cases have been found in the English language literature, which describe maxillofacial 'lesions', which may be tumours, new growths, neoplasms or overgrowths occurring in patients diagnosed with tuberous sclerosis.

PURPOSE

To review the literature for all maxillofacial lesions associated with tuberous sclerosis and to present an eleventh case of a patient with a maxillofacial lesion diagnosed as having tuberous sclerosis.

RESULTS

Eleven cases were found with maxillofacial fibroblastic lesions associated with tuberous sclerosis. These lesions were all fibrous benign neoplasms found in the maxillofacial bony complex.

CONCLUSIONS

Maxillofacial fibroblastic lesions in tuberous sclerosis have various histopathological presentations, some of which may be difficult to differentiate. Consequently, close microscopic examination of these lesions is necessary so that adequate surgical treatment is provided.

[The results of using a compression-distraction method for eliminating mandibular defects and deformities]

Intraoral supraosseous compression-distraction devices (CDA) have been used for repair of mandibular underdevelopment and defects of different etiology at Central Institute of Stomatology since 1997. The distraction regenerates have been examined by ultrasonography, roentgenography, and echo-osteometry. These methods allow timely correction of the course of distraction and rule out formation of wrong hypotrophic distraction regenerates.

[The combined treatment of children with congenital and acquired mandibular defects and deformities]

A total of 280 children and adolescents with congenital and acquired mandibular defects and deformations were treated. The main principle in the treatment of such children is to begin treatment as early as possible. Stages of rehabilitation and scope of therapeutic measures for each stage are determined. The best results were attained in patients administered multiple-modality treatment by surgical, orthodontic, physiotherapeutic methods and therapeutic exercises at an early age immediately after the defect was diagnosed.

[Congenital infiltrating lipomatosis of the face. Presentation of a new clinical case]

A new case of this rarely described pathology is reported. It concerns a benign infiltrating lipomatosis, strictly located to the face. However, dento-musculo-squelettal structures are constantly involved, usually located to a hemiface. A young female patient has been followed up from her birth. Surgical procedures are reported. Diagnostic and therapeutic difficulties of this rare clinicopathologic entity are discussed.

[A case of facial fibrous dysplasia in brothers]

Fibrous dysplasia is a benign bone tumor. The cranio-facial localization concern 20% of fibrous dysplasia. A congenital etiology is evoked by all the authors. Our observations ask for the real etiology of this affection: Congenital? Familial? The diagnosis is done by anatomo-pathology, and surgery is the treatment for severe cases. Relapses are frequent.

Incidence of maxillofacial involvement in arthrogryposis multiplex congenita

PURPOSE

This study determined the incidence of maxillofacial involvement in patients diagnosed with arthrogryposis multiplex congenita (AMC).

PATIENTS AND METHODS

Twenty-three patients were evaluated by the pediatric physical medicine and rehabilitation, orthopedic surgery, and pediatric oral and maxillofacial surgery departments. Any patient in whom the diagnosis of AMC was in doubt was excluded from the study. All patients with limited mandibular function underwent computed tomography (CT) examination of their temporomandibular joints (TMJ). The results of physical therapy were followed.

RESULTS

Five of the 23 patients diagnosed with AMC were found to have maxillofacial involvement, eg, presence of cleft palate, Robin-like sequence, high-arched palate, open-bite deformity, facial muscle weakness, esophageal dysfunction, and limited mandibular opening. No TMJ abnormalities were found by CT scan. Physical therapy was used for treatment of the limited opening, but relapse occurred quicky after therapy was discontinued.

CONCLUSION

The incidence of maxillofacial findings is similar to that of most other reports. Treatment involves surgical correction of abnormal anatomy when possible (ie, cleft repair), symptomatic management (ie, esophageal dysfunction), and physical therapy.

Syngnathia: a report of two cases

Syngnathia is a rare anomaly involving soft tissue or bony adhesions between the maxilla and mandible. Two cases of congenital syngnathia secondary to interalveolar soft tissue synechia are presented. These children present problems with airway protection and feeding in the immediate neonatal period. Most have multiple associated anomalies requiring concurrent management. Less than 50 cases have been described, most commonly in association with popliteal pterygium syndrome. Surgical management involves division of the adhesions in the first few days of life. Depending on the severity, these patients may present formidable anesthetic challenges. The prognosis is generally favorable in cases of soft tissue adhesions with eventual restoration of normal mandibular motion and function.

Congenital monostotic fibrous dysplasia--a new possibly autosomal recessive disorder

Two siblings, a 3-month-old white male infant and a 12-day-old female infant, had an anterior mandibular bony lesion that, in both cases, had been present at birth. After evaluation of clinical, physical, radiographic, laboratory, and histologic findings, a diagnosis of congenital monostotic fibrous dysplasia was made. Thorough review of the literature on fibrous dysplasia yielded no similar cases. The two cases presented appear to be the first reported examples of congenital monostotic fibrous dysplasia in siblings. The parents said there was no consanguinity. The possibility of a new autosomal-recessive disorder is likely.

Predominant of exclusive orbital and facial involvement in infantile cortical hyperostosis (de Toni-Caffey's disease). Report of four cases and a review of the literature

Four patients who presented with predominant or exclusive face and orbital involvement by de Toni-Caffey's disease are reported. Facial manifestations of infantile cortical hyperostosis may be the first and sometimes the only manifestion of the disease. A mandibular involvement is almost always present and its characteristic appearance leads to the diagnosis of de Toni-Caffey's disease.

Congenital epulis of the newborn

Reported is a case of congenital epulis of the newborn occurring in the mandible and the maxilla. The masses were of such size as to cause respiratory and nursing difficulties. The theories of pathogenesis, the surgical treatment, the histologic appearance, and a 5-year follow-up are described. As with previous cases reported, there has been no recurrence.