Efficacy and Complications of Mandibular Distraction Osteogenesis for Airway Obstruction in the Robin Sequence Population: A Comprehensive Literature Review

Abstract

Introduction: Mandibular distraction osteogenesis (MDO) is becoming the procedure of choice for patients with Robin Sequence (RS) as it offers superior long-term respiratory outcomes in avoidance of tracheostomy. Lacking, is an analysis of the short- and long-term complications. To that end, we have conducted a comprehensive review focusing on complications of MDO. Materials and Methods: A systematic review of primary clinical studies reporting outcomes and complications of MDO in RS patients. Outcomes included tracheostomy avoidance and decannulation rate. Complications included dental trauma, nerve injury, surgical site infection and hardware failure. Complications were stratified according to distractor type (internal versus external) and age (>2 months versus <2months). Results: A total of 49 studies yielded 1209 patients with a mean follow-up of 43.78 months. The tracheostomy avoidance rate was 94% (n = 817/870) and the mortality rate was 0.99% (n = 12/1209). The complication rate was 28.9% (n = 349/1209) with surgical site infections (10.5%) being most common. Dental and nerve injuries occurred in 7.9% and 3.2% of patients, respectively. Hardware replacement occurred in 1.2% of patients. internal distractors had higher rates of dental injury whereas external distractors had higher technical failure rates. There were no differences in complication rates (P = 0.200), mortality (P = 0.94) or tracheostomy avoidance (P = 0.058) between patients >2months or <2months of age. Conclusion: Mandibular distraction osteogenesis is highly reliable and effective with a low mortality and high tracheostomy avoidance rate. There are important complications including nerve and dental injuries which require long-term follow-up. Neonatal patients do not appear to be at higher risk of complications reinforcing the safety of MDO in this population.

Dental outcomes after neonatal mandibular distraction

“…Chocron et al [1 ▪▪ ] performed a systematic review of the literature that evaluated a total of 1209 patients. In this review, internal distractors had a higher dental injury rate than external distractors (11 vs. 3.2%).…”

“…Presurgical radiographs and CT scans can help the surgeon plan osteotomies and hardware placement around imaged tooth buds but are not always accurate and can be difficult to reliably transpose in vivo [1 ▪▪ ,15,19]. Virtual surgical planning (VSP), however, is a new technology in which the osteotomy can be mapped digitally using the preoperative CT scan, avoiding the tooth buds and the inferior alveolar nerve.…”

“…Precise cutting guides are then created to accurately transfer the design onto the neonatal mandible at the time of surgery. VSP can identify the location and depth of teeth and tooth buds to determine the depth of screws and ideal screw placement to reduce the risk of tooth bud injury as compared to traditional methods [1 ▪▪ ,11,18 ▪▪ ] (see Fig. 1).…”

“…Dental injury that occurs during MDO can have prolonged effects on overall dental outcomes and mandibular growth, often requiring a multidisciplinary approach to adequately treat [1 ▪▪ ]. Treatment options may require orthodontic and surgical interventions, including orthodontic alignment, extractions, surgical exposure and orthodontic traction, and prosthetic replacement.…”

“…Detailed description of the procedure has been well described [9 ▪ ,11]. With superior respiratory and feeding outcomes, it has become the surgical treatment of choice for many centres [1 ▪▪ ].…”