Mandibular Distraction Osteogenesis for Pediatric Airway Management

Purpose: Mandibular retrognathia may cause upper airway obstruction in the pediatric patient due to tongue collapse and physical obstruction in the hypopharyngeal region. Mandibular distraction osteogenesis (DO) may be a useful treatment option to avoid tracheostomy. This study reviews 35 patients who underwent DO as treatment for concomitant jaw discrepancy and corrective airway management. Patients and Methods: Thirty-five consecutive patients, 20 male and 15 female, with airway obstruction were evaluated retrospectively using clinic and hospital records. The mean age was 3.5 months (range, 36 weeks' gestation to 4 years). The group consisted of patients with Pierre Robin sequence, Stickler syndrome, Opitz's syndrome, Down syndrome with obstructive sleep apnea, Goldenhar's syndrome, Treacher Collins syndrome, and mandibular retrognathia. All patients had obstruction limited to the upper airway related to severe retrognathia and posterior tongue-base displacement confirmed with direct laryngoscopy. All patients underwent mandibular DO to avoid or remove a tracheostomy and allow development of speech and normal feeding. Each patient underwent bilateral mandibular corticotomies and placement of 2 percutaneous Kirchner wires and extraoral distraction devices. Following a 0-day latency, DO was performed at 3 to 5 mm per day (mean: 4 mm per day) for a mean total of 22.5 mm (range, 15-32 mm). The mean consolidation period was 28 days (range, 20-42 days). Preoperative radiographs (lateral cephalometric radiograph and/or CT scan) were obtained in all cases preoperatively and at least 3 months postoperatively for analysis. Results: All patients experienced resolution of obstructive upper airway symptoms during the DO process. No patient required tracheostomy, and pre-existing tracheostomy devices were decannulated before DO completion. Apnea monitors failed to trigger in any patient postdistraction, and sleep studies were normal. The mean follow-up period was 9 months (range, 4-18 months). Radiographic analysis revealed the mean increase in posterior airway space was 12 mm. The mean decrease in overjet was 12 mm. Mandibular length increased a mean of 15 mm, and the sella-nasion-B point angle increased a mean of 16 degrees. DO complications included premature consolidation requiring manual refracture, hypertrophic scarring, device replacement, apertognathia with resolution within 8 to 12 weeks following device removal, and intraoral pin exposure. There were no cases of pin site infections or development of temporomandibular ankylosis. Conclusion: Mandibular distraction osteogenesis is a viable option for the pediatric patient with upper airway obstruction due to mandibular deficiency to avoid a tracheostomy or other surgical intervention. Mandibular DO treats the etiology of the disease process and may allow for future growth. (C) 2010 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 68:1512-1523, 2010