Adi Rachmiel

Minimizing pin complications when using the rigid external distraction (RED) system for midface distraction

In this review we describe the advantages, complications, and preventive considerations encountered as a result of the use of a halo for distraction of a retrusive nasomaxillary complex. Distraction osteogenesis is a well accepted combined orthodontic-surgical technique used in the treatment of patients with hypoplastic craniofacial components. The rigid external distraction (RED) system is a useful external distraction device for the advancement of severe retrusive maxilla especially in cleft palate patients. However, the addition of this new technique to the surgeons armamentarium is accompanied by new complications and risks. Review of the literature on complications of the use of halo revealed that most complications are pin related. Complications with the use of RED have mainly included the penetration of intracranial pins. Risk management and preventive considerations propose several procedures to minimize the side effects when using RED: preoperative skull computerized tomography, pediatric neurosurgical consultation, proper pin care during distraction, frequent monitoring of the patients general condition, proper pin and torque design, and special attention to the removal process of the RED.

Nonsurgical Orthodontic Splinting of Mandibular Fracture in a Young Child : 10-Year Follow-Up

The management of mandibular fractures in children differs from that of adults because of concerns about mandibular growth and dentition development. Treatment modalities in young patients range from conservative treatment methods (eg, arch-bars, eyelets) to open reduction with internal fixation. Maxillomandibular fixation (MMF) including arch-bars or eyelets can cause avulsion of primary teeth that are insufficiently stable. The conical shape of the primary teeth, with their wide cervical margins and tapered occlusal surface, makes placement of these MMF devices or eyelets technically challenging. Internal rigid or semirigid fixation using titanium miniplates and screws or resorbable osteosynthesis plates and screws has become a standard of care for young adult and adult patients; however, its suitability in children remains controversial. There are many concerns about the effect of implanted hardware in the mandible of the growing child. In addition, some evidence suggests that disruption of the functional matrix bone may result in altered development. The potential for damage to the periosteum and the surrounding soft tissue must be taken into consideration when choosing an internal fixation technique. We report a conservative nonsurgical orthodontic treatment of a case of mandibular fracture using a modified orthodontic appliance for fixation. This type of orthodontic splint offers several advantages compared with other available conservative and nonoconservative techniques. We describe treatment considerations and fabrication of the orthodontic fixation appliance, as well as findings after long-term follow-up (10 years).

Controlling the vector of distraction osteogenesis in the management of obstructive sleep apnea

Background: Obstructive sleep apnea (OSA) in individuals with craniofacial anomalies can compromise airway and is a serious life-threatening condition. In many cases, tracheostomy is carried out as the treatment of choice. Distraction osteogenesis of the mandible as a treatment modality for OSA is very useful and may spare the need for tracheostomy or allow decannulation, yet controlling the vector of distraction is still a major challenge. We present a method for controlling the vector of distraction. Materials and Methods: Eight patients with severe respiratory distress secondary to a micrognathic mandible were treated by mandibular distraction osteogenesis using either external or internal devices. Temporary anchorage devices (TADs) and orthodontic elastics were used to control the vector of distraction. Cephalometric X-rays, computed tomography, and polysomnographic sleep studies were used to analyze the results. Results: A mean distraction of 22 mm using the internal devices and a mean of 30 mm using the external devices were achieved. Increase in the pharyngeal airway and hyoid bone advancement was also observed. Anterior-posterior advancement of the mandible was noted with no clockwise rotation. Most importantly, clinical improvement in symptoms of OSA, respiratory distress, and feeding was noted. Conclusions: We describe a method for controlling the vector of distraction used as a treatment for OSA. In these cases, TADs were used as an anchorage unit to control the vector of distraction. Our results show excellent clinical and radiographical results. TADs are a simple and nonexpensive method to control the vector of distraction.