Omri Emodi

Distraction osteogenesis for tracheostomy dependent children with severe micrognathia.

AbstractObstructive sleep apnea (OSA) in pediatric populations is often associated with congenital craniofacial malformations resulting in decreased pharyngeal airway, which in severe cases leads to tracheostomy dependence. The purpose of this study was to use distraction osteogenesis to improve the airway and decannulate the tracheostomy. This study involved 11 OSA tracheostomy-dependent patients (age range, 4 months to 6 years) who underwent bilateral distraction in the mandibular body using extraoral distraction devices. Following a latency period of 4 days, gradual distraction at a rate of 1 mm/d was performed followed by a consolidation period of 10 weeks. Three-dimensional computed tomography reconstruction of the face and neck before and after the mandibular lengthening aided in quantitative volumetric evaluation of mandibular volume and airway volume. The results demonstrated mandibular elongation of a mean of 30 mm on each side, an increase in mandibular volume by an average of 29.19%, and increase in pharyngeal airway by an average of 70.53%. Two to 3 months following the last lengthening, all 11 patients were decannulated with improvement of signs and symptoms of OSA and elimination of oxygen requirement. Mean follow-up was 2.0 years. The oxygen saturation level rose to more than 95%, and the apnea index respiratory disturbance index was less than 2 episodes per hour for all patients. Bilateral mandibular distraction is a useful method in younger children to decannulate permanent tracheostomy expanding the hypoplastic mandible and concomitantly advance the base of tongue and hyoid bone increasing the pharyngeal airway.

Treatment protocol for high velocity/high energy gunshot injuries to the face.

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

Management of obstructive sleep apnea in pediatric craniofacial anomalies

Introduction: Obstructive sleep apnea (OSA) is often associated with congenital craniofacial malformations such as Pierre-Robin Syndrome, Hemifacial Microsomia, Treacher Collins Syndrome resulting in decreased pharyngeal airway, which, in severe cases, leads to tracheostomy dependence. Some pediatric patients had tracheostomies done and others with severe respiratory distress were considered tracheostomy candidates. Materials and Methods: Twelve patients with severe respiratory distress without tracheostomy and ten patients with tracheostomy were treated by mandibular distraction osteogenesis using either external or internal devices. The expansion of mandibular framework was analyzed using bony cephalometric landmarks and computed tomography (CT). Results: The results demonstrated average mandibular elongation of 29 mm on each side using the external devices and 22 mm using the internal devices, and an increase in mandibular volume and pharyngeal airway. The group of patients with tracheostomies were decannulated and in the patients with respiratory distress there was improved airway with improvement of signs and symptoms of OSA with elimination of oxygen requirement. Conclusions: Mandibular distraction is a useful method in younger children with OSA expanding the mandible and concomitantly advancing the base of tongue and hyoid bone increasing the pharyngeal airway. The external devices permit greater distraction length, the removal is simple but the devices are uncomfortable for the patients. On the other hand, the internal devices are more comfortable for patients but permit shorter distraction length and require a second operation for removal.

Internal mandibular distraction to relieve airway obstruction in children with severe micrognathia

Congenital craniofacial malformations such as Pierre Robin sequence or Treacher Collins syndrome are associated with mandibular micrognathia, resulting in obstructive sleep apnea (OSA) due to a decreased pharyngeal airway; in severe cases this leads to tracheostomy dependence. We present a series of 18 patients in whom we performed mandibular lengthening using internal distraction devices to relieve airway obstruction. Seven were tracheostomy-dependent and 11 were respiratory distressed without tracheostomy. The mandible was distracted at a rate of 1mm per day. Following 3 months of consolidation for bony maturation, the distraction devices were removed. Results demonstrated forward mandibular elongation of a mean 22mm (range 20-25mm) and an increase in SNB angle and in pharyngeal airway. All patients with tracheostomies were decannulated, and there was an improved airway with resolution of signs and symptoms of OSA and elimination of oxygen requirement in all patients. We conclude that mandibular distraction using internal devices is a useful and comfortable method for younger children to expand the mandible forward and increase the pharyngeal airway.

External versus Internal Distraction Devices in Treatment of Obstructive Sleep Apnea in Craniofacial Anomalies.

Background: Obstructive sleep apnea is often associated with congenital craniofacial malformations due to hypoplastic mandible and decreased pharyngeal airway. In this study, we will compare external and internal distraction devices for mandibular lengthening in terms of effectiveness, results, patient comfort, and complications. Methods: Thirty-seven patients were treated by bilateral mandibular distraction osteogenesis for obstructive sleep apnea: 20 with external and 17 with internal distraction devices. Results: Lengthening of the mandible and increase of the pharyngeal airway were obtained in all patients. Using the external devices, the average mandibular elongation was 30 mm versus 22 mm with the internal devices; however, after 1 year, the results were more stable with internal devices. External devices carried greater risk for pin tract infection than the internal devices (27.5% vs 5.88%). In addition, pin loosening in 22.5% required pin replacement or led to reduced retention period. Internal devices had a precise and predictable vector of lengthening and left less visible scars at the submandibular area but carried the disadvantage of requiring a second operation for device removal. In very young children with severe micrognathia, it was impossible to place internal devices, and external devices were used. Conclusions: Internal devices should be the first choice because they are more comfortable to the patients, more predictable vector of lengthening, are less vulnerable to dislodgement, and leave reduced scarring, with the great disadvantage of second operation for removal. However, external devices still should be considered mainly in severely hypoplastic cases, and the surgeon should be prepared for both options.

Three-dimensional reconstruction of large secondary alveolar cleft by two-stage distraction.

Objective Our aim is to demonstrate a method for reconstruction of a wide alveolar cleft before implant placement. Patient and Method An adult patient with a unilateral cleft palate and a wide alveolar and maxillary bone defect underwent transport distraction osteogenesis to medialize the left segment and reduce the alveolar cleft to a minimum. Removal of the transport distraction device was accompanied by autogenous bone grafting to the remaining alveolar defect in the medial cleft, attaining an osseous closure with adequate soft-tissue coverage. Three months later, vertical alveolar distraction of the newly reconstructed bone was performed. Implants were placed after the removal of the distraction device. Results Alveolar bone was transported forward 20 mm followed by 15 mm vertical distraction. The large cleft palate defect was reconstructed in three dimensions by the two-stage distraction osteogenesis, and the soft tissues were expanded to achieve functional correction. After removal of the distraction device, dental implants were osteointegrated in the newly reconstructed bone for fixed dental rehabilitation. Conclusions The two-stage distraction allowed gradual closure of a large defect three dimensionally. This method can be safely performed not only in patients undergoing initial treatment for large alveolar clefts but also after failed bone grafting.

Three-dimensional planning and printing of guides and templates for reconstruction of the mandibular ramus and condyle using autogenous costochondral grafts

Fig. 1. Lateral view of a 3-dimensional reconstruction (with no right ramus o h ostochondral grafts are conventionally used for the recontruction of the ascending ramus and condyle of the andible.1–3 Their main advantages are their biocompatiility and potential for growth, and disadvantages are the npredictability of the pattern of this growth, and the large mounts of cartilage that are needed. 4,5 When we harvest the graft we estimate the amount of bone equired intraoperatively and must be cautious not to remove xcessive cartilage. Later we trim the graft and attempt to dapt it to the missing bony segment. We use 3-dimensional planning and manufacture guides nd templates for the optimal reconstruction of the mandible. he software used for planning applies mirroring technology nd creates 3-dimensional printed stereolithographic temlates of the planned graft, which results in precise harvesting nd accurate reconstruction. We used this technique on an 8-year-old boy with no right ygomatic arch, condyle, or ascending ramus, and on a 6ear-old boy, who had hemifacial microsomia, Pruzansky ype III (Fig. 1). First, the patients were scanned with spiral com-

Secondary bone grafting of the cleft maxilla following reverse quad-helix expansion in 103 patients

Introduction: The main points to consider in secondary alveolar bone grafting (ABG) of cleft patients are age at the time of surgery, the type of bone graft, and pre/postorthodontic expansion of the upper jaw. Purpose: The aim of this study is to evaluate the reverse quad-helix (RQH) expander device. Does RQH improve the surgical procedure before ABG? We will evaluate the outcome of the procedure, duration of the operation, hospitalization time, satisfaction of the surgeon with this procedure and the success of the bone graft in the long-term. Patients and Methods: We reviewed the medical records of 103 cleft patients who underwent secondary bone grafting at our institution between 2001 and 2012. All patients were treated presurgically with a RQH appliance to expand the cleft area. The following data were recorded for each of the patients: Unilateral/bilateral cleft, surgery time, hospital stay, success/failure, and follow-up. Conclusion: Presurgical orthodontic application of the RQH expander in the cleft area enabled improved anterior expansion rather than posterior expansion. This technique improves access for surgery and bone grafting, the use of RQH facilitates the improved manipulation of the nasal mucosa via direct view due to the wide separation of the alveolar segments in the cleft area. Furthermore, this gap enables improved access for the bone grafting procedure, shortens the surgery time and provides stable maxillary transverse correction.

Maxillary tumour-induced osteomalacia

Tumour-induced osteomalacia (TIO) is a rare paraneoplastic form of renal phosphate wasting that results in severe hypophosphatemia, defective vitamin D metabolism, and osteomalacia. In the case reported here, maxillary TIO was not diagnosed for 6years, although initial complaints were reported when the patient was 12years old. Meanwhile she suffered from profound growth limitation, pain, weakness, and spontaneous multiple bone fractures, culminating in complete loss of ambulatory ability and severe limitation in daily activities. At age 18years, she finally received an accurate diagnosis and definitive treatment was administered. She underwent a partial maxillectomy with complete removal of the tumour, resulting in a full cure. Shortly afterwards the patient regained the ability to walk, no longer needing the wheelchair to which she had been confined. This definitive diagnosis was based on three modalities: (1) fibroblast growth factor 23 analysis (high levels of the secreted hormone were found on the left side of the maxilla in the facial vein and pterygoid plexus, pinpointing the tumour location), (2) octreotide scan, and (3) 68Ga-DOTA-NOC-PET/CT. TIO removal via partial maxillectomy led to a complete reversal of this patients health condition, restoring her ability to walk and function. The importance of prompt employment of these diagnostic modalities and the high level of clinical suspicion required in such cases are clear.

Sandwich osteotomy for the reconstruction of deficient alveolar bone

Alveolar bone deficiency is a very common problem encountered by the practitioner when planning dental implants. The severity of the deficiency is variable. Many practitioners perform augmentation using the method they feel comfortable with and do not necessarily use the most appropriate method. This is a retrospective study on 21 patients between the ages of 25 and 63 years exhibiting moderate vertical alveolar bone deficiency and treated by the sandwich technique. Mean vertical bone gain was 7.5mm. Sixty-one dental implants were inserted showing a survival rate of 96.7% with a median of 3.1 years follow-up. Main advantages of the method include minimal relapse, single operation and preservation of the native cortical bone in the occlusal surface. We believe the surgeon should maintain the capability of using different augmentation techniques and utilize them appropriately for different severities of deficiency. We wish to establish a paradigm for using different augmentation methods We recommend using the sandwich technique in the moderate deficient cases as described in this work, using alveolar distraction osteogenesis for the severe cases as described in our previous work, where lack of soft tissue for proper closure is a major limitation, and using guided bone regeneration for minor deficiencies.