- •
In properly selected patients, neonatal mandibular distraction osteogenesis can resolve tongue-based airway obstruction and obviate tracheostomy in Pierre Robin sequence patients with severe airway obstruction.
- •
Understanding mandibular morphology in Robin sequence is crucial to plan and to properly place osteotomies and vectors.
- •
The complication rate associated with neonatal mandibular distraction is low in both occurrence and level of acuity.
- •
Specific indications for neonatal mandibular
Robin Sequence: Neonatal Mandibular Distraction
Section snippets
Key points
Surgical management
Robin sequence patients with severe airway obstruction, who fail nonsurgical management, are considered for surgical intervention, including tracheostomy, tongue-lip adhesion (TLA), MDO, or subperiosteal release of the floor of mouth.27 Tracheostomy is a direct, effective method to establish the airway, which relies on subsequent mandibular growth to facilitate decannulation.28 As tracheostomy is associated with multiple morbidities, including laryngeal stenosis, tracheomalacia, chronic
Surgical considerations in mandibular distraction
As most Robin sequence cases have primary hypoplasia of the mandibular body, a horizontal vector is commonly used. In contrast, several other institutions do use a vertical vector for the mandibular distraction.22,49 Duarte and Collares,66 comparing pre-MDO and post-MDO, showed horizontal vectors resulted in an increase of 11% for ramus, and 36% in body length, whereas the vertical vectors showed an elongation of 34% in ramus and 27.5% in body length. Vertical vectors were used in 30% of their
Long-term outcomes of mandibular distraction osteogenesis
A dearth of primary literature exists on long-term outcomes of MDO, given it is a newer treatment modality than tracheostomy and TLA. A robust meta-analysis review of MDO surgical outcomes in the Robin sequence literature from 1960 to 2017 demonstrates 95% avoidance of tracheostomy, 80% decannulation, 87% full oral feeds at follow-up, and a 4% to 6% rate of reoperation.40 MDO patients were found to have 6.1 times increased odds of successful resolution of obstructive apnea compared with TLA
Future directions
Surgical treatment in this challenging patient population has been previously hindered by noncomparative analyses of techniques and low-level evidence recommendations that are largely based on expert opinion. Although there has been a steady improvement in the scientific quality of clinical outcomes reports over the last 10 years, further research is required. Currently, there is a paucity of high-level evidence regarding diagnosis, treatment, and long-term outcomes of infants with Robin
Clinics care points
Consensus on the definition of Robin sequence is paramount to facilitate future prospective and comparative research studies examining treatment protocols and clinical outcomes in this challenging, heterogenous patient population. A validated evaluation protocol is needed to standardize patient care. Specifically, objective studies to evaluate the severity of airway obstruction, namely polysomnography, must be universally incorporated into such protocol. Mandibular distraction is proven to be a
Disclosure
The authors have nothing to disclose.
References (80)
- et al.
Pierre Robin sequence
Clin Plast Surg
(2019) - et al.
Severity of clinical manifestations and laryngeal exposure difficulty predicted by glossoptosis endoscopic grades in Robin sequence patients
Int J Pediatr Otorhinolaryngol
(2016) - et al.
Characteristics of sleep apnea in infants with Pierre-Robin sequence: is there improvement with advancing age?
Int J Pediatr Otorhinolaryngol
(2015) - et al.
Airway, feeding, and growth in infants with Robin sequence, and sleep apnea
Int J Pediatr Otorhinolaryngol
(2013) - et al.
Subglottic stenosis: another challenge for intubation and potential mechanism of airway obstruction in Pierre Robin sequence
Int J Pediatr Otorhinolaryngol
(2011) - et al.
Tracheostomy versus mandibular distraction osteogenesis in infants with Robin sequence: a comparative cost analysis
Br J Oral Maxillofac Surg
(2014) - et al.
Defining failure and its predictors in mandibular distraction for Robin sequence
J Craniomaxillofac Surg
(2015) - et al.
Is tongue-lip adhesion or mandibular distraction more effective in relieving obstructive apnea in infants with Robin sequence?
J Oral Maxillofac Surg
(2019) Distraction osteogenesis in Pierre Robin neonates with airway obstruction
Clin Plast Surg
(2004)- et al.
Mandibular distraction osteogenesis in children with Pierre Robin sequence: impact on health-related quality of life
Int J Pediatr Otorhinolaryngol
(2012)