Mandibular Advancement with Bilateral Vertical Ramus Osteotomies in an Infant: A Novel Technique for Addressing Airway Distress in Patients with Craniofacial Anomalies

Abstract

Patients with craniofacial syndromes that affect mandibular conformation and growth may face significant airway difficulties. Mandibular distraction osteogenesis is a favored surgical approach for addressing micrognathia or retrognathia, in which bone is generated at distracted osteotomized segments in order to advance the mandible and improve airway patency1. Patients with severe craniofacial anomalies, including Goldenhar Syndrome, may have unfavorable mandibular anatomy for distraction, and it has been shown that patients with Goldenhar Syndrome have lower success rates with mandibular distraction and more often require tracheostomy2. Novel approaches must be explored to better treat the respiratory issues these patients endure as a result of their craniofacial abnormalities. One infant with a severe form of hemifacial microsomia and airway obstruction requiring oxygen via nasal cannula underwent a novel technique of bilateral extraoral vertical ramus osteotomies with bone graft placement to advance the mandible. Patient outcomes were assessed clinically and with pre- and post-operative computed tomography (CT) scans and polysomnograms (PSG). In November of 2020, one 2-month-old male with hemifacial microsomia and respiratory difficulties underwent bilateral extraoral vertical ramus osteotomies with bone graft placement, as his anatomy made him a poor candidate for mandibular distraction. Post-operative CT scan showed a more anatomical condylar position relative to the glenoid fossa bilaterally, improved chin point position to midline, a more favorable maxillomandibular position, and improved airway patency. Pre-operative PSG showed an apnea-hypopnea index (AHI) of 29.3, with the 1-month post-operative PSG showing an AHI of 17.3 and the 4-month post-operative PSG showing an AHI of 0.6. In neonatal or infant patients with severe forms of craniofacial anomalies, including Goldenhar syndrome, mandibular advancement via bilateral vertical ramus osteotomies with bone grafting is a functional alternative to mandibular distraction osteogenesis. For patients with more severe forms of hemifacial microsomia, including Goldenhar Syndrome, mandibular distraction osteogenesis may not be a predictable approach for relieving airway distress. This case report presents a novel technique for addressing the respiratory difficulties associated with this congenital condition. Bilateral vertical ramus osteotomies with bone graft placement can effectively advance the mandible, stabilizing the airway and avoiding the need for tracheostomy in this population.