Mandibular Distraction: An Overview
Guest: Dr. Christopher Discolo - Otolaryngology - Head & Neck Surgery, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. Christopher Discolo, Assistant Professor of Ear, Nose, and Throat here at the Medical University of South Carolina. Dr. Discolo, let’s talk, today, about a procedure called jaw distraction, or mandibular distraction. The mandible, of course, is the jaw. What condition is it that children are born with that requires them to have that operation?
Dr. Christopher Discolo: There are several conditions that might require this operation. The most common is a condition called Pierre Robin Sequence. In this condition, children are born with a very small jaw. And what that does is push the tongue up and back, into the back of the throat, which makes feeding and breathing very difficult for those children.
Dr. Linda Austin: Can this be diagnosed by ultrasound when the mother is pregnant, or is this something that the pediatrician diagnoses after birth?
Dr. Christopher Discolo: It’s something that we most commonly see diagnosed after birth, either by the pediatrician or the neonatologist.
Dr. Linda Austin: So it can be diagnosed, then, at the time of birth, it’s not a developmental problem?
Dr. Christopher Discolo: That’s correct. It’s usually diagnosed immediately at birth, given the fact that the children have very small jaws, and this is a physical exam finding that’s pretty readily apparent.
Dr. Linda Austin: How common is this problem?
Dr. Christopher Discolo: Here at MUSC, we see several patients per year with this problem, although it is extraordinarily rare in the general population.
Dr. Linda Austin: So, rare for physicians to see outside of a major medical center such as ours, is that right?
Dr. Christopher Discolo: That’s correct.
Dr. Linda Austin: When you’re counseling parents, what do you tell them about what to expect? Are there feeding problems, for example, or speech problems, or is it really more a cosmetic problem; appearance problem?
Dr. Christopher Discolo: Early on in life, it’s mostly a feeding and breathing problem that these children have. Children who are born with Pierre Robin Sequence will very often, eventually, develop normal-sized jaws as they grow older. However, if the jaw is small enough when they’re just born, they will not be able to eat or breathe very effectively and something will need to be done.
Dr. Linda Austin: And what is that something? What do you do for this?
Dr. Christopher Discolo: Well, there are several options. We tend to start with the simplest and least invasive options, which include positioning the baby on their belly to take advantage of gravity, pulling the tongue out of the back of the mouth. If that doesn’t work, we would usually progress to inserting a small tube through the nose, bypassing the tongue, which will help the child breathe. If that doesn’t work, and the child is still having difficulty feeding or breathing, there are three surgical options that are commonly performed.
One is called a tongue-lip adhesion where the tongue is basically sewn forward to the lip. This is done in an attempt to bring the tongue into a more natural position and to prevent it from blocking the baby’s ability to breathe. Another procedure which has been used for many years with good success is something that’s called the tracheotomy, which is where a small hole is made in the baby’s windpipe, through the neck, and a tube is placed so the baby can breathe, and again, bypassing the area of obstruction. Those two procedures, however, are associated with lots of complications. A newer procedure that we employ to deal with this problem is the jaw distraction surgery.
In that operation, we make a controlled cut in the child’s jaw bone and place some specialized screws and plates on the jaw. We’re able to advance these screws a little bit each and every day to move the bones further and further apart. If you do this slowly enough, you’ll actually regenerate bone in between the two parts of bone that you’re pulling apart from each other. This will help bring the jaw forward, relieve the baby’s obstruction, and allow them to feed more effectively.
Dr. Linda Austin: So, that sounds like it’s a more definitive operation, or it might have better long-term results, is that correct?
Dr. Christopher Discolo: Well, that’s correct. The other two operations are seeking to just bypass the problem. The jaw distraction is designed to address the problem directly and move the jaw and the tongue forward, then hopefully improve the baby’s ability to breathe and feed.
Dr. Linda Austin: Now, you mentioned that the screw is something that you turn a little bit every so often. How often?
Dr. Christopher Discolo: It’s generally turned twice a day. Initially, that’s done in the hospital by the doctor or nurse. However, the parents are taught how to do this, and after the child goes home, they’ll be the ones performing the distraction each and every day.
Dr. Linda Austin: For how long?
Dr. Christopher Discolo: It depends on how bad the jaw is to begin with. Generally, it’s about 10 to 14 days of active movement of the jaw.
Dr. Linda Austin: That’s actually not so long.
Dr. Christopher Discolo: It’s not. But after that, you need to hold the bone in place for about four to six weeks so that it can regenerate. All in all, it’s about a two-month process from start to finish.
Dr. Linda Austin: And usually at what age? How old is the baby?
Dr. Christopher Discolo: We do it as early as the children need it. It’s been done as early as few days of life in children who have significant problems with breathing. Most commonly it’s performed within the first couple of months of life.
Dr. Linda Austin: And what is the success rate for that surgery?
Dr. Christopher Discolo: The success rate is very high, on the order of 80 to 90 percent.
Dr. Linda Austin: Wow. And so then, is that it? Once a child has that, if they’re in that 80 to 90 percent, is that it for the rest of their lives, or are there other procedures that they have to have?
Dr. Christopher Discolo: That is generally the only procedure that they’ll need for their jaw problem. Many of these children will also have a cleft palate which will need to be repaired at some point. But in terms of the small jaw causing issues, if the surgery is a success, then the family doesn’t have to worry about that anymore.
Dr. Linda Austin: This is a personal story. My son actually had the opposite problem. His lower jaw was protruding, and when he was about eight, I think, he had an orthodontic appliance installed that had a little screw that we had to turn every night for a month. And it astounded me that within the course of a month, that was correctible. Do you have any comments on just how amazing it is that the jaw is so capable, I guess, of responding to what seems like, actually, a rather small appliance, and yet somehow it stimulates growth?
Dr. Christopher Discolo: That’s very true. These techniques have really revolutionized the way that we’re able to care for children and young adults that need to have parts of their facial skeleton moved, either because they’re too small, or perhaps even too big.
Dr. Linda Austin: Yeah. Do these kids with small jaws end up needing braces, typically, later on, as children?
Dr. Christopher Discolo: Very often, they will, especially if there’s a cleft palate associated with the small jaw. Children with cleft palate will almost universally need braces at some point during their life.
Dr. Linda Austin: But they’ll have plenty of company in that they’ll look around at their classmates and a lot of their classmates will be in braces as well.
Dr. Christopher Discolo: That’s correct. It’s very common.
Dr. Linda Austin: Dr. Discolo: You’re doing such phenomenal work here at MUSC. I know that you just came here in 2008, and we welcome you, and we’re so pleased to have you here with us.
Dr. Christopher Discolo: Thank you very much.
Dr. Linda Austin: Thank you.
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