Complications of mandibular distraction osteogenesis for acquired deformities: a systematic review of the literature

Abstract

A systematic review on complications in all forms of mandibular distraction osteogenesis (MDO) for acquired deformities was performed. Search terms expressing distraction osteogenesis were used in ‘AND’ combination with search terms comprising ‘mandible’ and terms for complication, failure, and morbidity. A search using PubMed (National Library of Medicine, NCBI), EMBASE, and the Cochrane Controlled Trials Register yielded 644 articles published between 1966 and mid October 2013. Three hundred and twenty-one eligible articles were screened in detail. Complications related to MDO in acquired deformities were reported in 105 clinical articles, involving 1332 patients. Treatments included alveolar distraction osteogenesis (ADO), mandibular lengthening, DO in bone grafts, and bi-/trifocal transport disc DO (TDDO) for segmental mandibular defects. A high incidence of complications was seen in MDO for acquired deformities (ADO 44.4%; residual group 43.9%). An index for classifying complications in MDO, based on the impact and further treatment or final results, was used. In the ADO group, soft tissue complications (8.0%), insufficient vector control (7.6%), temporary inferior alveolar nerve (IAN) neurosensory disturbances (6.5%), device-related problems (3.5%), mandible fractures (2.8%), insufficient bone formation (2.5%), and fracture of the transport disc (1.3%) were seen. In the residual group, temporary IAN neurosensory disturbances (13.4%), minor infection (5.3%), DO failure (4.0%), and device-related problems (3.8%) were reported.

Mandibular distraction osteogenesis (MDO) is a versatile technique that is applied in patients with congenital, developmental, and acquired mandibular deformities. After its introduction for the lengthening of the human mandible by McCarthy in 1992, a broad spectrum of indications and applications has arisen.

Vertical distraction osteogenesis of the alveolar bone (ADO) for dental implant placement as an alternative to bone grafting is a common indication. However, this challenging technique is prone to a variety of complications.

Patients with indications for reconstructive surgery for segmental mandibular defects after ablative oncology surgery, post-traumatic patients, and patients with complications following prior surgery to the mandible have been treated successfully using a form of DO. Transport disc DO (TDDO) can be applied in a bifocal or trifocal manner, enabling DO at more than one location in the patient. DO can also be used for bone regeneration in free vascularized bone grafts (e.g. fibula). Temporomandibular joint (TMJ) ankylosis can be treated successfully by means of DO for mandibular lengthening, and this can be done in combination with a gap arthroplasty in some patients.

The aims of this study were (1) to perform a systematic review of the literature on complications of MDO for acquired deformities, and (2) to classify all complications using a new classification.

Materials and methods

Literature search

A comprehensive systematic review of the literature was performed in the bibliographic databases PubMed (National Library of Medicine, NCBI), EMBASE, and the Cochrane Central Register of Controlled Trials from inception to 15 October 2013; the review was performed in accordance with the PRISMA statement. Search terms included controlled terms from medical subject headings (MeSH) in PubMed and Emtree in EMBASE, as well as free text terms. We used free text terms only in The Cochrane Library. Search terms expressing distraction osteogenesis were used in ‘AND’ combination with search terms comprising ‘mandible’ and terms for complication, failure, and morbidity’ ( Table 1 ). The references of the articles identified were searched for additional relevant publications.

Table 1
Primary and secondary keywords used for the systematic research.
Primary keywords Secondary keywords
Distraction Mandible
Distraction osteogenesis Mandibular
Lengthening Alveolar
Complication
Complicated
Failure
Morbidity

Study selection and inclusion criteria

Two reviewers independently screened all potentially relevant titles and abstracts for pre-specified eligibility criteria. If necessary, the full text article was checked for the eligibility criteria. Differences in judgement were resolved through a consensus procedure. Full text articles were then obtained for further review.

Articles were included if they met the following eligibility criteria: (1) clinical article, (2) mandibular distraction osteogenesis (MDO), (3) acquired mandibular deformity, and (4) a report on complications. Exclusion criteria were (1) insufficient data on complications, (2) no available translation, and (3) non-clinical article ( Table 2 ).

Table 2
Inclusion and exclusion criteria.
Condition Article types Number of papers ( n )
Excluded from the systematic review Non-acquired deformity 130
No relevance: complications and/or methods were inadequately or not mentioned 41
Non-clinical articles (experimental, scientific, synopsis) 17
Non-(mandibular) distraction osteogenesis 4
No translation available 10
Publication type, e.g. letter to the editor, discussion 9
Not available in international libraries 5
Included in the systematic review Clinical articles on complications in mandibular distraction osteogenesis for acquired deformities 105

The remaining articles, which were clinically relevant to the subject of the study, were included in the systematic review. According to their emphasis, these relevant papers were included if they described MDO in acquired deformities. The articles were screened for the following data: type of deformity, number of patients, type of DO, distraction device, vector, and type and number of complications. The latter were classified according to the proposed classification index shown in Fig. 1 . This classification places emphasis on the severity and clinical consequences of a complication by dividing events according to whether they are spontaneously resolving or permanent complications, and whether hospitalization or general anaesthesia is required for correction of the complication.

Fig. 1
Distraction osteogenesis complication index.

The initial literature search yielded a total of 973 references: 521 in PubMed, 437 in EMBASE, and 15 in The Cochrane Library. After removing duplicate references that were selected from more than one database ( n = 329), 644 papers remained. The titles and abstracts were screened for eligibility. Three hundred and twenty-three articles were excluded from the review based on the abstract. The full text was obtained for 321 papers and analyzed further. In total, 216 articles were excluded from the review ( Table 2 ): (1) 130 articles described MDO in patients with non-acquired mandibular deformities; (2) 41 articles had insufficient or no information on complications and/or methods; (3) 17 papers were non-clinical (three scientific, 14 synopsis); (4) four papers had no relevance (three non-DO, one maxilla); (5) 10 papers had no available translation (four Russian, three Chinese, two Hebrew, one Japanese); (6) nine articles had an edited publication type (five discussion, four letters to the editor/authors); and (7) five papers were not available in the international libraries. These seven groups were excluded from further evaluation. In the case of a paper that reported complications in a mixed population (congenital, developmental, and/or acquired), in which the complications could not be traced back to the exact patient subgroup, the article was excluded on the basis of insufficient data. A total of 105 articles met the inclusion criteria and described MDO in acquired deformities. A flowchart of the literature search and selection process through the different phases of the systematic review (PRISMA) is given in Fig. 2 .

Fig. 2
Flowchart of the search and selection procedure using PubMed, EMBASE, and The Cochrane Library.

Results

This selection of acquired deformities consisted of six groups: (partial) atrophic mandible, reconstructive surgery of mandibular defects, TMJ ankylosis, post trauma, obstructive sleep apnoea syndrome (OSAS), and complications of prior treatment. The group comprised a total of 1332 treated patients. Treatments varied from local procedures such as alveolar or vertical DO and mandibular lengthening, to extensive surgery involving DO in bone grafts or bi/trifocal TDDO for segmental mandibular defects.

Fifty-one publications discussed cases involving 936 patients (70.3% of the acquired group) who had undergone pre-implant alveolar or vertical DO of the (partial) atrophic mandible. These surgical techniques involve mainly vertical bone augmentations facilitated by DO. Twelve publications mentioned no occurrence of complications. This group experienced 416 complications ( Table 3 ), giving an overall incidence of 44.4%.

Table 3
Complications in mandibular distraction osteogenesis for the treatment of (partial) atrophic mandibles ( n = 936), classified according to the DO classification index.
Complications n (%)
Type I (complications resolving spontaneously within 6 months)
Temporary neurosensory disturbances of the IAN or mental nerve 61
Minor relapse of distracted bone 14
Pain/discomfort 10
Fracture of the mandibular basal bone 4
Fracture of the transport segment 2
Premature union 2
Immature bone quality 2
Subtotal 95 (10.1%)
Type II (medically or technically manageable complication, without hospitalization)
Lingual displacement of transport disc (technically manageable with/without supporting miniplast splint/traction appliance) 71
Soft tissue dehiscence 31
Minor infection (including pin tract infection) 16
Intermaxillary interference of device 5
Subtotal 123 (13.1%)
Type III (surgically manageable complication requiring local anaesthesia only, without hospitalization)
Soft tissue dehiscence (requiring closure) 29
Insufficient bone formation (requiring bone graft) 23
Inadequate/insufficient attached mucosa (requiring vestibuloplasty with or without additional grafting) 15
Dislocated device 1
Subtotal 68 (7.3%)
Type IV (technical complication, necessitating general anaesthesia for correction)
Premature loss of the device 12
Device failure (requiring replacement) 10
Fracture of device 10
Insufficient length of device 1
Subtotal 33 (3.5%)
Type V (medically/surgically manageable complication with hospitalization or general anaesthesia)
Mandible fracture (basal bone) 26
Fracture of the transport disc 12
Insufficient bone formation (requiring bone grafting) 7
Major displacement of transport disc (requiring additional osteotomy) 6
Subtotal 51 (5.4%)
Type VI (permanent sequelae, functionally and/or psychosocially disabling, and unachieved goal or unsatisfactory result)
Insufficient bone formation 23
Permanent IAN neurosensory disturbance 7
Premature loss of device 5
Fracture/resorption of the transport disc 4
Fracture of the basal bone 3
Insufficient length of device 1
Incorrect osteotomy 1
Excessive tilting 1
Non-union 1
Subtotal 46 (4.9%)
Total 416 (44.4%)
DO, distraction osteogenesis; IAN, inferior alveolar nerve; TMJ, temporomandibular joint.

The residual acquired group (reconstructive surgery of mandibular defects, TMJ ankylosis, post trauma, OSAS, and complications of prior treatment) consisted of 396 patients. Patients underwent mandibular lengthening (combined with TMJ arthroplasty in some patients), TDDO, DO in bone grafts (iliac crest, fibula, rib, scapula), mandibular widening, and vertical DO in native (residual) mandible. A combination of treatments also took place. Fifty-four publications listed 174 complications ( Table 4 ). No complications were reported in 19 publications. The overall complication incidence in this group was 43.9%. An overview of all complications is listed in Table 4 .

Table 4
Complications in mandibular distraction osteogenesis for the treatment of acquired mandibular defects ( n = 396), classified according to the DO classification index.
Complications n (%)
Type I (complications resolving spontaneously within 6 months)
Temporary neurosensory disturbances of the IAN 53
Pain 20
Seroma 6
Hematoma 4
Delayed bone formation 2
Pressure ulcer 1
TMJ complaints 1
Transient facial nerve palsy 1
Minor occlusal discrepancy 1
Subtotal 89 (22.5%)
Type II (medically or technically manageable complication, without hospitalization)
Minor infection 21
Anterior open bite 3
Lingual displacement of the transport disc 2
Pin loosening 1
Subtotal 27 (6.8%)
Type III (surgically manageable complication requiring local anaesthesia only, without hospitalization)
Abscess 4
Subtotal 4 (1.0%)
Type IV (technical complication, necessitating general anaesthesia for correction)
Device failure 4
Fracture of the device 3
Loosening of the pins 1
Subtotal 8 (2.0%)
Type V (medically/surgically manageable complication with hospitalization or general anaesthesia)
Mandible fracture 7
Insufficient bone formation 4
Incomplete osteotomy 1
Hypertrophic scar formation 3
Lateral open bite 3
Exposure of the distractor 2
Disproportion of soft tissue (TDDO) 1
Subtotal 21 (5.3%)
Type VI (permanent sequelae, functionally and/or psychosocially disabling, and unachieved goal or unsatisfactory result)
Insufficient bone formation 7
Premature loss of the device 7
Hypertrophic scar formation 6
Permanent neurosensory disturbance of the IAN 3
Fibrous non-union 1
Loss of transport disc 1
Subtotal 25 (6.3%)
Total 174 (43.9%)
DO, distraction osteogenesis; IAN, inferior alveolar nerve; TMJ, temporomandibular joint; TDDO, transport disc DO.

Results

This selection of acquired deformities consisted of six groups: (partial) atrophic mandible, reconstructive surgery of mandibular defects, TMJ ankylosis, post trauma, obstructive sleep apnoea syndrome (OSAS), and complications of prior treatment. The group comprised a total of 1332 treated patients. Treatments varied from local procedures such as alveolar or vertical DO and mandibular lengthening, to extensive surgery involving DO in bone grafts or bi/trifocal TDDO for segmental mandibular defects.

Fifty-one publications discussed cases involving 936 patients (70.3% of the acquired group) who had undergone pre-implant alveolar or vertical DO of the (partial) atrophic mandible. These surgical techniques involve mainly vertical bone augmentations facilitated by DO. Twelve publications mentioned no occurrence of complications. This group experienced 416 complications ( Table 3 ), giving an overall incidence of 44.4%.

Table 3
Complications in mandibular distraction osteogenesis for the treatment of (partial) atrophic mandibles ( n = 936), classified according to the DO classification index.
Complications n (%)
Type I (complications resolving spontaneously within 6 months)
Temporary neurosensory disturbances of the IAN or mental nerve 61
Minor relapse of distracted bone 14
Pain/discomfort 10
Fracture of the mandibular basal bone 4
Fracture of the transport segment 2
Premature union 2
Immature bone quality 2
Subtotal 95 (10.1%)
Type II (medically or technically manageable complication, without hospitalization)
Lingual displacement of transport disc (technically manageable with/without supporting miniplast splint/traction appliance) 71
Soft tissue dehiscence 31
Minor infection (including pin tract infection) 16
Intermaxillary interference of device 5
Subtotal 123 (13.1%)
Type III (surgically manageable complication requiring local anaesthesia only, without hospitalization)
Soft tissue dehiscence (requiring closure) 29
Insufficient bone formation (requiring bone graft) 23
Inadequate/insufficient attached mucosa (requiring vestibuloplasty with or without additional grafting) 15
Dislocated device 1
Subtotal 68 (7.3%)
Type IV (technical complication, necessitating general anaesthesia for correction)
Premature loss of the device 12
Device failure (requiring replacement) 10
Fracture of device 10
Insufficient length of device 1
Subtotal 33 (3.5%)
Type V (medically/surgically manageable complication with hospitalization or general anaesthesia)
Mandible fracture (basal bone) 26
Fracture of the transport disc 12
Insufficient bone formation (requiring bone grafting) 7
Major displacement of transport disc (requiring additional osteotomy) 6
Subtotal 51 (5.4%)
Type VI (permanent sequelae, functionally and/or psychosocially disabling, and unachieved goal or unsatisfactory result)
Insufficient bone formation 23
Permanent IAN neurosensory disturbance 7
Premature loss of device 5
Fracture/resorption of the transport disc 4
Fracture of the basal bone 3
Insufficient length of device 1
Incorrect osteotomy 1
Excessive tilting 1
Non-union 1
Subtotal 46 (4.9%)
Total 416 (44.4%)
Only gold members can continue reading. Log In or Register to continue

Jan 17, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Complications of mandibular distraction osteogenesis for acquired deformities: a systematic review of the literature
Premium Wordpress Themes by UFO Themes