Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2018; 63:(1 Suppl): S69–S78

doi: 10.1111/adj.12592

Paediatric oral & maxillofacial surgery

JM Shand*†
*Department of Plastic & Maxillofacial Surgery, The Royal Children’s Hospital of Melbourne, Parkville, Victoria, Australia.
†Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.

ABSTRACT
Children have differences in their physiology, anatomy and they are continuing to grow and develop. The management
of pathology, trauma, deformity and upper airway obstruction in the young growing patient has to take into account
these factors in the treatment planning for these conditions. It is important for Oral & Maxillofacial Surgeons to under-
stand the potential impact of disease or injury on the developing facial skeleton and dentition. This chapter will provide
an overview of the some of the major components of paediatric maxillofacial surgery and their management.
Keywords: Craniofacial, Oral & Maxillofacial Surgery, Paediatrics.
Abbreviations and acronyms: CCD = cleidocranial dysplasia or dysostosis; CPAP = continuous positive airway pressure; ENT = ear
nose and throat; ICP = intracranial pressure; LCH = langerhans cell histocytosis; NBCCS = naevoid basal cell carcinoma syndrome;
NGT = nasogastric tube; OKC = odontogenic keratocyst; OSA = obstructive sleep apnoea; PEG = percutaneous endoscopic gastros-
tomy; SAME = surgically assisted maxillary expansion.
Accepted for publication October 2017.

approach that often includes Neonatal Medicine,

INTRODUCTION
Respiratory Medicine, Ear-Nose & Throat Surgery,
Paediatrics involves the care of infants, children and Plastic Surgery and Paediatricians.
adolescents. Neonatal and infant patients have signifi-
cant physiological differences and older paediatric
CLEFT LIP AND PALATE
patients are continually developing towards adulthood
and this impacts upon the care of these individuals. Cleft lip and cleft palate are fusion disorders affecting
Paediatric Oral & Maxillofacial Surgery (OMS) is a the mid-facial skeleton. Clefting can occur in isolation
sub-specialty that has evolved to manage the specific or as a feature in a range of syndromes. The incidence of
needs of neonates, infants and the growing child and cleft lip and palate varies worldwide and is affected by
it involves the care of patients with congenital cranio- region of birth, gender, ethnicity and maternal charac-
facial & developmental facial anomalies, cleft lip and teristics. Cleft lip, cleft palate and the cleft alveolus
palate, trauma, abnormal jaw growth, TMJ disorders (maxillary cleft) are a group of conditions that represent
in children, dentoalveolar conditions/anomalies, paedi- the most common facial deformity and may occur in iso-
atric pathology and obstructive sleep apnoea. The lation or in combination, such as cleft lip & palate.
more complex areas of paediatric OMS are under- Patients with both cleft lip & palate will also have
taken in tertiary paediatric hospitals in Australasia an alveolar cleft (maxillary cleft) with associated
and in the major cities of the world. This chapter will labial and palatal oro-nasal fistulae that may permit
provide an overview of some of the major compo- oro-nasal regurgitation (Fig. 1). A contour depression
nents of treating the paediatric patient with maxillofa- at the region of the pyriform aperture accentuates the
cial surgery. alar base asymmetry. In the region of the alveolar
The management of patients may involve liaison cleft, the dentition is typically distorted. While the
and the co-ordination of care with all dental speciali- permanent lateral maxillary incisor is usually absent
ties, principally with orthodontics and paediatric or malformed in a complete cleft of the alveolus, there
dentistry. may also be one or more small, conical supernumer-
For patients with craniofacial syndromes and disor- ary teeth present in the alveolar cleft (Fig. 2).
ders, obstructive sleep apnoea and some pathologies, Patients with cleft deformities often have multiple
care is undertaken within a multidisciplinary team dental anomalies and may have supernumerary or

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JM Shand

secondary alveolar bone grafting of the maxillary cleft

is the next phase of surgical care.
The optimal time for performing alveolar bone
grafting has been the subject of debate over many
years and the recommended timing has varied. Pri-
mary bone grafting, usually performed before the age
of 2 years, has been advocated by some centres but
significant inhibition of growth and development of
the maxilla has been recognised. The prevailing con-
sensus is that outcomes are optimised when sec-
ondary bone grafting is undertaken. Boyne et al.1 in
1972 followed by Bergland et al.2 in 1986 proposed
that the ideal time for grafting is between 9 and
11 years before the eruption of the canine and when
the canine root has 1/2 to 2/3 development. Subse-
quent studies have supported this timing for recon-
struction of the maxillary alveolus. Daskalogiannakis
Fig. 1 Maxillary cleft with oro-nasal fistula. et al.3 demonstrated that grafting during the mixed
dentition phase has a minimal effect on subsequent
vertical and antero-posterior development of the
maxilla.
Late secondary grafting, after the completion of
maxillary growth and tertiary grafting, following the
failure of previous grafts, are much less successful in
comparison. Tertiary grafting is recognised as techni-
cally extremely difficult, particularly in bilateral cases,
and requires additional surgical experience and skill.
The majority of paediatric surgery units preferentially
perform alveolar bone grafting in the mixed dentition,
Fig. 2 OPG radiograph demonstrating right maxillary alveolar cleft. between 8 and 12 years, with orthodontic arch expan-
sion undertaken when required prior to surgery to
impacted teeth that require removal or exposure or improve access to the alveolar cleft and nasal floor
missing teeth that require management with either closure (Figs 3a–3c).4 Dental age rather than chrono-
replacement or orthodontic space closure. The maxilla logical age determines the timing of surgery. One of
is often narrow with a transverse discrepancy and the most challenging areas is the protrusive premaxil-
expansion may be required before the alveolar bone lary segment in bilateral cleft patients. The procedure
graft. of premaxillary repositioning is technically challenging
The management of the secondary cleft deformity is to adequately reposition the segment and there are
undertaken in stages and is challenging. After the pri- significant potential complications relating to the vas-
mary repair of the cleft lip and palate in infancy, cularity.

(a) (b) (c)

Fig. 3 (a) Intraoperative view of maxillary cleft exposed with closure of the lining of the nasal floor. (b) Alveolar bone graft with iliac crest (hip) graft to
maxillary cleft. (c) Closure of mucosal flaps overlying the alveolar bone graft in a bilateral cleft lip and palate patient.

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 Paediatric OMS

A variety of donor sites have been described for presence of fistulae, potential fracture through the
alveolar bone grafting and include the iliac crest, cal- maxillary cleft sites, tight soft tissue envelope and
varium, mandibular symphysis, and tibia. Particulate scarring and obtaining the required mobilisation to
marrow and cancellous bone has good osteogenic advance the maxilla, without vascular compromise,
potential and large cell population to respond to the and the long-term stability with an increased risk of
osteoinductive stimulus. Particulate marrow and can- relapse for larger advancements.5
cellous bone harvested from the iliac crest has long- If the skeletal discrepancy is very severe, a staged
term follow-up and reliability, and is considered the advancement of the maxilla, particularly when the
‘gold standard’ in most centres (Fig. 4). mandible is normal in dimension, can be considered
Following the alveolar bone grafting procedure of (Figs 6a and 6b) Staging the surgery has often been per-
the maxillary cleft, the next stages of the management formed by an early Le Fort I osteotomy with bone graft-
of the secondary cleft deformity may involve any of ing before the completion of growth to minimize the
the following stages: deformity or via intra-oral distraction maxillary as the
• Orthodontic extractions in crowded dental arches first stage of maxillary advancement (Fig. 5). The second
with the removal of third molars stage is undertaken with conventional orthognathic sur-
• Many patients will require either palatal maxillary gery to achieve the final occlusal result (Figs 7a–7c).
expansion or a surgically assisted maxillary expan- Following the correction of the skeletal malocclu-
sion (SAME) for the correction of the maxillary sion, the need for a naso-labial (lip and nose) region
transverse deficiency can be assessed. The cleft nasal deformity is a com-
• Full fixed orthodontic appliances to align and co- plex 3-D challenge that involves the skin, mucosa and
ordinate the arches cartilage and there is often a significant component of
• Orthognathic surgical procedures are performed nasal obstruction that needs to be addressed.
usually at the completion of skeletal growth
• Finishing phase of orthodontic treatment and then CONGENITAL CONDITIONS AFFECTING THE
retention
DEVELOPMENT OF TEETH AND SKELETON
• If required, lip revision and/or septorhinoplasty for
management of the nasal deformity and obstruction There are a number of conditions that can affect the
• Replacement of missing teeth with conventional or dentition such as congenitally missing teeth, mal-
implant prosthodontics. formed teeth or supernumerary teeth. Supernumerary
In the management of maxillary hypoplasia in the teeth are most common in the maxillary incisor,
cleft patient, difficulties in repositioning the maxilla mandibular premolar and third molar regions.
are greater due to lip and palatal scarring as there is Oligodontia may occur in a number of conditions for
less flexibility of the mucosa as well as additional pos- example, ectodermal dysplasia or Down Syndrome,
terior maxillary bone resulting from primary palatal and more rarely anodontia may occur with ectoder-
surgery. Mobilization and passive repositioning of the mal dysplasia. In contract, some conditions may be
maxilla into the desired position is more of a chal- associated with multiple supernumerary teeth such as
lenge due to the scarring, vascularity issues and addi- cleft lip & palate, cleidocranial dysplasia or Gardner
tional bone in the posterior maxillary region. The Le syndrome.
Fort I maxillary down-fracture procedure has to be Cleidocranial Dysplasia or Dysostoses (CCD) is one
undertaken with consideration of the need to separate of the most challenging conditions and it requires
the nasal mucosa from the palatal mucosa. Cleft max- multidiscplinary care and long-term management from
illary advancement is more challenging due to the

Fig. 4 Radiograph demonstrating successful alveolar bone graft in the

right maxillary cleft site with eruption of the canine. Fig. 5 Maxillary distraction appliances used for maxillary advancement.

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JM Shand

(a) (b)

Fig. 6 (a) Pre-operative frontal view of patient with bilateral cleft lip and palate. (b) Pre-operative lateral facial view.

(a) (b) (c)

Fig. 7 (a) Post-operative view following 2-stage maxillary advancement and genioplasty, Abbe flap for lip revision & nasal septorhinoplasty. (b) Post-
operative lateral facial view. (c) Final occlusion.

(a)
childhood to adulthood. The condition is autosomal
dominant and characterised by bone and dental
anomalies that may include delayed loss of the pri-
mary teeth, delayed eruption of the permanent denti-
tion, multiple supernumerary teeth, frontal bossing,
malocclusion and skeletally small or absent clavicles
and scoliosis are common features. Individualised
treatment planning, for each patient, is required with
the Orthodontist, Oral & Maxillofacial Surgeon and
paediatric dentist to try to achieve the optimal out-
(b)
come and for as many permanent teeth to be aligned
within the arches.
Treatment is staged with an aim to erupt the inci-
sors and first molars initially and then the premolars
and canine teeth (Figs 8a and 8b). Orthodontic con-
sideration for anchorage to allow traction and align-
ment is an integral part of the planning with each
stage of treatment. The management of the second
and third molars is the final stage. This treatment
may involve sequential extractions of deciduous teeth
and supernumerary teeth. If there is non-eruption of
Fig. 8 (a) Radiograph of child with cleidocranial dysplasia. (b) Cleidocra-
the permanent successor then surgical exposure and nial dysplasia patient undergoing orthodontic alignment following removal
bonding of teeth for orthodontic traction is often of supernumerary teeth and stages of surgical exposure & bonding.

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 Paediatric OMS

(a) (b) (c)

Fig. 9 (a) Cleidocranial dysplasia, view following surgical exposure & bonding for management of non-eruption of permanent maxillary incisors. (b)
Mandibular incisor region. (c) Post-operative radiograph.

required (Figs 9a–9c). Supernumerary teeth often con- centuries, but the investigations of Gorlin & Goltz
tinue to develop with time and require management. lead to a definition of the condition in 1960. They
Patients with CCD often have a Class III malocclu- described a syndrome characterised by a triad of fea-
sion that will require orthognathic surgery to correct tures: multiple basal cell naevi, odontogenic kerato-
this deformity. The orthodontist will need to then cysts (OKC) and skeletal anomalies including bifid
undertake presurgical alignment of the dentition prior ribs (Fig. 11). A range of other features have been
to the jaw surgery and finishing orthodontic post-sur- recognised within the spectrum of the condition and
gery. The patients often have orthodontic and surgical are variable. The diagnostic criteria for NBCCS
treatment that spans their childhood and may not be requires the presence of two major features and two
completed until they are adults. minor features.6 It has now been established that
NBCCS is an autosomal dominant disorder and a
chromosomal change with 9q22 microdeletion, in that
PAEDIATRIC PATHOLOGY AND CYSTS OF THE
a small part of chromosome 9 deleted. The PTCH1
JAWS
gene, which is a tumour suppressor gene, causes the
Cysts involving the maxilla and mandible are com- syndrome.7 An odontogenic keratocyst is frequently
monly encountered and a full spectrum of these may the first detected feature of the condition and is often
present in the paediatric population. The majority of an incidental finding on radiographic screening during
these cysts are odontogenic in origin, such as dentiger- dental or orthodontic care in the first or second dec-
ous cysts, and are the same as in the adult patient. ades. The OKC’s have identical clinical and radio-
However there are a few cysts that are specific to the graphic features to those seen in isolated cases, except
paediatric patient. For example, eruption cysts, gingi- for their propensity to develop multiple cysts.
val cysts may be seen together with the inflammatory In view of the earlier age of presentation in the
follicular cyst that is associated with non-vital decidu- mixed dentition, the presence of multiple OKC lesions
ous teeth (Fig. 10). There is one specific cyst-related and the potential for recurrence, management of these
condition that requires long-term treatment in paedi- children into adulthood is challenging as these patients
atric patients and into adulthood. The Naevoid Basal require life-long follow-up. Each patient is individually
Cell Carcinoma Syndrome (NBCCS) or Gorlin-Goltz treatment planned as removal of each affected tooth
Syndrome has features that have been recognised for over a period of time may result in the loss of many
teeth. In addition, the management of recurrent lesions
in the paediatric patient has to be carefully considered

Fig. 11 Multiple odontogenic keratocysts involving the mandible &

Fig. 10 Inflammatory follicular cyst right mandible. maxilla in NBCCS.
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JM Shand

in the context of continued growth, as aggressive surgi-

cal management of resection may result in significant
long-term deformity. In the paediatric patient one of
the most prudent approaches is the initial enucleation
of the cyst with adjunctive therapy such as the applica-
tion of Carnoy’s solution and judicious removal of
associated teeth. Non-eruption of teeth may result from
displacement of tooth buds due to the lesion or as a
result of the surgical treatment. Referral to an orthon-
dontist for the combined exposure and orthodontic
alignment of impacted teeth may also be required.
In infants and children, other conditions that may
present in the maxillofacial region are congenital
granular cell tumours of the newborn (Fig. 12), giant Fig. 13 Peripheral giant cell granuloma in anterior maxillary region.
cell granulomas (peripheral and central), Langerhans
histocystosis and the paediatric jaw tumours (dis-
cussed in the chapter on craniofacial surgery). The clinicians advocate the use of adjunctive therapies
congenital granular cell tumours (congenital ‘epulis’) such as Carnoy’s solution. For rare, aggressive lesions,
are variable in size, can interfere with the feeding of recalcitrant to surgical treatment alone, a combination
the neonate and they are managed with excision. The of medical and surgical management has been
giant cell granulomas of the jaw are vary in presenta- described with the use of alpha interferon, intra-
tion from localised exophytic lesions to extensive, lesional steroid injections, calcitonin treatment and
aggressive intra-bony lesions. The peripheral giant cell more recently, bisphosphonate and denosumab
granuloma is also known as a ‘giant cell epulis’ and it therapies.
is the most common of the oral giant cell lesions Langerhans cell histocystosis (LCH), was formerly
(Fig. 13). These present as exophytic nodules and known as histocytosis X or eosinophilic granuloma,
some are thought to be reactive in nature and to and it can present in the craniofacial skeleton and
result from irritation or trauma but in others, no clear results from a proliferation of bone marrow derived
aetiology has been determined. The lesion is managed Langerhan cells. LCH is the most common of the his-
by local excision. The presentation of the central giant tocytic disorders and the cause is unknown. The peak
cell granuloma is variable and ranges from a well- incidence of LCH is between 5 and 10 years of age
defined unilocular lesion to an extensive multi-locular and it may present in one or multiple sites and may
lesion. The majority of these lesions are managed with affect the spleen and liver. In the skull and jaw the
surgical enucleation and peripheral ostectomy. Some lesions can be localised and present as areas of ill-
defined radiolucency with a ‘punched out’ appearance
(Fig. 14). In the jaws, the lesion may result in the loss

Fig. 12 Congenital granular cell tumour in a neonate. Fig. 14 Langerhans cell histocytosis of right mandibular ramus.
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 Paediatric OMS

of alveolar bone with the appearance of ‘floating’ haemarthosis within the temporomandibular joint,
teeth. intracapsular or extracapsular fractures (condylar or
The treatment involves a biopsy of the lesion for subcondylar regions) (Fig. 16). Haemarthosis and
confirmation of the diagnosis, full body screening as most paediatric condylar fractures are managed con-
part of the work-up and referral to paediatric oncol- servatively with mobilisation, soft diet and anti-
ogy who usually treat them with chemotherapy and inflammatory medication.
steroids. Displaced condylar fractures need to be assessed for
any evidence of vertical shortening that may result in
a malocclusion with a premature contact on the ipsi-
MANDIBULAR AND CONDYLAR FRACTURES
lateral side and a contralateral open bite. If mild,
Facial bone fractures are uncommon in children, par- management may be initially conservative with
ticularly under the age of 5 years, compared to adults. review. But if the malocclusion persists, or is marked
Mandibular fractures are the most common bony at presentation, then elastic traction can be applied
injury seen after dento-alveolar trauma. In children, for several weeks. The younger the child at the time
the pattern of mandibular fractures differs to the adult of injury, the risk of limitation in opening and ankylo-
patient. The most common sites are the condylar and sis is increased. The majority of condylar fractures in
subcondylar region, parasymphyseal, then body and children can be managed conservatively and open
ramus regions. The fractures may be monocortical or reduction with internal fixation is very rarely required.
incomplete (‘green stick’) due to the elasticity of the Small occlusal changes in the primary and mixed den-
bone. The management of mandibular fractures also tition will correct spontaneously during growth.
differs in children due to these anatomical variations, Mandibular parasymphyseal, body or angle frac-
the rapidity of healing compared to the adult and the tures may be managed conservatively if undisplaced
presence of developing tooth buds and level of patient or minimally displaced. If there is a diastema between
co-operation. the teeth due to fracture displacement, then a closed
The fracture site(s) in relation to the developing reduction of the fracture can be undertaken with ten-
tooth buds will influence the decision between a sion-band wires. More substantial mandibular injuries
closed reduction and an open reduction. Closed reduc- from falls, motor vehicle accidents or horse kicks will
tion may be performed with tension band wires or require open reduction and internal mini-plate fixation
arch bars around the dentition or for elastic traction to re-establish the mandible and the occlusion.
and uncommonly, intermaxillary fixation is employed
(Figs 15a and 15b). The presence of pain in the preau-
UPPER AIRWAY OBSTRUCTION
ricular region following trauma needs to be investi-
gated to exclude a condylar fracture. The nature of Upper airway obstruction in infants and children can
injuries in the condylar region can range from result from a number of factors either in isolation or
in combination. Tonsillar and adenoidal hypertrophy,
choanal atresia (blockage of the nasal passage), signifi-
(a)
cant mid-facial hypoplasia or micrognathia are com-
mon causes whereas macroglossia, laryngo-
tracheomalacia or subglottic stenosis are less com-
mon. Some children have apnoea due to a significant
central component that needs to be identified on
polysomnography (sleep study) as this will impact on
patient management. As the respiratory compromise
may have many causes, a multi-disciplinary team

(b)

Fig. 15 (a) Bilateral body of mandible fractures in child in the mixed

dentition. (b) Open reduction/fixation of right body fracture and conser-
vative management of undisplaced left body. Fig. 16 Fractured right condylar head of mandible.
© 2018 Australian Dental Association S75
JM Shand

approach is required for the comprehensive evaluation alleviate the obstruction and the technigue of internal
of the airway and, in our institution, involves neona- distraction was pioneered in Australasia by our ser-
tal medicine, respiratory medicine, ENT (Ear, Nose & vice.11,12
Throat) specialists, oral & maxillofacial surgery and Careful case selection is required before proceeding
craniofacial surgeons. Obstructive sleep apnoea (OSA) with distraction osteogenesis and for syndromic
has been shown to be associated with reduced neu- patients, such as Treacher-Collins Syndrome or Cran-
rocognitive performance in children however the aeti- iofacial Microsomia, additional investigations with a
ology is not fully elucidated.8 It has been proposed CT scan is required to assess the bony anatomy and
that during the period of rapid neurological develop- availability of bone for fixation of the distraction
ment in early childhood that chronic episodes of appliances.
hypoxia may potentially result in neurocognitive defi- Distraction osteogenesis has been used in the long
cits.9 An important relationship between airway bones for decades and its role in the craniofacial
obstruction and raised intracranial pressure (ICP) has skeleton has evolved over the past twenty years as the
also been recognised. It has been demonstrated that appliances have been developed and modified. In neo-
during episodes of apnoea, elevation of ICP has been nates and infants, the mandibular appliances are
observed. Respiratory obstruction, ICP and central placed via a submandibular approach and in older
perfusion pressure appear to interact in a vicious children an intra-oral approach can be used. Follow-
cycle. ing a bilateral osteotomy in the region of the junction
If airway obstruction is secondary to significant of the posterior body of mandible and ramus the dis-
mid-facial or mandibular hypoplasia in the growing traction appliances are positioned (Fig. 18). Daily
child, then distraction osteogenesis may be indicated activation of the appliances occurs until the
to advance the bony skeleton and its soft tissue
attachments to increase the airway and overcome the
obstruction. In young children with syndromic cran-
iosyntosis such as Crouzon or Apert Syndrome, there
is often severe mid-facial deficiency with restriction in
the airway space.10 The chapter on craniofacial sur-
gery discusses the stages of surgery associated with
the management of these conditions.
In infants and children with Robin Sequence, Stick-
ler Syndrome, craniofacial microsomia, Treacher Col-
lins Syndrome, Nager Syndrome and a number of
other conditions, severe mandibular mandibular hypo-
plasia may be present (Figs 17a and 17b).
In the severely retrognathic mandible, the tongue
base is posteriorly positioned (glossoptosis) and this
results in narrowing of the oro-pharyngeal airway at
Fig. 18 Intraoperative view of submandibular approach with distraction
this level. Distraction osteogenesis has been effectively appliance in-situ, corticotomy of mandible and inferior alveolar nerve
used to advance the mandible and tongue base and to bundle preserved.

(a) (b)

Fig. 17 (a) 5-week old infant with nasopharyngeal tube in place with Robin Sequence and micrognathia (b) CT scan demonstrating severe mandibular
hypoplasia.
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 Paediatric OMS

appliances, with the attached mandible, is lengthened around the activation arm sites, transient mandibular
(Fig. 19). The appliances remain in place during the branch VII weakness and device failure.13 The appli-
consolidation (bony healing) phase and they are then ances that are currently being used for mandibular
removed 6–8 weeks later. distraction now have detachable activation arms and
The outcome of 73 patients, who had mandibular this has eliminated the problem of skin reactions
distraction surgery performed between 2000 and 2012 around the arms during the consolidation phase. The
has been recently reviewed.13,14 The surgical tech- outcome study demonstrated in the 73 young chil-
nique as standardised with little variation across the dren, under the age of 5 years, who underwent
cohort was the procedure performed by our Unit. The mandibular distraction that 87% were discharged
mean age of surgery was 2-months for non-syndromic without any supplemental airway support and 56% of
children (31 patients) and 3.3 months for syndromic the tracheostomy-dependent patients were decannu-
infants (42 patients). The majority were managed lated by 1-year post-operation.
with naso-pharynegeal tubes (69%) and/or CPAP In the management of selected cases, mandibular
(18%)(continuous positive airway pressure) before distraction osteogenesis was found to be a pre-
surgery and nine patients were tracheostomy-depen- dictable and effective approach to managing children
dent. Following the distraction procedures and on dis- with micrognathia and upper airway obstruction
charge home none of the children without (Figs 20a and 20b). In patients with syndromic con-
tracheostomies required any airway support. Of the 9 ditions, they should be monitored for the develop-
tracheostomy dependent patients, 6 were decannu- ment of further obstructive symptoms and sleep-
lated from their tracheostomy by 12-months post-dis- disorder breathing over time that may require further
traction. With regard to feeding, most patients (77%) management.
required supplemental feeding with a naso-gastric
tube (NGT) and 6 had a percutaneous gastrotomy
CONCLUSION
tube (PEG) and these were all children with syn-
dromic conditions. The remaining group were feed Paediatric patients present with anatomic and physio-
with special nursing bottles, for example, Haberman. logical differences, along with behaviour factors that
By the time of distractor removal at 2–3 months fol- require additional consideration in their planning
lowing the first procedure, most children who were and treatment. These young patients that includes
NGT feed had changed to an oral diet (66% overall) infants, children and adolescents are also at varying
and the majority of non-syndromic children were phases of growth and their development impacts on
feeding orally (89%). The majority of these patients management and long-term outcomes. Children with
who were PEG feed were still dependent on the PEG congenital anomalies and syndromes have a special
1 year following surgery. There are a number of prob- range of needs that require multidisciplinary exper-
lems that can follow distraction osteogenesis proce- tise in their management. Paediatric Oral & Maxillo-
dures including low-grade inflammation or infection facial Surgery is now evolving into an important
sub-specialty of surgery with much to offer in the
care of children.

(a) (b)

Fig. 19 Radiograph of activated distraction appliances, with mandibular Fig. 20 (a) Frontal facial view of infant with Robin Sequence 6-months
lengthening. following mandibular distraction. (b) Lateral facial view.
© 2018 Australian Dental Association S77
JM Shand

8. Piteo AM, Kennedy JD, Roberts RM, et al. Snoring and cogni-
ACKNOWLEDGEMENTS tive development in infancy. Sleep Med 2011;12:981–987.
I would like to acknowledge our colleagues in the 9. Bass JL, Corwin M, Gozal D, et al. The effect of chronic or
intermittent hypoxia on cognition in childhood: a review of the
neonatal, respiratory & ENT units, craniofacial team, evidence. Pediatrics 2004;114:805–816.
dentistry and the allied health care workers who have 10. Heggie AA, Kumar R, Shand JM. The role of distraction osteo-
been involved in the care of these patients. genesis in the management of craniofacial syndromes. Ann
Maxillofac Surg 2013;3:4–10.
11. Lam DL, Tabangin ME, Shikary TA, et al. The outcomes of
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