Early treatment of severe mandibular hypoplasia with distraction mesenchymogenesis and bilateral free fibula flaps

The technique of distraction has revolutionized the treatment of mandibular hypoplasia; however, presently large mandibular defects still require bone grafts. Microvascular grafting is commonly used in adults. Conversely, in pediatric reconstruction, nonvascularized rib grafts remain standard. Unfor tunately, resorption of nonvascularized bone remains a major issue, particu larly when soft tissue is hypoplastic. This case study represents a combina tion of techniques in the treatment of severe mandibular deficiency, and in troduces the concept of distraction mesenchymogenesis. The patient was a 21 /2-year-old boy with severe bilateral Pruzansky class III mandibular hypopl asia. He had a permanent open mouth posture, an overjet of 23 mm, and was u nable to move the lower mandibular segment. His oropharyngeal airway diamet er was 2.2 mm and he was tracheostomy dependent, The patient was treated wi th distraction of the lower jaw mesenchyme followed by bilateral functional free fibular microvascular flaps containing reinnervated muscle. This crea ted a well-vascularized body, ramus, and condyle bilaterally within an adeq uate soft-tissue envelope. Postoperatively, the overjet was reduced to 5 mm . The patient can now actively move his mandible. Airway diameter increased to 10 mm, and the patient is able to tolerate intermittent tracheostomy pl ugging. This innovative combination of techniques allows early intervention , limits,graft resorption, and improves airway control.