Mapping the knowledge of stomatognathic functions and orthognathic surgery

Residents' journal review

Cleft-orthognathic surgery

“Silent” Sleep Apnea in Dentofacial Deformities and Prevalence of Daytime Sleepiness After Orthognathic and Intranasal Surgery

Objective To investigate the skeletal stability after maxillary advancement with orthognatic surgery in patients with cleft lip and palate and the factors related to relapse.Methods 34 cleft lip and palate patients underwent modifiedLeFort I maxillary advancement osteotomy,29 of them also had BSSRO and/or genioplasty.The clinical follow-ups were no shorter than 12 months.Lateral cephalograms were taken at presurgery,immediately postsurgery and at least 1 year postsurgery.The positional change of point A and PNS and angular change of SNA were measured by serial cephalometric analysis.Results Horizontal advancement averaged (4.38±1.88) mm,and the mean relapse was (20.10±18.39) 0％.Downward surgical movement averaged (3.46±2.15) mm,and the vertical relapse was (34.78±32.89)％.∠SNA was 77.9° presurgicaly,82.3° immediately after surgery and 81.4°at least 1 year postoperatively.There was no significant correlation between surgical movement and postoperative relapse in the horizontal plane(P＞0.05),but had a significant positive correlation in the vertical plane (P＜0.05).Variance analysis of continuous follow-ups of 15 patients showed most of the relapse occurred in the first 3 months after surgery.Conclusions Maxillary surgical advancement in patients with CLP showed relapse to a certain extent.Most of the relapse occurred in the first 3 months after surgery.The vertical relapse was positively correlated with inferior surgical movement of the mandible. Key words: Orthognathic surgery; Cleft lip and palate; Maxillary advancement; Skeletal stability

Modified Maxillary Osteotomy With Distraction to Preserve Velopharyngeal Function in the Cleft Patients

Among the treatment options for Obstructive Sleep Apnea (OSA) we have surgery to correct dentofacial deformities. OSA patients are routinely and predictably submitted to surgical treatment for dentofacial deformities. Frequently, orthognathic surgery and osseointegrated implants may be necessary to enable fixed rehabilitation. Patients submitted to orthognathic surgery have a transient decrease in blood supply after maxillary and mandibular osteotomy procedures, which can impair the results in these cases. This case report aimed to present and discuss the conflicting situation of an OSA patient in need of orthognathic surgery and dental implants. The treatment consisted of: (1) extraction of all teeth; (2) complete rehabilitation of the upper and lower jaw with dental implants and prosthesis without compensation; (3) bimaxillary orthognathic surgery to re-establish the maxillomandibular relationship and increase the upper airway volume. This rehabilitation sequence was a safe alternative for a case of Class II OSA, and rapidly achieved a final restoration with enhanced esthetics, functionality, biomechanics, maintenance of oral hygiene, and patient satisfaction.

Retrospective Analysis of the Effects of Orthognathic Surgery on the Pharyngeal Airway Space

To classify the patients with cleft lip and palate who need orthognathic surgery and to propose the corresponding operations. From January 2005 to May 2015, 121 patients with cleft lip and palate diagnosed as maxillary retrusion were treated by orthognathic surgery. Inclusion criteriar: (1) male aged over 16, female aged over 14; (2) diagnosed as non-syndromic cleft lip and palate without systemic disease and other genetic diseases; (3) without previous orthodontic and orthognathic treatment; (4) having no other craniofacial malformation. Maxillary features and repaired types were recorded. 93 patients were included and divided into two categories depended on the dental crowding. Class I: the teeth quantity and bone quantity is coordinated, space analysis ≤ 4 mm (mild dental crowding). The forward distance of maxillary less than 6 mm was defined as Class I a (36 cases) more than 6 mm as Class I b (28 cases). Class II: the teeth quantity and bone quantity is not coordinated, space analysis > 4 mm ( moderate or severe dental crowding). After the simulation of distraction osteogenesis, the anterior crossbite was corrected defined as Class II a (23 cases), not corrected defined as Class II b (6 cases). Class I a were corrected by conventional orthognathic surgery. While Class I b were corrected by Le Fort I maxillary advancement using distraction osteogenesis. Class II a were repaired just by anterior maxillary distraction. While Class II b need to combine conventional orthognathic surgery with anterior maxillary distraction. All the patients were satisfied with the treatment effect. The patients of cleft lip and palate with maxillary retrusion who need orthognathic surgery can be classified as the method mentioned above, and then choose the appropriate operations.

INTRODUCTION: Maxillomandibular advancement (MMA) is an orthognathic surgical procedure that has been used to manage OSA in individuals who are noncompliant with CPAP therapy.1 MMA is a site-specific procedure, performed for the purpose of creating an enlarged posterior airway space at multiple anatomic levels, including the nasopharynx, oropharynx, and hypopharynx.2 MMA has been shown to significantly improve OSA, with reported short term success rates ranging from 75% to 100%.3–5 This prospective investigation describes the functional and aesthetic outcomes after the counter clock wise rotational orthognathic surgery in skeletal class II patients with the obstructive sleep apnea based on pre and postoperative polysomnography and cephalometry. MATERIALS AND METHODS: This retrospective study investigated the surgical outcome of 12 patients who suffered from obstructive sleep apnea following the counter clock wise rotational orthognathic surgery in terms of functional and aesthetic outcomes. The patients included in this study were skeletal class II patients who underwent orthognathic surgery between March, 2013 and December, 2014 at the Seoul Asan Medical Center, University Medical Center for tertiary care. The pharyngeal airway assessment was done through polysomnography and cephalometric posterior airway analysis using PRL–PSP, PRL–PTO and PRL–E distances. RESULTS: The follow-up period ranged from 10 to 36 months (average, 20.5 months). The average age of the patients was 28.5 years, with 9 male and 11 female patients. Compared to preoperative results (mean preop distance of PRL–PSP: 19.97, PRL–PTO: 18.68, PRL–E: 16.2), PRL–PSP, PRL–PTO and PRL–E distances were increased statistically significant in immediate postoperative cephalometry. (p<0.005) (mean immediate postop distance of PRL–PSP: 23.1, PRL–PTO: 22.9, PRL–E: 18.6). The results were maintained 6 months after the surgery(mean distant postop distance of PRL–PSP: 22.2, PRL–PTO: 22.5, PRL–E: 18.0). There was no significant change in PRL–PSP, PRL–PTO and PRL–E distances.(p>0.05). CONCLUSION: The change of the posterior pharyngeal space in counter clock-wise rotational orthognathic surgery without maxilla advancement for the correction of obstructive sleep apnea is presented. Our findings indicate that this approach can lengthen the posterior pharyngeal space effectively. With considered application, this novel approach could be an alternative to standard approaches in the correction of obstructive sleep apnea using orthognathic surgery. DISCLOSURES/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Fernández-Ferrer L, Montiel-Company JM, Pinho T, Almerich-Silla JM, Bellot-Arcís C. Effects of mandibular setback surgery on upper airway dimensions and their influence on obstructive sleep apnoea - a systematic review. J Craniomaxillofac Surg. 2015;43:248–53. 2. Demetriades N, Chang DJ, Laskarides C, Papageorge M. Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders. J Oral Maxillofac Surg. 2010;68:2431–6. 3. Gonçalves JR, Gomes LC, Vianna AP, Rodrigues DB, Gonçalves DA, Wolford LM. Airway space changes after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: three-dimensional assessment. Int J Oral Maxillofac Surg. 2013;42:1014–22. 4. Hatab NA, Konstantinović VS, Mudrak JK. Pharyngeal airway changes after mono- and bimaxillary surgery in skeletal class III patients: Cone-beam computed tomography evaluation. J Craniomaxillofac Surg. 2015;43:491–6. 5. Jakobsone G, Stenvik A, Espeland L. The effect of maxillary advancement and impaction on the upper airway after bimaxillary surgery to correct Class III malocclusion. Am J Orthod Dentofacial Orthop. 2011;139:e369-76.

The incidence of obstructive sleep apnea (OSA) immediately after surgery in patients with dentofacial deformities without previous OSA remains unknown. We aimed to perioperatively evaluate factors associated with oxygen desaturation index (ODI) during sleep, 7days after bilateral splitting ramus osteotomy (BSSRO) in patients without previous OSA. Fifty-one patients (15 males, 36 females) with dentofacial deformities, scheduled to undergo BSSRO, were included. Polysomnography was performed before orthognathic surgery. Perioperative OSA was evaluated with peripheral arterial tonometry on the day of surgery and 1, 2, 3, 4, and 7days postoperatively. Rapid eye movement (REM) sleep periods and the ODI were measured. Factors associated with perioperative ODI after surgery were statistically analyzed. REM sleep periods were significantly decreased on the day of surgery and significantly increased at 4 and 7days postoperatively, compared to the preoperative period. ODI increased on the day of surgery, decreased after 1day, and increased again at 4 and 7days postoperatively. ODI on the day of surgery was significantly increased due to increased preoperative ODI, overjet, and SN-MP angle and decreased SNA and SNB angle. ODI at 7days postoperatively was significantly increased due to increased REM sleep periods and decreased SN-MP and gonial angle. ODI was increased in response to REM sleep periods 7days after BSSO. Airway management in patients with dentofacial deformity should be given more attention by preoperative assessment for OSA, even in the absence of previous OSA, until 7days postoperatively due to REM rebound.

Introduction: In the scenario of Obstructive Sleep Apnea Syndrome (OSAS), Orthognathic Surgery (OS) corrected the deformities of the maxillary and mandibular bones OS has evolved a lot in the last two decades. OS treats patients with moderate and severe facial deformities, allowing the achievement of functional balance and harmony in facial aesthetics. Objective: To present the current findings of the importance of orthognathic surgery in the treatment of obstructive sleep apnea syndrome. Methods: A total of 78 articles were found involving mesh terms about Orthognathic Surgery and OSAS. Initially, was held the exclusion of existing title and duplications following the interest described in this work. After this process, the summaries were evaluated, and a new exclusion was held. Thus, 20 articles were included and discussed in this study. Major considerations and conclusion: In recent years, with the involvement and deepening of oral medicine in the diagnosis and treatment of OSAS, the role of OS in OSAS has become increasingly recognized. Early appropriate diagnosis and treatment can significantly improve patients' quality of life, reduce sudden death, and prevent various complications. OS corrects maxillofacial deformities through an incision of the upper and lower jaws, which has a significant relief effect on the symptoms of OSAS in patients with upper airway stenosis, especially in small mandibular patients.

Soft Tissue Changes From Maxillary Distraction Osteogenesis Versus Orthognathic Surgery in Patients With Cleft Lip and Palate—A Randomized Controlled Clinical Trial

Introduction: Orthognathic surgery can be a treatment for occlusal, oro-facial functional disorders and esthetics discrepancies as well as for obstructive sleep apnea. It is often practiced after an orthodontic preparation, but in edentulous patients, the preparation can be replaced with implant supported prosthesis to simulate the final occlusion. Observation: A patient presenting severe obstructive sleep apnea, vertical and sagittal insufficiency of the lower third of the face and poor dental health was treated with a guided mandibular advancement and an almost complete implant supported prosthesis rehabilitation. At first, the implants were placed and immediately loaded, giving the patient a class 2 occlusion. Then, an orthognathic surgery was performed, giving the patient a class 1 occlusion, and then the final prosthesis was made. Commentaries: The interest of this case is the combined treatment of the obstructive sleep apnea, the dental and facial deformities by mandibular retrognathia and the edentulous jaws. The gold standard for obstructive sleep apnea is a maxillary and mandibular advancement. In this case, for esthetic and anatomic reasons, a mandible propulsion alone has been performed, showing a positive and stable result for the treatment of obstructive sleep apnea. The use of surgical guide permitted to plan the treatment with more accuracy. Conclusion: This case combines a fixed prosthetic rehabilitation, which permitted to guide the orthognathic surgery and the treatment of obstructive sleep apnea.

When treating patients with orthognathic surgery, there might be a risk of obstructive sleep apnoea (OSA) due to soft tissue changes in the upper airways, especially in patients treated with isolated mandibular setback or mandibular setback in combination with maxillary advancement. In the present study, we assessed respiratory function during sleep with home cardiorespiratory polygraphy in 62 patients who had not been previously been diagnosed with OSA at three times: prior to orthognathic surgery for aesthetic and functional indications, and then 3 months and 1 year after surgery. We evaluated surgical displacement based on measurements in three dimensions using pre- and post-operative computed tomography. There were only minor changes in the respiratory parameters such as the apnoea-hypopnoea index (AHI), the apnoea-hypopnoea index in the supine position (AHIsup), the oxygen saturation index (ODI) and the snore index. There was no significant correlation between surgical displacement and the AHI, AHIsup and ODI. There was a weak but significant correlation between vertical displacement of the anterior mandible and the snore index. Within the limitations of the present study, the risk for iatrogenic obstruction of the upper airways seems to be low in patients without OSA treated with orthognathic surgery.

Although maxillomandibular advancement (MMA) is an orthognathic surgical procedure used to manage obstructive sleep apnea (OSA) in individuals who are noncompliant with continuous positive airway pressure therapy, simple MMA encounters problems in terms of aesthetic outcomes in Asian populations with preexisting dentoalveolar protrusion. Our current prospective investigation describes changes in posterior pharyngeal space and aesthetic outcomes after counterclockwise rotational orthognathic surgery, which is known to be quite difficult in terms of the maintenance of the skeletal stability in skeletal class II patients with OSA. This prospective study investigated the surgical outcome of patients who suffered from OSA following counterclockwise rotational orthognathic surgery. The patients were skeletal class II patients who underwent orthognathic surgery between March 2013 and December 2014. Cephalometric posterior airway analysis and a questionnaire for facial perception were used to assess pharyngeal airway and patient perception of facial appearance. A total of 14 patients were included. Satisfactory results were achieved without complications in all OSA patients. The airway parameters for anteroposterior length significantly increased. Thirteen patients answered a questionnaire on their facial appearance, and the visual analog scale averaged 7.31 points, indicating a favorable facial appearance. Counterclockwise rotational orthognathic surgery without maxilla advancement for the correction of OSA can effectively increase the posterior pharyngeal space, with favorable aesthetic results. With thoughtful application, this novel approach may be an alternative to standard approaches for the correction of OSA using orthognathic surgery.