Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients

Expert consensus on orthodontic treatment of protrusive facial deformities

Protrusive facial deformities, characterized by the forward displacement of the teeth and/or jaws beyond the normal range, affect a considerable portion of the population. The manifestations and morphological mechanisms of protrusive facial deformities are complex and diverse, requiring orthodontists to possess a high level of theoretical knowledge and practical experience in the relevant orthodontic field. To further optimize the correction of protrusive facial deformities, this consensus proposes that the morphological mechanisms and diagnosis of protrusive facial deformities should be analyzed and judged from multiple dimensions and factors to accurately formulate treatment plans. It emphasizes the use of orthodontic strategies, including jaw growth modification, tooth extraction or non-extraction for anterior teeth retraction, and maxillofacial vertical control. These strategies aim to reduce anterior teeth and lip protrusion, increase chin prominence, harmonize nasolabial and chin-lip relationships, and improve the facial profile of patients with protrusive facial deformities. For severe skeletal protrusive facial deformities, orthodontic-orthognathic combined treatment may be suggested. This consensus summarizes the theoretical knowledge and clinical experience of numerous renowned oral experts nationwide, offering reference strategies for the correction of protrusive facial deformities.

Maxilla management in "phase II" skeletal surgery for obstructive sleep apnea

This study investigates the management of patients with obstructive sleep apnea (OSA) who have previously undergone palatal surgery and subsequently undergo maxillomandibular advancement (MMA). The research entails a retrospective analysis of phase II MMA cases from 2017 to 2022. Data encompassing demographics, clinical profiles, pre- and post-operative polysomnographic and radiological findings, surgical techniques, and complications were collected. Out of the 14 patients studied, conservative vestibular approaches were applied universally, with four cases necessitating the sectioning of descending palatine arteries. Results indicate an average maxillary sagittal advancement of 10.07 mm, a mean counterclockwise rotation of the maxillary occlusal plane at 9.35°, and a decline in apnea-hypopnea index from 45.5 to 4.5 events per hour. Surgical success and cure rates were 93.3% and 40%, respectively, with no major complications observed throughout the 45-month follow-up. This study underscores the safe and efficacious application of MMA in OSA patients with prior palatal surgery, offering valuable insights into their management.

Impacts of conservative treatment on the clinical manifestations of obstructive sleep apnea-systematic review and meta-analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is a chronic disease with a high populational prevalence that is characterized as airway closure during sleep. Treatment is multidisciplinary and varies according to each case. Continuous positive airway pressure (CPAP), oral appliances, and surgery are the primary therapeutic options. Non-invasive conservative treatments such as sleep hygiene, positional therapy, physical exercises, and weight loss aim to reduce the worsening of the disease while being complementary to the invasive primary treatment.

OBJECTIVE

To analyze the impact of non-invasive conservative therapies on the clinical manifestations of OSA syndrome (OSA), compared with other interventions.

METHOD

This was a systematic review with meta-analysis. The searches were performed without filters for the time period, type of publication, or language. Randomized clinical trials on subjects over 18 years of age diagnosed with untreated OSA were included. Responses to non-invasive conservative treatment were compared with responses to the primary intervention. Primary outcomes were assessed using the Epworth Sleepiness Scale and/or Functional Outcomes of Sleep Questionnaire (FOSQ).

RESULTS

A total of eight studies were included in the review. The heterogeneity of the effect was estimated at 89.77%. Six studies compared conservative treatment with CPAP, one with oral appliances, and one with oropharyngeal exercises. Using the Epworth Sleepiness Scale measurements, the standardized difference in the estimated means, based on the random-effects model, was 0.457 (95% CI (1.082 to 0.169)) and the mean result did not differ significantly from zero (z = 1.43; p = 0.153). The conservative therapies assessed in this study improved the subjective quality of sleep, although the post-treatment ESE scores did not show significant results. The reduction in AHI and better outcomes in the evaluated domains, as well as in cognition and mood, were superior in the groups that received CPAP and IOD.

CONCLUSION

The most commonly used treatments of choice for OSA are invasive, including the use of CPAP, oral appliances, and surgeries, being the most utilized options. This study demonstrated that non-invasive conservative treatments, such as sleep hygiene, yield results as effective as invasive treatments. Further studies are needed to confirm this result and to predict whether invasive treatment can be used as the primary treatment or only as a supplement.

Non-sleep related outcomes of maxillomandibular advancement, a systematic review

Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.

Patient Referral and Acceptance of Maxillomandibular Advancement for Obstructive Sleep Apnea

OBJECTIVE

Maxillomandibular advancement (MMA) is an effective surgical treatment for obstructive sleep apnea (OSA); however, it is unclear how many patients who are referred for MMA actually undergo surgery. This study aims to determine follow-up rates for patients referred for MMA and the reasons behind their choices.

METHODS

Via retrospective review, we assessed consecutive patients with OSA intolerant to continuous positive airway pressure (CPAP) who underwent drug induced sleep endoscopy (DISE) between 2018 and 2020 at our institution. Patients recommended for MMA based on DISE and other findings were included. Patients were then contacted and administered an IRB-approved survey in present time.

RESULTS

One hundred and fifty nine patients were referred to oral maxillofacial surgery (OMFS) for MMA consult. Seventy seven patients (48%) followed up with OMFS and 29 (18%) underwent MMA. Sixty two (40%) patients resumed CPAP. Fifty eight patients (36.5%) were lost to follow up. Seventy three patients (46%) completed our survey. Of those patients, 37 (51%) followed up with OMFS and 17 (23%) underwent MMA. Patients who did not follow up with OMFS cited the invasiveness of the surgery (39%), recovery time (17%), or both (31%) as reasons. Those who pursued consultation cited inability to tolerate CPAP (73%), not being a candidate for inspire (14%), and desire to learn about alternative treatments (14%) as reasons. Of those who did not undergo MMA, 28.6% are not using OSA treatment.

CONCLUSION

Less than half of patients referred for MMA followed up, and less than half of those patients underwent MMA. Most patients cited concerns about the invasiveness of the surgery and recovery process.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2964-2969, 2024.

Hypoglossal Nerve Stimulation and Cardiovascular Outcomes for Patients With Obstructive Sleep Apnea: A Randomized Clinical Trial

Importance

Sham-controlled trials are needed to characterize the effect of hypoglossal nerve stimulation (HGNS) therapy on cardiovascular end points in patients with moderate-severe obstructive sleep apnea (OSA).

Objective

To determine the effect of therapeutic levels of HGNS, compared to sham levels, on blood pressure, sympathetic activity, and vascular function.

Design, Setting, and Participants

This double-blind, sham-controlled, randomized crossover therapy trial was conducted from 2018 to 2022 at 3 separate academic medical centers. Adult patients with OSA who already had an HGNS device implanted and were adherent and clinically optimized to HGNS therapy were included. Participants who had fallen asleep while driving within 1 year prior to HGNS implantation were excluded from the trial. Data analysis was performed from January to September 2022.

Interventions

Participants underwent a 4-week period of active HGNS therapy and a 4-week period of sham HGNS therapy in a randomized order. Each 4-week period concluded with collection of 24-hour ambulatory blood pressure monitoring (ABPM), pre-ejection period (PEP), and flow-mediated dilation (FMD) values.

Main Outcomes and Measures

The change in mean 24-hour systolic blood pressure was the primary outcome, with other ABPM end points exploratory, and PEP and FMD were cosecondary end points.

Results

Participants (n = 60) were older (mean [SD] age, 67.3 [9.9] years), overweight (mean [SD] body mass index, calculated as weight in kilograms divided by height in meters squared, 28.7 [4.6]), predominantly male (38 [63%]), and had severe OSA at baseline (mean [SD] apnea-hypopnea index, 33.1 [14.9] events/h). There were no differences observed between active and sham therapy in 24-hour systolic blood pressure (mean change on active therapy, -0.18 [95% CI, -2.21 to 1.84] mm Hg), PEP (mean change on active therapy, 0.11 [95% CI, -5.43 to 5.66] milliseconds), or FMD (mean change on active therapy, -0.17% [95% CI, -1.88% to 1.54%]). Larger differences between active and sham therapy were observed in a per-protocol analysis set (n = 20) defined as experiencing at least a 50% reduction in apnea-hypopnea index between sham and active treatment.

Conclusions and Relevance

In this sham-controlled HGNS randomized clinical trial, mean 24-hour systolic blood pressure and other cardiovascular measures were not significantly different between sham and active HGNS therapy. Several methodologic lessons can be gleaned to inform future HGNS randomized clinical trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT03359096.

Mean disease alleviation between surgery and continuous positive airway pressure in matched adults with obstructive sleep apnea

STUDY OBJECTIVES

Polysomnography parameters measure treatment efficacy for obstructive sleep apnea (OSA), such as reduction in apnea-hypopnea index (AHI). However, for continuous positive airway pressure (CPAP) therapy, polysomnography measures do not factor in adherence and thus do not measure effectiveness. Mean disease alleviation (MDA) corrects polysomnography measures for CPAP adherence and was used to compare treatment effectiveness between CPAP and multilevel upper airway surgery.

METHODS

This retrospective cohort study consisted of a consecutive sample of 331 patients with OSA managed with multilevel airway surgery as second-line treatment (N = 97) or CPAP (N = 234). Therapeutic effectiveness (MDA as % change or as corrected change in AHI) was calculated as the product of therapeutic efficacy (% or absolute change in AHI) and adherence (% time on CPAP of average nightly sleep). Cardinality and propensity score matching was utilized to manage confounding variables.

RESULTS

Surgery patients achieved greater MDA % than CPAP users (67 ± 30% vs. 60 ± 28%, p = 0.04, difference 7 ± 3%, 95% confidence interval 4% to 14%) in an unmatched comparison, despite a lower therapeutic efficacy seen with surgery. Cardinality matching demonstrated comparable MDA % in surgery (64%) and CPAP (57%) groups (p = 0.14, difference 8 ± 5%, 95% confidence interval -18% to 3%). MDA measured as corrected change in AHI showed similar results.

CONCLUSIONS

In adult patients with OSA, multilevel upper airway surgery and CPAP provide comparable therapeutic effectiveness on polysomnography. For patients with inadequate CPAP use, surgery should be considered.

Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome: Long-Term Results of Respiratory Function and Reverse Face-Lift

PURPOSE

Scientific literature considers maxillomandibular advancement (MMA) as the most effective surgical treatment for the management of adult obstructive sleep apnea syndrome (OSAS). Maxillomandibular advancement enlarges the pharyngeal space by expanding the skeletal framework. Moreover, it projects the soft tissue of the cheeks, the mouth, and the nose in the aging face, which is characterized by multiple signs affecting the middle third and the lower third. The potential of orthognathic surgery (double jaw surgical advancement) of expanding the skeletal foundation to increase the facial drape support and to rejuvenate the face by a "reverse face-lift" is now recognized. The aim of this study was to review the surgical outcomes after MMA in terms of respiratory function and assessment of facial esthetics.

METHODS

We retrospectively reviewed the charts of all patients affected by OSAS who underwent maxillomandibular advancement between January 2010 and December 2015 in 2 tertiary hospitals (IRCCS Policlinico San Martino of Genoa and IRCCS Policlinico Ca' Granda of Milan). During the postoperative follow-up examination, all patients underwent polysomnographic examination and esthetic assessment to evaluate the respiratory function and facial rejuvenation after double jaw surgical advancement.

RESULTS

The final study sample included 25 patients (5 females, 20 males). The overall success rate of the surgical treatment (apnea/hypopnea index, AHI <20) was 79%; the overall rate of surgical cure (AHI <5) was 47%. Twenty-three patients (92%) showed a degree of rejuvenation after MMA.

CONCLUSIONS

Maxillomandibular advancement is currently the most effective surgical treatment for the management of OSAS in adult patients who are not responders to medical treatment. "Reverse face-lift" is the consequence of the double jaw surgical advancement.

Distraction Osteogenesis as a reliable method in management of Obstructive Sleep Apnoea (OSA) secondary to TMJ Ankylosis: A Case Report

Obstructive sleep apnoea (OSA) is identified as repetitive and intermittent upper airway collapse or narrowing during sleep. Skeletal advancement through maxillomandibular surgery remains the most effective surgical treatment for OSA but is radical with certain relapse rate. Distraction Osteogenesis of mandible is a single-jaw surgical treatment alternative to bi-jaw surgeries having lesser complications. This case report describes successful management of a 46-year-old patient who reported with a chief complain of obstruction in breathing while sleeping since one year. Obstructive Sleep Apnoea (OSA) secondary to a retrognathic mandible was the final diagnosis, which was successfully treated by Distraction Osteogenesis (DO) of the mandible. The case showed enhancement in airway by 13mm and marked forward movement of Point-B (SNB increased by 6 degrees). The Epworth Sleepiness Scale value decreased from 19mm to 8 mm indicating substantial increase in the airway with stable results after 18 months of follow-up (elimination of symptoms and subsequent sound sleep). Distraction osteogenesis is an effective and reliable method to treat obstructive sleep apnoea secondary to retrognathic mandible.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Satisfaction With Facial Aesthetic Appearance Following Maxillomandibular Advancement (MMA) for Obstructive Sleep Apnea (OSA): A Meta-Analysis

PURPOSE

A large cohort of patients diagnosed with obstructive sleep apnea (OSA) require surgical intervention, sometimes in the form of maxillomandibular advancement (MMA), to correct their functional disturbance. Such a surgical procedure typically results in a slight modification of the patients' facial appearance. The purpose of the current systematic review and meta-analysis was to examine the rate of satisfaction with facial aesthetics post-MMA intervention and to assess its dependability on and relationship with other patient or treatment factors. Based on the literature currently available, and to the best of our knowledge, this is the first paper to draw on the topic analytically.

METHODS

A search was conducted on four electronic literature databases (Pubmed, Ovid, Science Direct, and Scholar). Using referred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), our inclusion criterion covered any case with adequate reported data pertaining to the research question up to June 2021. Three evaluator groups were utilized. Satisfaction was defined as either an obvious reported increase in fondness for facial appearance or a state of indifference to the cosmetic results of the conducted changes. Dissatisfaction was defined as a clear discontent with the post-operative esthetic results. A multivariate analysis of the data was conducted, and Chi-square tests for independence were used to detect any significant associations. A meta-analysis of proportion was employed to permit for Freeman-Tukey double arcsine transformation and stabilize the variance of each study's proportion. Cochran's Q was computed, and the significance level was gauged as a function of P value.

RESULTS

Meta-analyses of proportion conducted for assessment of aesthetic appraisal following surgical MMA for OSA elucidated a significantly higher predilection towards aesthetic satisfaction after surgical MMA for OSA for all evaluator groups in the encompassed studies. 94.2% of patients were satisfied with their facial esthetics postoperatively.

CONCLUSION

The vast majority of patients that undergo MMA for the correction of OSA report satisfaction with post-surgical facial aesthetics. The subjective assessment of this parameter by physicians and laypeople portrays an equivalently significant skew toward post-surgical appearance improvement. MMA is a generally safe procedure that substantially contributes to enhancement of both overall quality of life and perceived aesthetic appeal.

Presurgical orthodontic decompensation with clear aligners

INTRODUCTION

Orthodontists, surgeons, and patients have taken an interest in using clear aligners in combination with orthognathic surgery. This study aimed to evaluate the accuracy of tooth movements with clear aligners during presurgical orthodontics using novel 3-dimensional superimposition techniques.

METHODS

The study sample consisted of 20 patients who have completed presurgical orthodontics using Invisalign clear aligners. Initial (pretreatment) digital dental models, presurgical digital dental models, and ClinCheck prediction models were obtained. Presurgical models were superimposed onto initial ones using stable anatomic landmarks; ClinCheck models were superimposed onto presurgical models using surface best-fit superimposition. Five hundred forty-five teeth were measured for 3 angular movements (buccolingual torque, mesiodistal tip, and rotation) and 4 linear movements (buccolingual, mesiodistal, vertical, and total scalar displacement). The predicted tooth movement was compared with the achieved amount for each movement and tooth, using both percentage accuracy and numerical difference.

RESULTS

Average percentage accuracy (63.4% ± 11.5%) was higher than in previously reported literature. The most accurate tooth movements were buccal torque and mesial displacement compared with lingual torque and distal displacement, particularly for mandibular posterior teeth. Clinically significant inaccuracies were found for the buccal displacement of maxillary second molars, lingual displacement of all molars, intrusion of mandibular second molars, the distal tip of molars, second premolars, and mandibular first premolars, buccal torque of maxillary central and lateral incisors, and lingual torque of premolars and molars.

CONCLUSIONS

Superimposition techniques used in this study lay the groundwork for future studies to analyze advanced clear aligner patients. Invisalign is a treatment modality that can be considered for presurgical orthodontics-tooth movements involved in arch leveling and decompensation are highly accurate when comparing the simulated and the clinically achieved movements.

Effect of modified genioglosuss advancement on hyoid bone position: Cephalometric study

OBJECTIVE

To assess Hyoid bone position and retrolingual airway space after Modified Genioglossus Advancement Surgery by cephalometry in patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective study.

SETTING

Zagazig University Hospital.

METHODS

Eighteen patients with moderate to severe OSA having multilevel airway obstruction confirmed by fiberoptic endoscopy during Muller's maneuver and DISE. All patients underwent modified genioglossus advancement surgery associated with antrolateral advancement pharyngoplasty. Beside Polysomnography and Drug induced sleep endoscopy, Cephalometry was done preoperatively and 6 months postoperative.

RESULTS

Improved Polysomnography parameters as Postoperative mean ± SD apnea hypopnea index decreased from 52 ± 17.1 to 17 ± 3 (P < 0.001, 95% confidence interval 27.71 to 42.41). LOS increased from 79.89 ± 4.43% to 83 ± 4.05% (P 0.07, 95% confidence interval -0.31 to 6.97). Cephalometry analysis showed a significant difference between preoperative and postoperative findings, including: Retrolingual airway space at three levels significantly increased; Level 1 from 6.1 ± 1.6 to 8.5 ± 1.7, Level 2 from 10.5 ± 2.4 to 13.9 ± 2.1, Level 3 from 15.7 ± 3.1 to 21 ± 4, H-GN decreased from 51 ± 7 to 39 ± 8, H-MP decreased from 31.6 ± 7.7 to 24.9 ± 7.3, HS decreased from 121 ± 15 to 102 ± 12, H-PH increased from 29 ± 8 to 43 ± 9. With a success rate defined as AHI <20 and a 50% decrease in AHI of the preoperative value, the surgical success rate was 83.33%.

CONCLUSION

This study showed that Modified genioglossus advancement procedures done for OSA patients significantly changed the position of hyoid bone into a more anterior and superior position and this was reflected in the postoperative Polysomnography.

Skeletal and upper airway stability following modified maxillomandibular advancement for treatment of obstructive sleep apnea in skeletal class I or II deformity

OBJECTIVES

Maxillomandibular advancement (MMA) is an effective short-term treatment for obstructive sleep apnea (OSA). This study aimed to evaluate the long-term stability of the facial skeleton, upper airway, and its surrounding structures, as well as improvement in OSA following MMA.

MATERIALS AND METHODS

Thirty-one adults with moderate-to-severe OSA underwent surgery-first modified MMA as primary surgery. Polysomnography and cone-beam computed tomography were obtained pre-surgery, early post-surgery, and at follow-up (i.e., ≥ 2 years post-surgery). Image analysis software assessed the facial skeleton, upper airway, and its surrounding structures.

RESULTS

Early post-surgery, apnea-hypopnea index (AHI) had decreased significantly (p < 0.001) and the minimum oxygen saturation (MSAT) increased (p = 0.001), indicating significant improvement in OSA. At follow-up, the AHI and MSAT remained stable. However, the anterior maxilla, soft palate, and tongue moved backward while the hyoid moved downward. There was also a significant decrease in the minimal cross-sectional area of the oropharynx. The reduction in AHI was significantly related to the anterior movement of the anterior maxilla and tongue, inferior movement of the posterior maxilla, and superior movement of the soft palate tip.

CONCLUSIONS

The improvement of OSA after modified MMA remained stable for at least 2 years following treatment, despite the relapse of the facial skeleton, upper airway, and its surrounding structures. The reduction of AHI was not related to changes in the caliber of the upper airway but to the movement of the maxilla, soft palate, and tongue. Clinical relevance Modified MMA is clinically effective for long-term treatment of patients with moderate-to-severe OSA.

Effects of Single-Dose Preoperative Pregabalin on Postoperative Pain and Opioid Consumption in Cleft Orthognathic Surgery

BACKGROUND

Several studies have illustrated the efficacy of pregabalin in decreasing postoperative opioid use in adults undergoing orthognathic surgery. We aimed to study the effects of a single dose of preoperative pregabalin on total opioid consumption after orthognathic surgery in individuals with cleft lip and palate.

METHODS

This is a retrospective cohort study of consecutive patients who underwent Le Fort I midface advancement between June 2012 and July 2019. All patients had a diagnosis of cleft lip and palate. The treatment group received a 1-time preoperative dose of pregabalin; the control group did not. Total morphine milligram equivalent (MME) consumption was calculated by adding intraoperative and postoperative opioid use during admission.

RESULTS

Twenty-three patients were included in this study; 12 patients received pregabalin. The pregabalin group had significantly lower total opioid consumption (total MME 70.95 MME; interquartile range [IQR]: 24.65-150.17) compared to the control group (138.00 MME; IQR: 105.00-232.48) (MU = 31.00, P = 0.031). The difference in mean pain scores in the treatment group (3.21 ± 2.03) and the control group (3.71 ± 2.95) was not statistically significant (P = 0.651, 95% confidence interval -1.75 to 2.75).

CONCLUSIONS

A 1-time preoperative dose of pregabalin before orthognathic surgery in patients with cleft lip and palate reduced total opioid consumption during admission without increasing patient pain. A single preemptive dose of pregabalin should be considered an effective adjunct to pain management protocols in patients undergoing orthognathic surgery.

Transoral robotic OSA surgery

Continuous positive airway pressure (CPAP) is the primary treatment of obstructive sleep apnea/hypopnea syndrome (OSA). Most sleep physicians are in agreement that a certain number of OSA patients cannot or will not use CPAP. Although other conservative therapies such as oral appliance, sleep hygiene and sleep positioning may help some of these patients, there are many who fail all conservative treatments. As experts of upper airway diseases, we often view an airway clearly and help OSA patients understand the importance of assessment and treatment for OSA. Surgery for OSA is not a substitute for CPAP but is an alternative treatment for those who failed conservative therapies and therefore have no other options. Transoral robotic surgery (TORS) is a relatively new technique and a valid option with minor post-operative morbidities for selected OSA patients. In the article, we provide an updated overview of the role and evidence of TORS for the treatment of OSA.

Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea

There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion

BACKGROUND

Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies.

METHODS

A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20.

RESULTS

A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups.

CONCLUSIONS

While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.

Comparison of anterior mandible anatomical characteristics between obstructive sleep apnea patients and healthy individuals: a combined cone beam computed tomography and polysomnographic study

PURPOSE

This study aims to evaluate the morphology of the genial tubercle (GT) and lingual foramen (LF) between obstructive sleep apnea (OSA) and non-OSA patients for considerations of mandibular advancement surgery.

METHODS

Cone beam CT records of 198 patients were retrospectively collected and analyzed. Five variables were measured for genial tubercle; anterior mandible thickness (AMT), the distance from the lower incisors to the superior border of the genial tubercle, the distance from the inferior border of the genial tubercle to inferior border of the mandible, the height of GT, and genial tubercle width. Lingual foramen were classified according to the genial tubercle. The frequencies, distances of lingual foramen to alveolar crest, lower border of mandible (LVDL) and diameter of LF were also measured.

RESULTS

Significant differences was found for genial tubercle width, anterior mandible thickness, and the distance of lower mandibular border to the midline lingual foramina between OSA and non-OSA patients (p < 0.05). AMT gets thicker and GT gets narrower in OSA patients (p < 0.05). A linear regression analysis on the apnea hypopnea index with measured anatomical variables showed the LVDL (R = - 0.355*), body mass index (R = 0.254), and age (R = 0.33) showed a statistically significant association (p < 0.05). None of the other variables reached formal significance.

CONCLUSION

LVDL is linearly associated with sleep apnea severity. The variable dimensions and anatomy of genial tubercle as well as lingual foramen for OSA patients suggest the need of 3D preoperative radiological evaluation before genioglossus advancement surgery. Cone beam CT can be a powerful low radiation dose tool both for evaluating the anatomy of the upper airway and mandibular structures at the same time for OSA patients.

The influence of position dependency on surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement

STUDY OBJECTIVES

(1) To evaluate surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement (MMA) stratifying for the reduction of both the total apnea-hypopnea index (AHI) and the AHI in the supine and nonsupine position; (2) to evaluate the influence of position dependency on surgical outcome; and (3) to analyze the prevalence of residual position-dependent obstructive sleep apnea (OSA) in nonresponders after MMA.

METHODS

A single-center retrospective study including a consecutive series of patients with OSA undergoing MMA between August 2011 and February 2019.

RESULTS

In total, 57 patients were included. The overall surgical success was 52.6%. No significant difference in surgical success between nonpositional patients (NPP) and positional patients (PP) with OSA was found. Surgical success of the supine AHI was not significantly different between NPP and PP, but surgical success of the nonsupine AHI was significantly greater in NPP than in PP. Of the 17 preoperative NPP, 13 of them moved to being PP with less severe OSA postoperatively. In total, 21 out of 27 nonresponders (77.8%) were PP postoperatively.

CONCLUSIONS

No significant difference in surgical success between NPP and PP undergoing MMA was found. However, the improvement of total and nonsupine AHI in NPP was significantly greater compared to PP. In nonresponders, a postoperative shift from severe OSA in NPP to less severe OSA in PP was found, caused by a greater reduction of the nonsupine AHI than the supine AHI postoperatively. In patients with residual OSA in the supine position after MMA, additional treatment with positional therapy can be indicated.

Impact of surgical maxillomandibular advancement upon pharyngeal airway volume and the apnoea-hypopnoea index in the treatment of obstructive sleep apnoea: systematic review and meta-analysis

Background

A systematic review was carried out on the effect of surgical maxillomandibular advancement (MMA) on pharyngeal airway (PA) dimensions and the apnoea-hypopnoea index (AHI) in the treatment of obstructive sleep apnoea (OSA), with the aim of determining whether increased PA in the context of MMA is the main factor conditioning the subsequent decrease in AHI.

Methods

A search was made of the PubMed, Embase, Google Scholar and Cochrane databases. A total of 496 studies were identified. The inclusion criteria were a diagnosis of moderate to severe OSA, MMA success evaluated by polysomnography, reporting of the magnitude of MMA achieved, PA increase and a minimum follow-up of 6 months.

Results

Following application of the eligibility criteria, eight articles were included. Metaregression analysis showed MMA to significantly increase both pharyngeal airway volume (PAV) (mean 7.35 cm³ (range 5.35-9.34)) and pharyngeal airway space (mean 4.75 mm (range 3.15-6.35)) and ensure a final AHI score below the threshold of 20 (mean 12.9 events/hour).

Conclusions

Although subgroup analysis showed MMA to be effective in treating OSA, more randomised trials are needed to individualise the required magnitude and direction of surgical movements in each patient, and to standardise the measurements of linear and nonlinear PAV parameters.

Obstructive sleep apnea in adults

INTRODUCTION

Obstructive Sleep Apnea and Hypopnea Syndrome (OSAS) is a highly prevalent disease with serious consequences for the patients' lives. The treatment of the condition is mandatory for the improvement of the quality of life, as well as the life expectancy of the affected individuals. The most frequent treatments provided by dentistry are mandibular advancement devices (MAD) and orthognathic surgery with maxillomandibular advancement (MMA). This is possibly the only treatment option which offers high probability of cure.

OBJECTIVE

The present article provides a narrative review of OSAS from the perspective of 25 years of OSAS treatment clinical experience.

CONCLUSION

MADs are a solid treatment option for primary snoring and mild or moderate OSAS. Patients with severe apnea who are non-adherent to CPAP may also be treated with MADs. Maxillomandibular advancement surgery is a safe and very effective treatment option to OSAS.

Maxillomandibular Advancement for Obstructive Sleep Apnea Produces Long-Term Horizontal Advancement of the Maxilla and Mandible

PURPOSE

Because limited data have been reported, the purpose of the present study was to evaluate the long-term craniofacial cephalometric skeletal changes associated with maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA).

MATERIALS AND METHODS

We performed a retrospective cephalometric cohort study of craniofacial skeletal changes in patients who had undergone MMA for OSA. The primary predictor and outcome variables were time and the change in SNB over time, respectively. Digitized cephalometric radiographs were analyzed by an independent third-party cloud-based tracing software for 6 skeletal landmarks at 3 points-preoperatively, within 1 month postoperatively, and at the last follow-up evaluation. Post hoc stratification bidimensional analyses by gender and preoperative age and body mass index (BMI) were performed. Clinically significant results were determined as a greater than 2% change from baseline. Univariate and bivariate statistics were computed, and the statistical significance level was set at P < .05.

RESULTS

Thirty consecutive subjects with an even gender distribution were included in the present study. The average preoperative age, apnea hypopnea index, and BMI were 43.7 years, 59.8, and 39.3 kg/m². The average follow-up duration was 10.7 years (range, 5.6 to 18.8). Statistically and clinically significant long-term postoperative changes were found only for SNA (+4.9° or +6.0%; P < .001) and SNB (+3.8° or +4.9%; P < .001). Stratification by gender and median preoperative age and BMI did not find any statistically or clinically significant results.

CONCLUSIONS

Within the limitations of the present study, MMA for OSA produced statistically and clinically significant long-term cephalometric skeletal horizontal angular advancement of the maxilla and mandible of 6 and 4.9%, respectively, independently of gender, age, or BMI.

Computational fluid dynamics analysis for the preoperative prediction of airway changes after maxillomandibular advancement surgery

Maxillomandibular advancement surgery is useful for treatment of sleep apnea. However, preoperative analysis and evaluation to facilitate decision-making regarding the direction and distance of maxillomandibular movement has primarily consisted of morphological analysis; physiological function is not evaluated. To improve preoperative prediction, this study used fluid simulation to investigate the characteristics and effects of airway changes associated with maxillomandibular movement. A one-dimensional model with general applicability was thus developed. Actual measurements of flow in patients were used in this fluid simulation, thus achieving an analysis closer to clinical conditions. The simulation results were qualitatively consistent with the actual measurements, which confirmed the usefulness of the simulation. In addition, the results of the one-dimensional model were within the error ranges of the actual measurements. The present results establish a foundation for using accumulating preoperative measurement data for more-precise prediction of postoperative outcomes.

Maxillomandibular Advancement: Contemporary Approach at Stanford

Maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) has remained a reliable and highly effective surgical intervention since its introduction in 1989. Modifications have been made to maximize skeletal movement and upper airway stability without compromising facial balance. Contemporary indications of recommending MMA prior to other soft tissue surgery are described. MMA poses unique challenges to surgeons. There are patient-related factors, including OSA, a chronic inflammatory condition with associated cardiovascular and metabolic comorbidity. Perioperative management is more complex than routine orthognathic patients. Key details are shared from a 3-decade experience at Stanford.

Is Maxillomandibular Advancement Associated With Comorbidity Reduction in Patients With Obstructive Sleep Apnea?

PURPOSE

This study investigated whether patients with documented obstructive sleep apnea (OSA) who have a decrease in apnea-hypopnea index (AHI) score and self-reported symptoms after maxillomandibular advancement (MMA) with genial tubercle advancement (GTA) also have a change in their medical comorbidity profile a minimum of 2 years postoperatively. Changes in the quantity of medical diagnoses, quantity of prescription medications, and average weight and body mass index (BMI) were assessed.

PATIENTS AND METHODS

This is a retrospective cohort study of patients with a diagnosis of OSA (AHI score >5 on polysomnogram [PSG]) treated at the Massachusetts General Hospital (Boston, MA) with MMA and GTA from 2001 through 2015. Patients were identified through the oral and maxillofacial surgery patient data registry. Inclusion criteria were the availability of complete clinical records and requisite follow-up time. The primary predictor variable was operative status (preoperative or postoperative). The primary outcome variables were comorbidities reported to be associated with OSA and identified in the authors' previous study (J Oral Maxillofac Surg 76:1999.e1, 2018). Two-tailed paired t tests were used for continuous variables and χ² or Fisher exact tests were used for categorical variables.

RESULTS

Forty-six patients (39 men, 7 women) met the inclusion criteria. Average weight (206.7 ± 42.4 lb preoperatively; 213.8 ± 41.7 lb postoperatively; P = .014) and average BMI (30.0 ± 5.7 kg/m² preoperatively; 30.9 ± 5.3 kg/m² postoperatively; P = .041) significantly increased in patients postoperatively. No meaningful changes in the number of medical diagnoses or number of prescription medications were noted. Stratification of patients by BMI showed significant increases in weight (188.6 ± 21.5 lb preoperatively; 200.1 ± 27.9 lb postoperatively; P = .0085) and BMI (27.1 ± 1.44 kg/m² preoperatively; 28.9 ± 3.52 kg/m² postoperatively; P = .013) only in "overweight" patients. No other parameters were found to be relevant.

CONCLUSIONS

Subjective improvement in OSA symptoms was reported by all patients and objective PSG improvement was reported for 71% of those evaluated. However, no relevant changes in comorbidity profile were found, suggesting that the medical conditions commonly observed with OSA are likely of multifocal etiology.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis

Objective

To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA).

Data Sources

The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE.

Review Methods

Three authors systematically reviewed the international literature through July 26, 2018.

Results

A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term.

Conclusion

The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Skeletal Surgery for Obstructive Sleep Apnea

Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with uvulopalatopharyngoplasty, tongue-base surgeries, including the genioglossus advancement (GA), sliding genioplasty, and hyoid myotomy and suspension, have been developed to target hypopharyngeal obstruction. Total airway surgery consisting of maxillomandibular advancement (MMA) with/without GA has shown significant success. Skeletal procedures for OSA with or without a palatal procedure is a proven technique for relieving airway obstruction during sleep. A case study demonstrating the utility of virtual surgical planning for MMA surgery is presented.

Long-term effects of Class II Herbst treatment on the pharyngeal airway width

Objective

The aim was to assess the long-term effects of Class II malocclusion treatment with the Herbst appliance on the pharyngeal airway (PA) width in comparison to untreated individuals with Classes I and II malocclusion.

Methods

Lateral cephalometric radiographs of 13 male Class II patients from before (T1) and after (T2) treatment with the Herbst appliance as well as after the end of growth (T3) were retrospectively analyzed and compared to two untreated age- and gender-matched samples with Class I (n = 13) or Class II (n = 13) malocclusion. The PA dimensions were measured using the parameters p (narrowest distance between the soft palate and the posterior pharyngeal wall) and t (narrowest distance between the base of the tongue and the posterior pharyngeal wall). In addition, standard cephalometric measurements were performed.

Results

Relevant changes in PA dimensions were only seen for the post-treatment period, during which the distances p and t showed a significant increase in the Herbst group only (∆p: 2.3 mm, ∆t: 3.3 mm) while remaining similar in both untreated groups (∆p: 0.5 mm, ∆t: 0.5 mm, respectively, ∆p: 0.7 mm, ∆t: 1.6 mm). During the same period, posterior face height showed a significantly larger increase in the Herbst group than in both control groups (8.2 versus 5.8 mm, respectively, 5.4 mm), whereas anterior face height (NL-Me) showed a similar development in all groups (4.6 versus 4.4 mm, respectively 3.2 mm).

Conclusion

In the long term, Herbst treatment resulted in a significant post-treatment increase of PA width, possibly due to an increased lower posterior facial height development compared to untreated individuals.

Volumetric Tongue Reduction for Obstructive Sleep Apnea

Surgery for obstructive sleep apnea/hypopnea syndrome (OSA) is not a substitute for continuous positive airway pressure (CPAP) but is a salvage procedure for those who failed CPAP and other conservative therapies and therefore have no other options. The hypopharyngeal/tongue base procedures for the treatment of OSA are usually challenging to most sleep surgeons. In recent years, several procedures for OSA patients with hypopharyngeal obstructions have been developed to achieve higher response rates with decreased postoperative morbidities.

Orthognathic Correction in Prader-Willi Syndrome: Occlusion and Sleep Restored

Children with Prader-Willi Syndrome (PWS) may present with a malocclusion and have a high propensity of developing obstructive sleep apnea (OSA). Obstructive sleep apnea is associated with short- and long-term adverse effects that negatively impact children with PWS. A case of a 15-year-old male with PWS, OSA, and a debilitating malocclusion is presented who underwent a combination of Le Fort 1 osteotomy, genioplasty, and tongue reduction to successfully treat his OSA and malocclusion. In select cases, orthognathic correction and other surgical therapies should be considered in patients with PWS.

Does the Medical Comorbidity Profile of Obstructive Sleep Apnea Patients Treated With Maxillomandibular Advancement Differ From That of Obstructive Sleep Apnea Patients Managed Nonsurgically?

PURPOSE

Obstructive sleep apnea (OSA) patients with retrognathia and measurable anatomic airway determinants may represent a subset of OSA patients and have distinct comorbidity profiles. Our aim was to compare the medical comorbidities of OSA patients managed surgically with maxillomandibular advancement with those of nonsurgical patients.

PATIENTS AND METHODS

In this cross-sectional retrospective study, patients for both cohorts were identified through the Massachusetts General Hospital oral and maxillofacial surgery data registry and the Massachusetts General Hospital Research Patient Data Registry. The inclusion criteria consisted of clinical records documenting body mass index (BMI), apnea-hypopnea index, respiratory disturbance index, and/or oxygen nadir. The primary predictor variable was the treatment modality chosen: surgical (maxillomandibular advancement) or nonsurgical. Demographic information and OSA parameters were evaluated. The primary outcome variable was the number of documented comorbidities in each group. Two-sample t tests were used for continuous variables, whereas χ² or Fisher exact tests were used for categorical variables.

RESULTS

The nonsurgical cohort consisted of 71 patients (67.6% men), and the surgical cohort consisted of 51 patients (84.3% men). Comparison of descriptive characteristics showed that the nonsurgical cohort had a higher average age (49 ± 9.4 years) than the surgical cohort (41 ± 10.7 years, P < .001). In addition, a higher average BMI was present in the nonsurgical group (42.3 ± 11.9 in nonsurgical group vs 29.7 ± 5.5 in surgical group, P < .001). Polysomnogram parameters were comparable with the exception of a higher Epworth Sleepiness Scale score in the surgical cohort (15.5 ± 5.30 in surgical group vs 9.90 ± 6.80 in nonsurgical group, P = .005). The nonsurgical cohort had a higher total number of comorbidities (7 ± 4 in nonsurgical group vs 4 ± 3 in surgical group, P < .001). Hypertension, cardiovascular disease, hyperlipidemia, pulmonary hypertension, obstructive pulmonary disease, and type 2 diabetes mellitus had higher prevalences within the nonsurgical group.

CONCLUSIONS

The results of this study suggest that nonsurgically managed OSA patients tend to have more complex medical comorbidity profiles than those managed surgically. Obesity (BMI >30) was more prevalent in the nonsurgical cohort, which may be contributory. The additive contribution of OSA needs to be further elucidated.

Surgical Treatment of OSA on Cardiovascular Outcomes: A Systematic Review

BACKGROUND

OSA is an increasingly prevalent clinical problem with significant effects on quality of life and cardiovascular risk. Surgical therapy represents an important treatment for those unable to use positive airway pressure. This systematic review examines the available cardiovascular risk reduction data for the surgical treatment of OSA.

METHODS

A comprehensive literature search was performed. Articles were included if they met the following criteria: (1) the sample population consisted of adults (age ≥ 18 years); (2) OSA was diagnosed according to a sleep study; (3) surgical intervention was performed for OSA; and (4) one or more physical or biochemical cardiovascular and/or cerebrovascular variables was measured preoperatively and at ≥ 14 days postoperatively.

RESULTS

Thirty-three articles were included. The majority of studies were case series and cohort studies (42% and 44%, respectively), with wide-ranging follow-up periods (4 weeks-9 years) and sample sizes (range, 6-10,339; median, 34). The following classes of surgical intervention were examined: pharyngeal surgery (n = 23), tracheostomy (n = 6), maxillomandibular advancement (n = 3), and hypoglossal nerve stimulation (n = 1). In total, 19 outcome measures were assessed. Tracheostomy was most consistently associated with improvement in cardiovascular end points. Pharyngeal surgeries (eg, uvulopalatopharyngoplasty) were variably associated with improvement in cardiovascular end points.

CONCLUSIONS

The published literature examining cardiovascular end points following surgical treatment of OSA is limited and generally of poor quality. However, available data from mainly small and observational studies suggest that surgical treatment of OSA may provide improvement in some cardiovascular end points. Larger, randomized, and prospective trials with more rigorous study designs are needed.

TRIAL REGISTRY

PROSPERO International Prospective Register of Systemic Reviews (PROSPERO 42016040120).

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

PURPOSE

The purposes of this study were to determine the occurrence of undiagnosed "silent" obstructive sleep apnea (OSA) in dentofacial deformity (DFD) patients at initial surgical presentation and to report on the level of daytime sleepiness in DFD patients with OSA and chronic obstructive nasal breathing (CONB) after undergoing bimaxillary, chin, and intranasal surgery.

MATERIALS AND METHODS

A retrospective cohort study of patients with a bimaxillary DFD and CONB was implemented. Patients were divided into those with no OSA (group I) and those with OSA (group II). Group II was further subdivided into patients referred with polysomnogram (PSG)-confirmed OSA (group IIa) and those with a diagnosis of OSA only after surgical consultation, airway evaluation, and a positive PSG (group IIb). Group II patients were analyzed at a minimum of 1 year after surgery (range, 1 to 10 years) for daytime sleepiness with the Epworth Sleepiness Scale. Patients with postoperative excessive daytime sleepiness were assessed for risk factors and continued need for OSA treatment. Patients in group II were studied to determine which DFD patterns were most associated with OSA. We compared the prevalence of OSA between our study population and the general population.

RESULTS

Two hundred sixty-two patients met the inclusion criteria. Of these, 23% (60 of 262) had PSG-confirmed OSA (group II). This rate was much higher than that found in the general population. Of the patients, 7% (19 of 262) were known to have OSA at initial surgical consultation (group IIa). An additional 16% (41 of 262) were later confirmed by PSG to have OSA (group IIb). Patients with primary mandibular deficiency and short face DFDs were most likely to have OSA (P < .001 and P = .001, respectively). In group II, 91% (55 of 60) rated their daytime sleepiness as "not sleepy" at a minimum of 1 year after surgery. A significant association was found between group II patients with postoperative excessive daytime sleepiness ("sleepy" or "very sleepy") and a preoperative body mass index category of overweight (P = .026).

CONCLUSIONS

Our study found silent OSA to be frequent in the DFD population. The prevalence of OSA in DFD patients exceeded that estimated in the general population, with retrusive jaw patterns most affected. In DFD patients also presenting with OSA and CONB, we confirmed low levels of daytime sleepiness long-term after simultaneous bimaxillary orthognathic, chin, and intranasal surgery.

Evaluation of genial tubercle anatomy using cone beam computed tomography

The purpose of this study was to characterize the anatomy of the genial tubercle using cone beam computed tomography (CBCT). The morphology and detailed anatomy of the genial tubercle were assessed retrospectively in 201 patients (101 females, 100 males) using CBCT images. The parameters examined were the height (GH) and width (GW) of the genial tubercle, the distance from the lower incisors to the superior border of the tubercle (I-SGT), the distance from the inferior margin of the tubercle to the inferior margin of the mandible (IGM-IBM), and the anterior mandible thickness (AMT). Statistical analysis was performed to assess relationships among these parameters, gender, and orthodontic malocclusion (P < 0.05). The values obtained were GH 7.3-8.7 mm, GW 7.9-9.2 mm, I-SGT 7.1-9.1 mm, IGM-IBM 8.3-10.1 mm, and AMT 14.0-16.2 mm. GH, GW, and I-SGT showed no significant differences between genders (P > 0.05). However, IGM-IBM was larger for class III than for class I and class II male patients, and larger than for class I female patients. AMT in class III patients was greater than in class I and II patients (P < 0.05). The use of CBCT, which employs less radiation, is important for dental professionals, especially those performing surgery for obstructive sleep apnea (OSA), in order to avoid possible surgical complications.