Monitoring of Home Respiratory Polygraphy During Mandibular Distraction Osteogenesis Succeeded by LeFort I Osteotomy in Adult Patients With Obstructive Sleep Apnea.

BACKGROUND: Bilateral internal ramus distraction (BIRD) is now part of select protocols for treating obstructive sleep apnea (OSA). Introducing a home monitoring protocol offers a valuable alternative to overnight laboratory polysomnography (PSG). PURPOSE: The purpose of this study was to evaluate and compare OSA parameters obtained via home respiratory polygraphy (HRP) and hospital PSG in a cohort of patients undergoing mandibular distraction for OSA management. STUDY DESIGN, SETTING, SAMPLE: Hospital Universitario La Princesa (Madrid) researchers conducted a prospective cohort study with patients diagnosed with moderate (apnea-hypopnea index (AHI) = 15 to 30) to severe (AHI>30) OSA undergoing BIRD followed by LeFort maxillary osteotomy. Exclusion criteria were as follows: severe systemic diseases, central apneas, smoking, poor dental hygiene, or prior OSA interventions. PREDICTOR VARIABLE: The predictor variable was PSG and HRP techniques. MAIN OUTCOME VARIABLES: The main outcome variable comprises a collection of OSA parameters, including the AHI, oxygen desaturation index (ODI), and time spent below 90% oxygen saturation (T90). These data were measured both before and after distraction, as well as after 6 mm, 9 mm, and 12 mm of mandibular distraction. COVARIATES: The covariates were age, sex, cardiovascular risk parameters, and the Epworth sleepiness scale. ANALYSES: Pearson's correlation analyzed AHI, ODI, and T90 values from PSG and HRP. Wilcoxon Signed Rank-Sum Test compared 2 distraction stages, and the Friedman Test evaluated 3 stages (P < .05). Multiple regression analysis assessed if covariates were independent risk factors for postoperative persistent OSA. RESULTS: The study included 32 patients (25% with moderate and 75% with severe OSA). Final AHI was 10.9 ± 8.9 (events/hour) with HRP, compared to 15.2 ± 13.4 with PSG (r = 0.7, P < .05). ODI was 9.0 ± 8.1 (des/h) with HRP and 8.7 ± 9.5 with PSG (r = 0.85, P < .05). T90 was 1.6 ± 2.2 with HRP and 1.3 ± 3.0 with PSG (r = 0.6, P < .05). Based on HRP data, AHI improved from D1 (34.0 ± 19.5) to D2 (20.8 ± 14.1) and D3 (12.5 ± 10.4) (P < .05). ODI decreased from D1 (26.1 ± 19.0) to D2 (16.0 ± 12.6) and D3 (9.4 ± 8.8) (P < .05). T90 reduced from D1 (8.2 ± 12.6) to D2 (4.1 ± 5.2) and D3 (1.9 ± 2.8) (P < .05). Multiple regression analysis of comorbidities produced nonsignificant results. CONCLUSION AND RELEVANCE: Monitoring BIRD through HRP has demonstrated efficacy in yielding results that align with PSG.

Improved Quality of Life After Mandibular Advancement by Bilateral Internal Ramus Distraction.

BACKGROUND: Obstructive Sleep Apnea (OSA) is a significant health issue due to noncompliance with continuous positive airway pressure treatment. Therefore, evaluating alternative treatments is crucial. PURPOSE: Analyze the impact of maxillomandibular advancement using bilateral internal ramus distraction (BIRD) on quality of life (QOL) in OSA patients. STUDY DESIGN, SETTING, AND SAMPLE: A prospective cohort study was conducted at the Oral and Maxillofacial Surgery Department of the University Hospital "La Princesa." The study included patients with moderate to severe OSA who were treated with the BIRD approach. PREDICTOR VARIABLE: Changes in measured variables were analyzed at three time points: before surgery (T1), after mandibular advancement (T2), and after maxillary advancement (T3). MAIN OUTCOME VARIABLE(S): QOL changes measured by Quebec Sleep Questionnaire and the Epworth Sleepiness Scale. Secondary outcomes included: apnea-hypopnea index (AHI), oxygen desaturation index, and percentage of time with saturation below 90%. COVARIATES: Age, sex, continuous positive airway pressure treatment, cephalometric variables and cardiovascular risk parameters were considered. ANALYSES: Statistical analysis employed the Friedman test and χ2 test, with a significance level of P ≤ .05. RESULTS: The study included 32 patients (22% with moderate OSA, 78% with severe OSA). Epworth Sleepiness Scale scores significantly decreased between T1 (13.4 ± 4.4) and T2 (5.8 ± 3.6) and T3 (1.9 ± 1.8) (P < .001). QOL improvements were observed in all domains: daytime sleepiness T1 (3.0 ± 1.3) T2 (5.4 ± 1.4) T3 (6.3 ± 1.0); diurnal symptoms T1 (2.5 ± 1.4) T2 (5.2 ± 1.3) T3 (6.2 ± 1.1); nocturnal symptoms T1 (2.5 ± 1.1) T2 (5.6 ± 1.1) T3 (6.5 ± 0.8); emotions T1 (2.6 ± 1.6) T2 (5.3 ± 1.4) T3 (6.5 ± 0.9); and social interaction T1 (2.5 ± 1.6) T2 (5.4 ± 1.6) T3 (6.3 ± 1.2) (P < .001). AHI decreased between T1 (47.9 ± 23.1) and T2 (14.4 ± 14.3) and T3 (4.7 ± 5.6) h-1 (P < .001), with a final cure rate of 81.2% (defined as final AHI<5 h-1). Oxygen desaturation index and percentage of time with saturation below 90% also showed significant reductions (P < .001). CONCLUSIONS AND RELEVANCE: BIRD approach for OSA demonstrated a high cure rate and significant QOL improvements. It shows promise as an effective surgical option. Further research and long-term follow-up are needed.

Apnea obstructiva del sueño: un abordaje innovador mínimamente invasivo mediante distracción de rama mandibular / Obstructive sleep apnoea: An innovative minimally invasive approach using mandibular branch distraction

Presentamos un nuevo abordaje mínimamente invasivo mediante distracción intraoral de rama mandibular bilateral (bilateral internal ramus distraction) para el tratamiento del síndrome de apnea obstructiva del sueño en el paciente adulto. Tras la planificación virtual 3D, el paciente es intervenido bajo anestesia general y asistencia endoscópica, dentro de un protocolo de cirugía mayor ambulatoria, y es dado de alta el mismo día de la cirugía. Tras un periodo de 5días, la rama mandibular se alarga verticalmente durante un periodo que oscila entre 10 y 50 días, a un ritmo de 0,5 a 1mm diario, hasta que el índice de apnea hipopnea alcanza una cifra inferior a 5 pausas por hora (nivel de curación) o el resalte negativo dentario (overjet) se sitúa en valores que ya superan los 10mm. La titulación del procedimiento mediante parámetros clínicos, poligráficos o polisomnográficos permite al cirujano personalizar el avance mandibular en cada caso. Tras un alargamiento que suele oscilar entre 10 y 25mm, los distractores se mantienen durante 6meses hasta que concluye el periodo de consolidación. La indicación de cirugía maxilar tras el avance mandibular se realizará en dependencia del índice de apnea hipopnea residual, de la oclusión y del análisis facial. La distracción intraoral de rama mandibular bilateral es una técnica altamente efectiva para la curación del síndrome de apnea obstructiva del sueño en pacientes adultos con o sin retrognatia, y podría estar indicada incluso en pacientes con morbilidades asociadas, como enfermedades cardiovasculares graves u obesidad mórbida, en los que un procedimiento quirúrgico de mayor envergadura, como el avance maxilomandibular clásico, se descarta como alternativa quirúrgica

An innovative and minimally invasive approach for adult obstructive sleep apnoea by using bilateral internal ramus distraction osteogenesis of the mandible is presented. After a careful virtual 3D planning, mandibular distraction surgery is performed under general anaesthesia and endoscopic assistance, using a major ambulatory surgery protocol, with the patient being discharged home the same day. After an initial latency of 5days, the ascending ramus is gradually lengthened vertically during a period varying between 10 and 50 days, at a rate of 0.5mm to 1mm daily, until an apnoea-hypopnoea index below 5/h is achieved (cure level), and/or a negative overjet>10mm is reached. Titration of the procedure according to clinical criteria with the assistance of polygraphy and/or polysomnography allows the clinician to customise the mandibular advancement to each particular case. After a mandibular ramus lengthening ranging between 10 and 25mm, the distraction devices are kept in place for 6months after completion of the consolidation period. Bilateral internal ramus distraction is a highly effective surgical technique in curing obstructive sleep apnoea in adults with or without retrognathia, and could be indicated even in patients with comorbidities, such as cardiovascular disease or morbid obesity, in which a major surgical procedure, i.e. conventional maxillomandibular advancement, should be discouraged

Evidence of Active Pro-Fibrotic Response in Blood of Patients with Cirrhosis.

The role of systemic immunity in the pathogenesis of cirrhosis is not fully understood. Analysis of transcriptomic profiles in blood is an easy approach to obtain a wide picture of immune response at the systemic level. We studied gene expression profiles in blood from thirty cirrhotic patients and compared them against those of eight healthy volunteers. Most of our patients were male [n = 21, 70%] in their middle ages [57.4 ± 6.8 yr]. Alcohol abuse was the most frequent cause of cirrhosis (n = 22, 73%). Eleven patients had hepatocellular carcinoma (36.7%). Eight patients suffered from hepatitis C virus infection (26.7%). We found a signature constituted by 3402 genes which were differentially expressed in patients compared to controls (2802 over-expressed and 600 under-expressed). Evaluation of this signature evidenced the existence of an active pro-fibrotic transcriptomic program in the cirrhotic patients, involving the [extra-cellular matrix (ECM)-receptor interaction] & [TGF-beta signaling] pathways along with the [Cell adhesion molecules] pathway. This program coexists with alterations in pathways participating in [Glycine, serine and threonine metabolism], [Phenylalanine metabolism], [Tyrosine metabolism], [ABC transporters], [Purine metabolism], [Arachidonic acid metabolism]. In consequence, our results evidence the co-existence in blood of a genomic program mediating pro-fibrotic mechanisms and metabolic alterations in advanced cirrhosis. Monitoring expression levels of the genes involved in these programs could be of interest for predicting / monitoring cirrhosis evolution. These genes could constitute therapeutic targets in this disease.

Exposición a plaguicidas, desnutrición crónica y daño genotóxico en menores de tres años. Luribay / Pesticide exposure, chronic malnutrition and genotoxic damagein children under three years. Luribay

OBJETIVO: Evaluar si la exposición a plaguicidas y la desnutrición crónica son factores de riesgo para daño genotóxico en menores de tres años del municipio de Luribay del departamento de La Paz. Noviembre ­ 2008. MATERIAL Y MÉTODOS: estudio de casos y controles. 155 niños y niñas menores de tres años estudiados, habitantes de ocho poblaciones de Luribay, La Paz - Bolivia de las 15 intervenidas por el Programa de Crecimiento Comunitario (Save the Children). Se aplicó a las madres una encuesta validada y adaptada al lugar para medir la exposición a plaguicidas y se realizó a los niños(as) la técnica de citoma bucal para determinación del daño genotóxico. RESULTADOS: un 61% de las madres se dedicaba a la agricultura, de ellas un 33% fumigó al menos una vez estando embarazada y 85% no utiliza equipo de protección completo. 83% de los niños presentan daño genotóxico, de ellos 84% se encuentran expuestos a plaguicidas. Los niños no desnutridos y expuestos a plaguicidas con daño genotóxico alcanzan un total de 35%. No se encontraron diferencias significativas entre los grupos de no desnutridos y expuestos a plaguicidas con Daño Genotóxico y los niños desnutridos crónicos y expuestos a plaguicidas también con Daño Genotóxico, (no desnutridos p=1,00) (desnutridos crónicos p=0,70). Los resultados en relación a la diferencia de edad en los pacientes con y sin daño genotóxico, son significativos (p=0.05).

OBJECTIVE: to assess whether exposure to pesticides and chronic malnutrition are risk factors for genotoxic damage in children under three years of age, of the municipality of Luribay, Department of La Paz. November -2008. METHODS: case study and control. 155 boys and girls were studied from eight Luribay towns, La Paz -Bolivia out of 15 involved by the Communitarian Development Program (Save the Children). A survey was applied, validated and adapted to the location in order to measure pesticide exposure, and the buccal cytome technique was applied on children for determining genotoxic damage. RESULTS: 61 percent of the mothers dedicated themselves to agriculture, out of them a 33 percent had fumigated at least once being pregnant, and 85 percent did not use appropriate protective gear. 83 percent of the children have genotoxic damage, out of them 84 percent are exposed to pesticides. Non-malnourished children and exposed to pesticides with genotoxic damage reach 35 percent. No meaningful differences were found between the group of Non-malnourished children and exposed to pesticides with genotoxic damage and the chronic malnourished children and exposed to pesticides with genotoxic damage, (Non-malnourished p=1,00) ( chronic malnourished p=0,70). Results concerning age difference in patients with and without genotoxic damage are meaningful (p=0.05).

Pedicled buccal fat pad flap for upper lip augmentation in orthognathic surgery patients.

PURPOSE: In this article, a new method of upper lip augmentation using a bilateral buccal fat pad flap is reported. This prospective study evaluated the changes in the upper lip that occur after maxillary surgery with concomitant mobilization of the bilateral buccal fat to improve upper lip projection. MATERIALS AND METHODS: A bilateral pedicled buccal fat pad flap to fill the premaxilla, paranasal, and upper lip areas, in association with a Le Fort I osteotomy for maxillary advancement, was performed in 11 orthognathic surgical patients with a thin upper lip. Minimum follow-up was 12 months. Cone-beam computed tomograms from an i-CAT device (Imaging Sciences International, Hatfield, PA) were taken pre- and postoperatively and loaded into Dolphin software (Dolphin Imaging and Management Solutions, Chatsworth, CA) for analysis. Changes at the right upper incisor tip, upper lip anterior, upper inside, stomion superior, and subnasale were measured in each patient immediately before and 6 months after surgery. Dimensional changes of the upper lip were measured using lip length (from the subnasale to the stomion superior) and lip thickness (from the upper inside to the upper lip anterior). RESULTS: The average maxillary advancement was 4.81 ± 2.47 mm, and the average vertical movement was 1.00 ± 1.75 mm; both were measured at the upper incisor tip. Upper lip movement, measured at the upper lip anterior, was 5.98 ± 2.46 mm (124.32% of maxillary advancement, mean data). Lip thickness increased 0.9 ± 0.19 mm, and lip length increased 0.77 ± 0.32 mm. The new upper lip contour was considered good to excellent in all cases. CONCLUSIONS: The technique described was useful to increase the projection, volume, and contour of the premaxilla, paranasal, and upper lip areas in orthognathic surgical patients. Moreover, it appeared to be useful to control the length shortening of the upper lip in all cases.

Internal distraction osteogenesis in mandibular reconstruction: clinical experience in 10 cases.

BACKGROUND: Distraction osteogenesis has been used for reconstruction of bone and soft-tissue defects. The authors present their clinical experience in the reconstruction of mandibular segmental defects by means of internal distraction osteogenesis. METHODS: Ten patients with mandibular defects ranging from 30 to 80 mm in length were treated in the authors' department. Internal distraction devices with transcutaneous activators were placed immediately after complete resection of the affected bone. Distraction was initiated 10 days after surgery at a rate of 0.5 mm/day. The consolidation period ranged from 12 to 22 weeks. Finally, the distractor device was removed. In two patients, an additional iliac crest bone graft was needed to complete bone union. RESULTS: Follow-up ranged from 4 to 47 months after surgery. Partial cutaneous and intraoral exposure was observed in two patients. At the end of the follow-up period, successful distraction osteogenesis was achieved in eight patients. Six patients were alive and free of disease, whereas two patients showed local relapse and required new resective surgery. Complete intraoral exposure with failure of the distraction process was observed in one patient, whereas another patient did not complete distraction because of metastatic disease diagnosed 4 months after surgery. CONCLUSIONS: Good clinical results for reconstruction of mandibular and soft-tissue postablative defects are reported with the use of this technique. The use of semiburied devices provides better aesthetics and acceptable quality of life to the patients. Larger series are required to popularize the use of this procedure.

Internal distraction osteogenesis with a unidirectional device for reconstruction of mandibular segmental defects.

PURPOSE: To present the authors' clinical experience with unidirectional internal distraction devices to reconstruct mandibular defects. PATIENTS AND METHODS: Five patients have been treated with mandibular distraction osteogenesis to reconstruct different acquired segmental defects. These mandibular defects (35 to 80 mm in length) were reconstructed by means of internal distraction devices with a transcutaneous activator. All the patients underwent complete resection of the affected bone and immediate placement of the distraction device on the remaining mandible. RESULTS: The results' analysis was based on clinical observation, postoperative radiographs, histopathologic findings and 3-dimensional computed tomographic scans. Successful distraction osteogenesis was achieved in 3 cases. In 1 case, extensive intraoral exposure of the device was observed, resulting in a failure of the procedure. One patient died of distant metastases 4 months after the resective surgery. CONCLUSION: Because of the limited number of cases, this study is preliminary. However, considering the good experimental and clinical results, this new technique offers an alternative for patients with segmental mandibular defects in which, because of local or general reasons, a more aggressive procedure should be avoided.

Experimental mandibular regeneration by distraction osteogenesis with submerged devices: preliminary results of a canine model.

The authors describe a new technique for reconstruction of mandibular body defects. The feasibility of distraction osteogenesis with submerged (internal) devices for reconstruction of segmental mandibular defects is investigated in an experiment with five adult dogs. A segmental mandibulectomy was performed on the horizontal ramus. The bony defect was regenerated using distraction osteogenesis (bone transport) at a rate of 1 mm daily. The animals were killed after the consolidation period. Complete bone regeneration of the surgically created gap was successful in three of five dogs. Two animals failed to create new bone. In these two cases, the screws did not offer proper stability to the bony fragments, and this caused a lack of ossification. This experimental study demonstrates the possibility to use internal distraction devices to reconstruct segmental mandibular defects in a canine model. Internal devices show enormous advantages in comparison with the external ones. This method with no donor-site morbidity may become a very useful option in human mandibular reconstruction.