Nasal and maxillary sinus volume change in patients with obstructive sleep apnea after bimaxillary advancement surgery.

The airway complex is modified by bimaxillary advancement surgery performed in patients suffering from obstructive sleep apnea (OSA). The aim of the present study is to analyse the volume of nasal and maxillary sinus after bimaxillary advancement surgery in patients suffering from OSA. The maxillary sinus and nasal complex of eighteen patients with OSA was measured through cone-beam computed tomography (CBCT) before and after they were treated with bimaxillary advancement surgery. Digital planning software was used to effectively measure the upper volume changes, as well as, statistical analysis of the results was performed.Methods Eighteen patients were diagnosed with OSA the severity of which was measured by the apnea hypopnea index and were selected and submitted to preoperative and postoperative CBCT scans. Afterwards, datasets were uploaded into therapeutic digital planning software (Dolphin Imaging) to measure the volume of the right and left maxillary sinus and nasal and maxillary sinus complex. Statistically analysis between preoperative and postoperative measures was performed by Student t-test statistical analysis.Results The paired t-test showed statistically significant volumetric reductions in the left maxillary sinus (p = 0.0004), right maxillary sinus (p < 0.0001) and nasal and maxillary sinus complex (p = 0.0009) after bimaxillary advancement surgery performed in patients suffering from OSA.Conclusion The results showed that bimaxillary advancement surgery reduces the maxillary sinus volume as well as, the fossa nasal and sinus complex volume.

Maxillomandibular Advancement for OSA: A 25-year perspective / Avancement maxillo-mandibulaire pour le traitement du SAOS : une perspective sur 25 ans

Objective: The aim of this study was to evaluate the result of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) by a single surgeon. Materials and Methods: Patients that underwent MMA for the treatment of OSA over a 25-year period were included in the study. Patients who initially presented for revision MMA surgery were excluded. Demographics (e.g., age, gender, pre- and post-MMA body mass index [BMI]), pre- and post-MMA cephalometrics (e.g., sella-nasion-point A angle [SNA], sella-nasion-point B angle [SNB], posterior airway space base of tongue [PAS]) and pre- and post-MMA sleep study metrics (e.g., respiratory disturbance index [RDI], lowest desaturation [SpO2-nadir], oxygen desaturation index [ODI], total sleep time [TST], % TST Stage N3 sleep, % TST rapid eye movement [REM] sleep) were abstracted. MMA surgical success was defined as a ≥ 50% reduction in RDI (or ODI) and post-MMA RDI (or ODI) < 20 events/hour. MMA surgical cure was defined as a post-MMA RDI (or ODI) < 5 events/hour. Results: A total of 1010 patients underwent MMA for the treatment of OSA. The mean age was 39.6 ± 14.3 years, and the majority were male (77%). Nine hundred forty-one patients with complete pre- and postoperative PSG data were analyzed. The mean ODI and RDI improved from 32.6 ± 27.4 to 7.7 ± 15.5 and 39.1 ± 24.2 to 13.6 ± 14.6 events per hour, respectively. The overall surgical success and surgical cure based on ODI was 79.4% and 71.9%, respectively. The overall surgical success and surgical cure based on RDI was 73.1% and 20.7%, respectively. Stratified by preoperative RDI showed older age, greater BMI were associated with greater preoperative RDI. Bivariate predictors of greater RDI reduction include younger age, female gender, lower preoperative BMI, higher preoperative RDI, greater BMI reduction postoperatively and greater change in SNA and PAS. Bivariate predictors of surgical cure based on RDI (RDI < 5) include younger age, female gender, lower preoperative RDI, and greater change in SNA and PAS. Bivariate predictor of RDI success (RDI < 20) include younger age, female gender, lower preoperative BMI, lower preoperative RDI, greater BMI reduction, greater increase in SNA, SNB and PAS postoperatively. Comparison of the first 500 patients and the later 510 patients demonstrate patients undergoing MMA have become younger, having lower RDI while achieving a better surgical outcome. Linear multivariate associations of greater percentage RDI reduction include younger age, greater percent change of SNA, greater preoperative SNA, lower preoperative BMI and higher preoperative RDI. Conclusions: MMA is an effective treatment to improve OSA, but the result can vary. Patient selection based on favorable prognostic factors and maximizing the advancement distance can improve outcomes.

Introduction: L'objectif de cette étude était d'évaluer les résultats obtenus avec le recours à des chirurgies d'avancement maxillo-mandibulaire (AMM) réalisées par le même chirurgien pour le traitement du syndrome d'apnée obstructive du sommeil (SAOS). Matériels et méthodes: Les patients qui ont subi une AMM pour le traitement de leur SAOS tout au long d'une période de 25 ans ont été inclus dans l'étude. Les patients qui se sont initialement présentés pour une révision d'une précédente AMM ont été exclus. Les données démographiques (par exemple l'âge, le sexe, l'indice de masse corporelle [IMC] avant et après l'AMM), les données céphalométriques avant et après l'AMM (par exemple, l'angle sella-nasion point A [SNA], l'angle sella-nasion point B [SNB], l'espace des voies aériennes postérieures à la base de la langue [EAP]) et les mesures de l'étude du sommeil avant et après l'AMM (par exemple, l'indice de perturbation respiratoire [IPR], la désaturation la plus faible [nadir-SpO2], l'indice de désaturation en oxygène [ODI], le temps total de sommeil [TTS], % de TTS de stade N3, % de TTS à mouvements oculaires rapides [REM]) ont été extraites. Le succès chirurgical de l'AMM a été défini comme une réduction ≥ 50 % de l'IPR (ou de l'ODI) et un IPR (ou un ODI) post-AMM < 20 événements/heure. La guérison chirurgicale de l'AMM a été définie comme un IPR (ou ODI) post-AMM < 5 événements/heure. Résultats: Un total de 1010 patients a subi une AMM pour le traitement du SAOS. L'âge moyen des patients était de 39,6 ± 14,3 ans et la majorité d'entre eux étaient des hommes (77 %). Les dossiers de neuf cent quarante et un patients, pour lesquels des données PSG complètes avant et après l'opération étaient disponibles, ont été analysés. L'ODI et l'IPR moyens se sont améliorés respectivement de 32,6 ± 27,4 à 7,7 ± 15,5 et de 39,1 ± 24,2 à 13,6 ± 14,6 événements par heure. Le succès chirurgical global et la guérison chirurgicale basés sur l'ODI étaient de 79,4 % et 71,9 %, respectivement. Le succès chirurgical global et la guérison chirurgicale basés sur l'IPR étaient de 73,1 % et 20,7 %, respectivement. La stratification en fonction de l'IPR préopératoire a montré qu'un âge et un IMC plus élevés étaient associés à un IPR préopératoire plus important. Les prédicteurs bivariés d'une plus grande réduction de l'IPR comprennent un âge moindre, le sexe féminin, un IMC préopératoire plus faible, un IPR préopératoire plus élevé, une plus grande réduction de l'IMC postopératoire et une plus grande modification de SNA et de l'EAP. Les prédicteurs bivariés de la guérison chirurgicale basée sur l'IPR (IPR < 5) comprennent un âge moindre, le sexe féminin, un IPR préopératoire plus faible et une plus grande variation de SNA et de l'EAP. Les prédicteurs bivariés du succès de l'IPR (IPR < 20) incluent un âge moindre, le sexe féminin, un IMC préopératoire plus faible, un IPR préopératoire plus faible, une plus grande réduction de l'IMC, une plus grande augmentation de SNA, de SNB et de l'EAP en postopératoire. La comparaison entre les 500 premiers patients opérés et les 510 derniers montre que le profil des patients subissant une AMM a évolué avec des patients d'âge moindre et un IPR plus faible et que cette évolution s'est accompagnée d'un meilleur résultat chirurgical. Les associations multivariées linéaires d'un pourcentage plus élevé de réduction de l'IPR comprennent un âge moindre, un pourcentage plus élevé de changement de SNA, un SNA préopératoire plus important, un IMC préopératoire plus faible et un IPR préopératoire plus élevé. Conclusions: L'AMM est un traitement efficace pour améliorer le SAOS, mais le résultat peut varier. La sélection des patients en fonction de facteurs pronostiques favorables et l'optimisation de la distance d'avancement peuvent améliorer les résultats.

Treatment of OSA by maxillomandibular advancement: Serious Complications and Failures / Traitement du SAOS par avancement maxillomandibulaire : complications graves et échecs

Aim: The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA)performed elsewhere. Methods: During a five-year period, 16 patients presented with complications and/or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. Results: Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patient), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). Conclusions: Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.

Objectif: L'objectif de ce rapport était d'analyser les patients qui se sont présentés pour un deuxième avis, en raison de complications et d'un échec survenus après un avancement maxillo-mandibulaire (AMM) réalisé ailleurs. Méthodes: Au cours d'une période de cinq années, seize patients se sont présentés avec des complications et/ou un échec de leur AMM. L'indication du traitement était l'apnée obstructive du sommeil (AOS). Une analyse des dossiers de traitement, comprenant une radiographie 2D et/ou une tomographie à faisceau conique (CBCT), des photographies de l'évolution et un examen clinique, a été effectuée. Résultats: Des dossiers cliniques et d'imagerie complets étaient disponibles pour tous les patients aux fins d'analyse. Treize patients étaient des échecs chirurgicaux avec un avancement allant de -4 à 5 mm. Cinq des 13 patients avaient un avancement limité lors de la chirurgie initiale, et huit patients ont été confrontés à une défaillance du matériel qui en a nécessité la dépose avec pour conséquence un rétro-déplacement de la mandibule. En raison de complications survenues chez 11 patients, une chirurgie supplémentaire, allant de deux à six interventions additionnelles après l'opération initiale, a été nécessaire. Les complications comprenaient une défaillance du matériel (dix patients) qui a entraîné un déplacement du segment osseux (huit patients), une pseudarthrose du maxillaire (deux patients), une pseudarthrose de la mandibule (huit patients), une douleur faciale et/ou articulaire chronique (cinq patients), une lésion du nerf facial (deux patients), une anesthésie complète de la lèvre/menton (cinq patients) et une malocclusion grave (quatre patients). Conclusions: Bien que l'AMM soit généralement une opération prévisible avec d'excellents résultats, une absence d'amélioration et de graves séquelles à long terme dues à des complications chirurgicales sont possibles. La précision du geste chirurgical, associée à un avancement du squelette suffisant pour améliorer les voies respiratoires et une bonne stabilité de l'ostéosynthèse du squelette, sont nécessaires pour obtenir un résultat satisfaisant.

Long-term three-dimensional effects of orthognathic surgery on the pharyngeal airways: a prospective study in 128 healthy patients.

OBJECTIVE: To investigate volumetric and circumferential pharyngeal airway space (PAS) changes and stability over time as evaluated with cone beam computed tomography (CBCT) before and after orthognathic surgery 2 years postoperatively. MATERIALS AND METHODS: One hundred twenty-eight patients underwent bimaxillary orthognathic surgery at the Department of Maxillofacial Surgery of University Hospitals, Leuven, Belgium, were recruited prospectively. Patients were divided into 4 groups based on the amount of mandibular advancement in 5 mm increments (< 0 mm, 0-5 mm, 5-10 mm, or > 10 mm). CBCT data was acquired preoperatively and 1-6 weeks, 6 months, 1 year, and 2 years postoperatively. Patients with a history of maxillofacial trauma or surgery, obstructive sleep apnoea syndrome, or craniofacial anomalies were excluded. Nasopharyngeal, oropharyngeal, and hypopharyngeal PAS volumes and constriction surface areas (mCSA) were measured and compared between each time point with a paired t-test. RESULTS: The largest significant increase in oropharyngeal volume and mCSA were observed in the 5-10 mm (+ 13.3-21.7%, + 51.3-83.0%)) and > 10 mm (+ 23.3-44.6%, + 92.3-130.0%) mandibular advancement groups. This increase only remained stable 2 years postoperatively in the > 10 mm group. In other mandibular advancement groups, short-term oropharyngeal volume and mCSA increases were noticed, which returned to baseline levels 6 months to 1 year postoperatively. CONCLUSION: Bimaxillary advancement osteotomy significantly increases oropharyngeal volume and mCSA, which remains stable between 6 months to 1 year postoperatively. CLINICAL RELEVANCE: Long-term stable volumetric and mCSA enlargements were found with > 10 mm mandibular advancements over a period of 2 years. Return towards baseline levels was observed in the other mandibular advancement groups.

Maxillomandibular Advancement for OSA: Serious Complications and Failures

Objective: The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA) performed elsewhere. Materials and Methods: During a five-year period, 16 patients presented with complications and/ or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. Results: Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patients), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). Conclusions: Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.

Maxillomandibular Advancement for OSA: A 25-year perspective

Objective: The aim of this study was to evaluate the result of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) by a single surgeon. Materials and Methods: Patients that underwent MMA for the treatment of OSA over a 25-year period were included in the study. Patients who initially presented for revision MMA surgery were excluded. Demographics (e.g., age, gender, pre- and post-MMA body mass index [BMI]), pre- and post-MMA cephalometrics (e.g., sella-nasion-point A angle [SNA], sella-nasion-point B angle [SNB], posterior airway space base of tongue [PAS]) and pre- and post-MMA sleep study metrics (e.g., respiratory disturbance index [RDI], lowest desaturation [SpO2-nadir], oxygen desaturation index [ODI], total sleep time [TST], % TST Stage N3 sleep, % TST rapid eye movement [REM] sleep) were abstracted. MMA surgical success was defined as a ≥ 50% reduction in RDI (or ODI) and post-MMA RDI (or ODI) < 20 events/hour. MMA surgical cure was defined as a post-MMA RDI (or ODI) < 5 events/hour. Results: A total of 1010 patients underwent MMA for the treatment of OSA. The mean age was 39.6 ± 14.3 years, and the majority were male (77%). Nine hundred forty-one patients with complete pre- and postoperative PSG data were analyzed. The mean ODI and RDI improved from 32.6 ± 27.4 to 7.7 ± 15.5 and 39.1 ± 24.2 to 13.6 ± 14.6 events per hour, respectively. The overall surgical success and surgical cure based on ODI was 79.4% and 71.9%, respectively. The overall surgical success and surgical cure based on RDI was 73.1% and 20.7%, respectively. Stratified by preoperative RDI showed older age, greater BMI were associated with greater preoperative RDI. Bivariate predictors of greater RDI reduction include younger age, female gender, lower preoperative BMI, higher preoperative RDI, greater BMI reduction postoperatively and greater change in SNA and PAS. Bivariate predictors of surgical cure based on RDI (RDI < 5) include younger age, female gender, lower preoperative RDI, and greater change in SNA and PAS. Bivariate predictor of RDI success (RDI < 20) include younger age, female gender, lower preoperative BMI, lower preoperative RDI, greater BMI reduction, greater increase in SNA, SNB and PAS postoperatively. Comparison of the first 500 patients and the later 510 patients demonstrate patients undergoing MMA have become younger, having lower RDI while achieving a better surgical outcome. Linear multivariate associations of greater percentage RDI reduction include younger age, greater percent change of SNA, greater preoperative SNA, lower preoperative BMI and higher preoperative RDI. Conclusions: MMA is an effective treatment to improve OSA, but the result can vary. Patient selection based on favorable prognostic factors and maximizing the advancement distance can improve outcomes.

Three-dimensional pharyngeal airway space changes after bimaxillary advancement

ABSTRACT Introduction: The probability of improvement in the upper airway space (UAS) with orthognathic surgery should be considered during the surgical-orthodontic treatment decision, providing not only an esthetic, but also a functional benefit for the patient. Objective: The purpose of this study was to evaluate the 3D changes in the upper airway space after maxillomandibular advancement surgery (MMA). Methods: A retrospective analysis of 56 patients, 21 male and 35 female, with a mean age of 35.8 ± 10.7 years, who underwent MMA was performed. Pre- and postoperative cone-beam computed tomography scans (CBCT) were obtained for each patient, and the changes in the UAS were compared using Dolphin Imaging 11.7 software. Two parameters of the pharyngeal airway space (PAS) were measured: airway volume (AV) and minimum axial area (MAA). Paired t-test was used to compare the data between T0 and T1, at 5% significance level. Results: There was a statistically significant increase in the UAS. Bimaxillary advancement surgery increased the AV and the MAA, on average, by 73.6 ± 74.75% and 113.5 ± 123.87%, respectively. Conclusion: MMA surgery tends to cause significant increase in the UAS; however, this increase is largely variable.

RESUMO Introdução: A probabilidade de melhoria do espaço aéreo superior (EAS) com cirurgia ortognática deve ser considerada durante a decisão do tratamento ortodôntico-cirúrgico, proporcionando não somente um benefício estético, mas também funcional, para o paciente. Objetivo: O objetivo do presente estudo foi avaliar as alterações 3D no espaço das vias aéreas superiores após a cirurgia de avanço maxilomandibular (AMM). Métodos: Foi realizada uma análise retrospectiva de 56 pacientes, 21 homens e 35 mulheres, com média de idade de 35,8 ± 10,7 anos, submetidos a AMM. Foram obtidas tomografias computadorizadas de feixe cônico (TCFC) pré- e pós-operatórias para cada paciente, e as alterações no EAS foram comparadas usando o software Dolphin Imaging v. 11.7. Foram medidos dois parâmetros do espaço aéreo faríngeo (EAF): volume das vias aéreas (VVA) e área axial mínima (AAM). Foi utilizado o teste t pareado para comparar os dados entre T0 e T1, com nível de significância de 5%. Resultados: Houve um aumento estatisticamente significativo no EAS. A cirurgia de avanço bimaxilar aumentou o volume das vias aéreas (VVA) e a área axial mínima (AAM) em média 73,6 ± 74,75% e 113,5 ± 123,87%, respectivamente. Conclusão: A cirurgia de AMM tende a causar o aumento significativo do EAS; no entanto, esse aumento é altamente variável.

Avaliação das alterações nas vias aéreas superiores através de tomografia computadorizada Cone-Beam em pacientes submetidos à cirurgia ortognática de avanço bimaxilar / Three-dimensional upper airway space changes after bimaxillary advancement by Cone-Beam Computed Tomography

Introdução: O descontentamento com a estética facial é considerado o fator motivador mais frequente na procura pela cirurgia ortognática, visto que este é o procedimento indicado nos casos de severas discrepâncias dentoesqueléticas em pacientes adultos. A anatomia das vias aéreas superiores (VAS) permite que fatores como obesidade, hipotonia muscular e deficiência mandibular favoreçam sua obstrução, podendo gerar a Apneia Obstrutiva do Sono (AOS), caracterizada por episódios recorrentes de obstrução parcial ou completa das VAS durante o sono. As cirurgias de avanço bimaxilar estão associadas ao aumento do espaço aéreo, no entanto, as alterações morfológicas e volumétricas ainda não são bem conhecidas. Objetivos: Avaliar as alterações em 3D do espaço aéreo faríngeo frente aos procedimentos de cirurgia ortognática de avanço bimaxilar em pacientes Classe I e II esqueléticos. Material e Métodos: A análise da área axial mínima e do volume da aérea superior foi realizada em pré-operatório (T0) e pós-operatório (T1) de 56 pacientes, sendo 21 do sexo masculino e 35 do sexo feminino, com média de idade de 35,8 (±10,7) anos, submetidos ao avanço bimaxilar pela técnica da osteotomia sagital de mandíbula bilateral associada ao avanço de maxila por meio de osteotomia Le Fort I. As avaliações foram feitas através de tomografia computadorizada Cone-beam, utilizando-se o Programa Dolphin Imaging 11.7. Foi utilizado o teste t pareado para comparar os dados pré e pós-operatórios. Todos os testes foram realizados com o programa Statistica, adotando-se um nível de significância de 5%. Resultados: No estudo do erro do método, não houve erro casual nem sistemático entre a primeira e a segunda medição das variáveis (p >0,05 em todas as medidas). A cirurgia de avanço bimaxilar apresentou uma média de 73,6% (± 74,75%) de aumento volumétrico e 113,5% (±123,87%) de aumento na área axial mínima. Conclusões: Podemos concluir que a cirurgia de avanço bimaxilar proporciona um aumento volumétrico significativo no espaço aéreo superior, bem como na área axial mínima, no entanto, esse ganho nem sempre ocorre na mesma magnitude para todos os pacientes.(AU)

Introduction: Facial aesthetics dissatisfaction is considered the most common motivating factor in the search for orthognathic surgery. This procedure may be used in cases of severe dental and skeletal discrepancies in adult patients. The restricted space anatomy of the upper airway space (UAS) allows features such as obesity, muscular hypotonia and mandibular deficiency favor clogging, which may lead to obstructive sleep apnea (OSA), characterized by recurrent episodes of partial or complete obstruction of the UAS during sleep. Surgeries of bimaxillary advancement are associated with increased UAS, however, the morphological and volumetric changes are not well known. Objectives: to evaluate changes in 3D pharyngeal airway in front of orthognathic surgery procedures of skeletal Class I and II subjects. Material and Methods: 3D pharyngeal airway was evaluated preoperative (T0) and postoperative (T1), with the aid of the analysis of the minimum axial area and airway volume. Fifty-six patients 21 male and 35 female, with a mean age of 35.8 (± 10.7) years undergo bimaxillary advancement by the technique of bilateral sagittal split osteotomy of the mandible associated with maxillary advancement through Le Fort I osteotomy. Measurements were made using Cone-beam Computed Tomography, using the Dolphin Imaging program 11.7. Paired t test was used to compare to the data between T0 and T1. All tests were performed with the Statistica Program, adopting a 5% significance level. Results: In the method error of the study, there was no casual or systematic error between the first and second measurement variables (p > 0.05 for all measures). The bimaxillary advancement surgery showed an average of 73.6% (± 74.75%) of increase in volume and 113.5% (±123.87%) increase in the minimum axial area. Conclusions: We concluded that the maxillomandibular advancement surgery provides a significant increase in volume in the UAS as well as the minimum axial area; however, this gain is not always in the same magnitude for all patients.(AU)