Emergence of Central Sleep Apnea Events After Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea.

PURPOSE: Central sleep apnea (CSA) can develop after the treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP). No studies have identified whether treatment of OSA with maxillomandibular advancement surgery (MMA) can result in CSA. The purpose of our study was to determine the incidence and clinical significance of CSA emerging after MMA surgery to treat OSA. PATIENTS AND METHODS: A retrospective review was conducted of all patients who had undergone MMA surgery for OSA at the Department of Oral and Maxillofacial Surgery at the QEII Health Sciences Centre (Halifax, NS, Canada) from 1996 through 2016. All patients with preoperative level 1 polysomnography and follow-up level 1 study results available at least 6 months postoperatively were included the present study. The pre- and postoperative central apnea index (CAI) results were compared. RESULTS: A total of 113 patients (84 men and 29 women) with an average age of 44.0 years were included in the present study. In 35 patients (31.0%), the emergence of CSA events were recorded on postoperative polysomnograms. Only 2 of the 113 patients experienced the emergence of clinically significant postoperative CSA (CAI >5). In our patient cohort, gender (P = .085), patient age (P = .238), and preoperative (P = .716) and postoperative (P = .209) Apnea-Hypopnea Index (AHI) results correlated with the postoperative development of CSA events after MMA surgery. The mean AHI values had decreased from 41.4 to 8.7 in all patients treated with MMA in our study. CONCLUSIONS: The emergence of CSA events occurred in 31% of patients after OSA treatment with MMA surgery. The rate of clinically significant CSA events emerging after MMA surgery in our study was 1.8%. These findings help to support the use of MMA surgery for OSA as a reasonable treatment alternative for patients unable to tolerate CPAP.

An Unusual Case of Mandibular Squamous Cell Carcinoma in Intimacy with an Impacted Wisdom Tooth.

Squamous cell carcinoma is the most common head and neck malignancy. It can occur in the mandible or maxilla without a preexisting oral mucosal lesion. Often, the clinical and radiographic presentation of SCC directs the clinician to favour malignancy over other pathological conditions. However, SCC may also mimic an infectious condition and therefore can pose a diagnostic challenge even for the most experienced clinicians. Herein, we report a case of mandibular squamous cell carcinoma in a 53-year-old male who presented with symptoms of right facial swelling, trismus, pain, and right-sided lip paresthesia. The patient underwent a surgical removal of the presumed infected third molar of the right mandible, but histopathological analysis of the associated soft tissue unexpectedly yielded squamous cell carcinoma. Given the biopsy-proven diagnosis, the patient received a mandibular resection of the tumor followed by primary reconstruction with a fibular free flap. Patients presenting with symptoms mimicking odontogenic infections should receive vigilant attention by clinicians with regard to the disease history, clinical signs, radiographic evidence, and decision for histopathological analysis. This is especially true in the context of impacted dentition, where malignancy must be considered when formulating a differential diagnosis.

Maxillomandibular Advancement Improves Multiple Health-Related and Functional Outcomes in Patients With Obstructive Sleep Apnea: A Multicenter Study.

PURPOSE: To comprehensively determine the effectiveness and safety of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA). PATIENTS AND METHODS: We designed and implemented a prospective multicenter cohort study to evaluate OSA patients who underwent MMA. The primary outcome measures and associated instruments included sleepiness (Epworth Sleepiness Scale [ESS]), quality of life (QOL) (Functional Outcomes of Sleep Questionnaire [FOSQ]), sleep-disordered breathing (apnea-hypopnea index), cardiovascular risk (office blood pressure and levels of high-sensitivity C-reactive protein), and neurocognitive performance (psychomotor vigilance testing [PVT]). The outcomes were measured preoperatively and approximately 6 months postoperatively. Other variables were grouped into the following categories: demographic and pre-MMA use of continuous positive airway pressure. Descriptive and bivariate statistics were computed. RESULTS: The sample was composed of 30 adult patients (63% men; mean age, 45.9 ± 9.8 years). The median length of follow-up was 6.7 months (range, 4.3 to 12.7 months). The ESS score decreased from a mean of 13.3 to 4.9 (P < .001). The FOSQ score increased from a mean of 14.1 to 18.3 (P < .001). The apnea-hypopnea index decreased from a mean of 39.6 to 7.9 events per hour (P < .001). Mean diastolic blood pressure decreased from 83 to 79.7 mm Hg (P = .025). PVT response times improved after MMA (P = .04). Few treatment-related adverse events occurred, which had minimal impact on the QOL. Additional improvements in sleepiness (mean ESS score change, -7.6; P < .001), QOL (mean FOSQ score change, 3.9; P < .001), and PVT (mean change, 0.5; P = .004) occurred after MMA for patients using continuous positive airway pressure before surgery. CONCLUSIONS: MMA is a highly effective and safe treatment for OSA, which predictably leads to significant improvements in sleepiness, QOL, sleep-disordered breathing, and neurocognitive performance, as well as a reduction in cardiovascular risk (blood pressure).

Maxillary stability following Le Fort I osteotomy using prebent plates and wire fixation in patients undergoing surgery for OSAS.

The purpose of this study was to analyze the stability of Le Fort I maxillary advancement in the vertical and horizontal directions using a combination of wire and rigid fixation in patients undergoing surgery to treat obstructive sleep apnea (OSA). Wire osteosynthesis can be performed quicker and at a reduced cost. The lateral cephalograms of 21 patients were evaluated preoperatively (T0), immediately postoperatively (T1), and at least 6 months postoperatively (T2). Four cephalometric points were used to measure movement in the horizontal and vertical directions. Mean values were determined, and data were statistically analyzed by ANOVA to determine differences between time points. Of the four points analyzed, the average maxillary advancement in the horizontal direction was 7.48 mm and the relapse was 0.56 mm with absence of statistically significant differences between the measurements taken (T1) and (T2). There was a 5% probability of error in the vertical movements at the points I and posterior nasal spine. The combination of two pre-bent plates in piriform aperture with osteosynthesis using surgical steel wires in the zygomatic buttress in patients undergoing maxillary surgery for OSA stabilized the large horizontal maxillary advancements and enhanced vertical stability in the first molar and A point regions.

Objective and Subjective Outcomes Following Maxillomandibular Advancement Surgery for Treatment of Patients With Extremely Severe Obstructive Sleep Apnea (Apnea-Hypopnea Index >100).

PURPOSE: It is important for patients and treating clinicians to know whether maxillomandibular advancement (MMA) surgery is effective when treating patients with obstructive sleep apnea syndrome (OSAS) and an extremely high apnea-hypopnea index (AHI) score. The purpose of this study was to evaluate objective and subjective treatment outcomes after MMA surgery for the treatment of OSAS in patients with a preoperative AHI score higher than 100. PATIENTS AND METHODS: This retrospective study included all patients who underwent MMA surgery for OSAS by members of the Department of Oral and Maxillofacial Surgery, QEII Health Science Centre (Halifax, Nova Scotia, Canada) from November 1996 through February 2014. Objective data were available in the form of polysomnographs (PSGs) obtained before and a minimum of 6 months after surgery. Patients completed a self-administered questionnaire before and after surgery regarding snoring, witnessed apneas, continuous positive airway pressure (CPAP) use, daytime somnolence, and overall satisfaction. RESULTS: Two hundred sixty-five patients had MMA surgery, of which 13 had pre- and postoperative PSGs. PSGs showed a mean preoperative AHI score of 117.9 and a mean postsurgical AHI score of 16.1 (P < .001). Pre- and postoperative questionnaires were available for 9 patients. After surgery, 7 patients denied having any daytime sleepiness and 2 patients reported minimal daytime sleepiness. The mean preoperative Epworth Sleepiness Scale score was 12.9 (standard deviation [SD], 5.5), whereas the postoperative mean score was 5.0 (SD, 4.1; P = .004). Before surgery, all 9 patients reported loud snoring and 8 reported witnessed apneas. After surgery, 2 patients reported minimal snoring and only 1 patient continued to have witnessed apneas. Six patients used CPAP preoperatively and only 1 patient continued to use CPAP after surgery. CONCLUSIONS: The results of this study suggest that MMA surgery for treatment of extremely severe OSA can be a highly successful 1-stage surgery, which eliminates the use of CPAP, improves subjective outcomes, and considerably decreases the AHI score.

Preventive Strategies for Patients at Risk of Medication-related Osteonecrosis of the Jaw.

For patients at risk of osteonecrosis of the jaw (ONJ), information can be provided by the pharmaceutical manufacturer, pharmacist, prescribing physician, dentist, and oral and maxillofacial surgeon. Prevention strategies to reduce the incidence of osteonecrosis should be applied as soon as it is determined that a patient will be placed on antiresorptive medication. Proper screening involves a comprehensive oral examination with radiographs followed by oral hygiene instruction and necessary dental treatment; surgical techniques and adjunctive therapies that favor optimum healing of bone and soft tissue decrease the risk of ONJ. No dental procedures are absolutely contraindicated.

American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw--2014 update.

Strategies for management of patients with, or at risk for, medication-related osteonecrosis of the jaw (MRONJ) were set forth in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position papers in 2007 and 2009. The position papers were developed by a special committee appointed by the board and composed of clinicians with extensive experience in caring for these patients and basic science researchers. The knowledge base and experience in addressing MRONJ has expanded, necessitating modifications and refinements to the previous position paper. This special committee met in September 2013 to appraise the current literature and revise the guidelines as indicated to reflect current knowledge in this field. This update contains revisions to diagnosis, staging, and management strategies and highlights current research status. The AAOMS considers it vitally important that this information be disseminated to other relevant health care professionals and organizations.

Management of fractures of the mandibular body and symphysis.

Mandibular fracture, specifically in the symphysis and body regions combined, is the most common facial fracture requiring hospitalization in North America. The primary treatment objective is to restore form and function by achieving anatomic reduction and placing fixation that eliminates mobility of the bone fragments. Several treatment options and surgical techniques are available for performing closed or open reduction. Special considerations are necessary when treating pediatric patients and fractures of the edentulous mandible. Complications relating to the tooth and denture-bearing regions of the mandible include infection, nonunion, and neurosensory changes.

Subjective outcomes of maxillomandibular advancement surgery for treatment of obstructive sleep apnea syndrome.

PURPOSE: To evaluate subjective outcomes and use of continuous positive airway pressure (CPAP) after maxillomandibular advancement surgery for treatment of obstructive sleep apnea syndrome (OSAS). PATIENTS AND METHODS: A self-administered questionnaire was completed pre- and postoperatively by 116 patients who underwent maxillomandibular advancement surgery for treatment of OSAS from February 2000 through September 2010. The questionnaire included the Epworth Sleepiness Scale (ESS) for assessment of daytime somnolence and questions regarding snoring, witnessed apneas, CPAP use, and overall satisfaction. RESULTS: Preoperatively, 40% of patients were very sleepy (ESS ≥16), 32% were sleepy (ESS 10 to 16), and 28% were not sleepy (ESS ≤10). Postoperatively, only 1 patient (<1%) was very sleepy, 9% were sleepy, and 90% were not sleepy (McNemar test, P < .001). The mean ESS score for the very sleepy, sleepy, and not-sleepy groups decreased from 18.3 to 5.9, 12.9 to 4.4, and 7.3 to 4.5, respectively (P < .001). Surgery decreased snoring by 83%, witnessed apneas by 94%, and CPAP use by 96% (P < .001). The surgery was judged to be worthwhile by 89% of patients, and 95% of patients said they would recommend the treatment to other patients with OSAS. CONCLUSIONS: Maxillomandibular advancement surgery for treatment of OSAS is very effective at improving excessive daytime sleepiness, snoring, and witnessed apneas. Most patients in this study were able to discontinue the use of CPAP after surgery. Overall, patients reported the treatment to be worthwhile and would recommend it to others.

Concomitant removal of mandibular third molars during sagittal split osteotomy minimizes neurosensory dysfunction.

PURPOSE: Inferior alveolar nerve (IAN) injury is 1 of the most important postoperative complications after sagittal split osteotomy (SSO). The purpose of our study was to investigate the effects of the presence or absence of a mandibular third molar on the neurosensory recovery of the IAN after SSO. MATERIALS AND METHODS: A prospective cohort study enrolled a sample composed of patients who underwent SSO to correct mandibular deformities. The primary predictor variable was the status of the mandibular third molar at the time of SSO and it was divided into two levels, present at the time of SSO (Group I) or absent at the time of SSO (Group II). The primary outcome variable was neurosensory recovery of the IAN, assessed using the Medical Research Council scale, functional sensory recovery, and subjective evaluation. Neurosensory status was measured 3 times (preoperatively and 3 and 6 months postoperatively). Appropriate bivariate and multivariate statistics were computed, and the level of statistical significance was set at P < .05. RESULTS: A total of 120 SSOs were performed in 60 patients. Group I included 64 SSOs (mean patient age ± SD 19.3 ± 8.0 years) and group II, 56 SSOs (mean patient age 24.9 ± 10.0 years). The Medical Research Council scale scores showed that the presence of third molars during SSO was associated with a statistically significant decreased incidence of neurosensory disturbance of the IAN at 3 and 6 months postoperatively (all P < .01). Functional sensory recovery was achieved more frequently in group I, but this difference remained significant only at 3 months after adjusting (P = .01). A "normal sensation" was subjectively reported more frequently in group I at 3 and 6 months postoperatively (P ≤ .05). CONCLUSIONS: The presence of third molars during SSO minimizes postoperative neurosensory disturbance of the IAN.

The presence of mandibular third molars during sagittal split osteotomies does not increase the risk of complications.

PURPOSE: The purpose of this study was to investigate prospectively the effects of the presence or absence of third molars during sagittal split osteotomies (SSOs) on the frequency of unfavorable fractures, degree of entrapment and manipulation of the inferior alveolar nerve (IAN), and procedural time. MATERIALS AND METHODS: The investigators designed and implemented a prospective cohort study and enrolled a sample composed of patients who underwent SSOs to correct mandibular deformities. The primary predictor variable was the status of the mandibular third molar at the time of SSO, and it was divided into 2 levels, present at the time of SSO (group I) or absent at the time of SSO (group II). The primary outcome variable was unfavorable splits. The secondary outcome variables were the degree of entrapment/manipulation of the IAN and the procedural time. Appropriate bivariate and multivariate statistics were computed, and the level of statistical significance was set at P < .05. RESULTS: Six hundred seventy-seven SSOs were performed in 339 patients: group I consisted of 331 SSOs (mean age ± SD: 19.6 ± 7.4 yrs), and group II consisted of 346 SSOs (30.4 ± 12.1 yrs). The overall rate of unfavorable fractures was 3.1% (21 of 677), with frequencies of 2.4% (8 of 331) in group I, compared with 3.8% (13 of 346) in group II (P = .3). The rate of IAN entrapment in the proximal segment was significantly lower in group I (37.2%) than in group II (46.5%; P = .01). The degree of entrapment was also significantly more severe for group II (P < .001). Third molars increased procedural time by 1.7 minutes (P < .001). CONCLUSIONS: The presence of third molars during SSOs is not associated with an increased frequency of unfavorable fractures. Concomitant third molar removal in SSOs also decreases proximal segment IAN entrapment but only slightly increases operating time.

Diagnosis, treatment planning, and surgical correction of obstructive sleep apnea.

The aim of this report is to present the scientific rationale for considering maxillomandibular advancement as the surgical treatment of choice in selected patients with obstructive sleep apnea syndrome; review the treatment planning that will identify those patients who would benefit from this procedure; review the surgical techniques; and review the patient outcomes after maxillomandibular advancement surgery. Patients with obstructive sleep apnea syndrome who have demonstrable retropositioning of the maxilla and mandible should be informed of maxillomandibular advancement as the primary surgical treatment for obstructive sleep apnea syndrome.

Facial appearance following surgical treatment for obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is a serious medical condition that is associated with numerous negative health side effects. The general dentist plays an invaluable role in identifying patients with this condition. Certain OSAS patients receive significant medical and social benefits from orthognathic surgery to advance the maxilla, mandible, and chin. Anterior positioning of the maxilla and mandible is not only highly successful for curing OSAS but also results in favorable facial esthetic changes.

The effect of rubber dam placement on the arterial oxygen saturation in dental patients.

This study assessed the effect of rubber dam placement on arterial blood oxygen saturation in dental patients; it also determined whether the effects are technique sensitive. The study group consisted of 28 ASA Class I patients who were randomly allocated to one of two groups: Group A--rubber dam isolation of the maxilla (from tooth #14 to #6) and Group B-rubber dam isolation of the mandible (from tooth #19 to #27). A pulse oximeter was used to detect arterial blood oxygen saturation in both groups. Each patient's oxygen saturation (Sp02) was recorded every 30 seconds for two minutes to establish a baseline. Group A subjects received local infiltration in the vestibule above tooth #14, while Group B subjects received an inferior alveolar nerve block using 1.8 ml of 2% Lidocaine with 1:100,000 epiphrine, respectively. During the subsequent five minutes, the patient's Sp02 was recorded every 30 seconds. A rubber dam was then placed, which extended to the anterior septal angle (which completely covers the nose). This rubber dam remained in place for 20 minutes, with the patient's Sp02 being recorded every 30 seconds. The rubber dam was then altered (cut) to expose the nasal passages, creating what is known as proper rubber dam isolation, and the Sp02 was recorded every 30 seconds for 20 minutes. In both groups, there was no significant change in arterial oxygen saturation before or after rubber dam isolation was performed. Also, there was no significant difference in Sp02 when comparing the rubber dam isolation technique. Although rubber dam placement has no effect on blood oxygen levels in healthy patients, its effects on unhealthy patients are unknown.