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Poster 36: A 10-Year Review of Obstructive Sleep Apnea Surgery
Scientific Poster Session
POSTER 35 Treatment of Maxillary Transverse and Anterior/Posterior Deformity in 1 Stage With Resorbable Fixation David Y. Park, DDS, MD, Loma Linda, CA (Stringer D; Herford A) Statement of the Problem: Transverse palatal discrepancies greater than 5-7 mm have predictably been treated in adult patients with the surgically assisted rapid palatal expansion. Proffit and colleagues have found that as many as 30% of patients seeking orthognathic surgery have transverse maxillary discrepancy. Many of these patients have to undergo both the surgically assisted rapid palatal expansion to expand the maxilla and a secondary Le Fort I osteotomy to reposition the maxilla to the correct dental skeletal relation. Being able to reduce the two stage procedure to one stage would be beneficial in decreasing the morbidity and associated recovery with orthognathic surgery. Recently Cortese et al reported a new technique in which the expansion and advancement were done in a single stage. The authors employed the use of a palatal distraction device fixated to the palate to expand the maxilla and also miniplate fixation of the Le Fort osteotomy. The use of rigid fixation of the Le Fort I osteotomy can hinder the ability to expand the maxilla. We present our experience with one-stage maxillary advancement and/or impaction with concurrent palatal distraction using the traditional hyrax orthodontic appliance and resorbable fixation to allow for unhindered expansion of the maxilla. Materials and Methods: A total of 15 Patients were treated at Loma Linda University Medical Center with one stage transverse expansion and correction of anterior/posterior and/or vertical discrepancy in one stage. All patients had a traditional hyrax appliance and orthodontic brackets in place at the time of the surgery. Of the 10 patients 2 had correction of the dentofacial deformity only in the maxilla and 8 had treatment in both the maxilla and mandible. In treating the maxilla, a standard Le Fort I osteotomy was performed and the maxilla was downfractured. The midpalatal cut was made along the nasal floor lateral to the attachment of the septum and connected at the anterior nasal spine extending through the alveolus between the central incisors. The maxilla was then repositioned into the correct dentofacial position and secured with the use of 2-0 resorbable sutures. Special attention was paid to ensuring that the sutures would be tight in securing the downfractured maxilla to its newly placed position. Interarch elastics were then used to hold the maxilla in its repositioned state. Activation of the hyrax appliance began on post operative day 5 with an expansion of 0.5 mm per day. Each patient was followed closely on a weekly basis with the oral surgeon and orthodontist to AAOMS • 2009
ensure adequate movement of the maxilla. Once the expansion of the palate was complete the hyrax was retained to allow bony consolidation. Method of Data Analysis: Fifteen patients enrolled in the study were followed with lateral cephalograms and clinical exams up to 1 year after the initial surgery. Patients were monitored for complications including relapse, malunion, and nonunion. Results: All patients fixated with the sutures were stable after three weeks. All patients showed good bony consolidation without the use of miniplates that may hinder the transverse movement of maxilla in expansion. The maxilla was found to have more mobility than the standard surgically assisted rapid palatal expansion but the sutures were strong enough to hold the maxilla in position yet loose enough to allow unhindered expansion with the hyrax. Patients treated with one stage two plane surgeries showed no significant relapse postoperatively. Conclusion: In the treatment of two plane maxillary dentoskeletal deformities, one stage treatment is feasible and predictable with the use of loose fixation with sutures. This method of fixation allows the expansion of the palate with a traditional tooth borne hyrax device and more flexibility of movement in the maxilla. References Cortese A, Savastano G, Savastano M, Spagnuolo G, Papa F. New technique: Le Fort I osteotomy for maxillary advancement and palatal distraction in 1 stage. Journal of Oral and Maxillofacial Surgery. 2009; 67(1):223-228 Vandersea B, Ruvo A, Frost D. Maxillary transverse deficiency – surgical alternatives to management. Oral and Maxillofacial Surgery Clinics of North America. 2007;19(3):351-368
POSTER 36 A 10-Year Review of Obstructive Sleep Apnea Surgery Ramtin Amini, DMD, MD, Pittsburgh, PA (Thota G; Dattilo DJ) Statement of the Problem: To measure the effectiveness of obstructive sleep apnea surgery via objective and subjective evaluations. Materials and Methods: Patients who had phase I and phase II surgery by the senior author were mailed a questionnaire. Thirty-eight phase I patients and 25 phase II patients responded to the questionnaire. The questionnaire asked four questions which measured patient satisfaction and three questions which measured improvement in life. The questions regarding satisfaction dealt with the patient’s satisfaction with their surgery, willingness to recommend this treatment to a friend, acceptance of a repeat intervention, and post operative facial appearance. The questions regarding improvement dealt 89
Scientific Poster Session with the ability to sleep through the night, lifestyle improvement, and daytime sleepiness. The patients rated the questions on a scale from 0-8. In addition, a retrospective chart review was performed which measured preoperative and postoperative respiratory disturbance indices (RDI) and Epworth Sleep Scales (ESS). Method of Data Analysis: A mean was taken to compress all data, a t-test and ANOVA were employed, with a p-value less than 0.05 to be statistically significant. Results: Pre- versus postoperative ESS for phase I patients was 12.96 and 7.56. Pre- versus postoperative ESS for phase II patients was 16.29 and 5.47. Pre- versus postoperative RDI for phase I was 38.83 and 18.7. Preversus postoperative RDI for phase II was 67.27 and 10.46. Also, improvement average for phase II versus phase I was 5.80 and 4.16. Satisfaction average for phase II versus phase I was 5.75 and 5.0, p-value .258, not statistically significant. Conclusion: Reduction in the RDI to a value of less than or equal to 10, or of 50% or greater of the original is considered a success. In addition, a ESS value of less than 11 was considered successful. According to this criteria, phase I was 61% (RDI) and 74% (ESS) successful. Also, phase II was 100% (RDI) and 94% (ESS) successful. Overall, both phase I and phase II surgeries have shown increased improvement and satisfaction average, with phase II surgery showing higher averages when compared to phase I. References Dattilo D, Drooger S. “Outcome assessment of patients undergoing maxillofacial procedures for the treatment of sleep apnea: comparison of subjective and objective results. J Oral Maxillofac Surg. 2004;62: 164-168 Prinsell JR. “Maxillomandibular advancement surgery in site-specific treatment approach for obstructive sleep apnea 50 consecutive patients. Chest. 1999;116:1519-1524
Materials and Methods: Nasopharyngoscopy is routinely used to examine the airway before and approximately 4-6 weeks after maxillomandibular advancement. Photographs are taken to document changes in the nasal airway. The photographs of 8 patients status post maxillary and mandibular advancement were used to evaluate the nasal airway for ozena, nasal crusting, perforation, and septal deviation. Method of Data Analysis: A nasopharyngoscopy form was created to evaluate the nasal airway and septum for ozena, nasal crusting, perforation, and septal deviation. Nasopharyngoscopy photographs for 8 cases were reviewed and preoperative and postoperative forms were completed. Results: The mean age of patients is 54 years with a range of 35-74 years. The mean time to post-operative nasopharyngoscopy was 40 days with a range of 27-50 days. At post-operative nasopharyngoscopy, 25% of patients had nasal crusting and 62.5% of patients had a septal perforation; 83.3% of patients with septal deviation prior to surgery were corrected during surgery. No patients demonstrated post-operative ozena. Conclusion: A greater incidence of change in the nasal airway was shown than previously anticipated. A substantial change in the nasal airway was not expected, yet this limited study shows otherwise. Further research is necessary to determine whether the demonstrated septal perforations will close and whether the nasal crusting will resolve. References Lehotay, Göde U, Wigand ME, Neukam FW. Nasal airway changes M. Erbe, M. after Le Fort I—impaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg. 2001;30:123–129 Smith K, Heggie A. Vomero-sphenoidal disarticulation during the Le Fort I maxillary osteotomy. Journal of Oral and Maxillofacial Surgery. 1995;53:465-467
POSTER 37 Evaluation of the Nasal Airway and Septum Before and After Le Fort I Osteotomy Rakesh Shah, MD, DMD, Birmingham, AL (Waite P) Statement of the Problem: Little research has been done to examine the nasal septum after separation from the maxillary crest during Le Fort I procedures. Disruption of the interface between the nasal septum and the maxillary crest can permanently change the nasal anatomy. The changes in the nasal airway could potentially cause ozena, nasal crusting, perforation, or septal deviation. The project was designed to evaluate changes of the nasal airway before and after Le Fort I osteotomy for maxillomandibular advancement in patients with obstructive sleep apnea. 90
POSTER 38 Survey of General Dentist and Oral and Maxillofacial Surgeon Warfarin Protocol for Tooth Extractions Ryan D. Morris, DDS, Iowa City, IA (Morris R; Synan W; Morgan T; Zeitler D; Qian F; Damiano P) Statement of the Problem: Perioperative bleeding risk must be weighed against the risks of thromboembolic events when warfarin anticoagulant therapy discontinuation is considered. Dentists and dental specialists may not be aware of the protocols recommended by current literature that discourage discontinuation of warfarin prior to dental treatment as patients may be placed at unnecessary medical risk. AAOMS • 2009
POSTER 35 Treatment of Maxillary Transverse and Anterior/Posterior Deformity in 1 Stage With Resorbable Fixation David Y. Park, DDS, MD, Loma Linda, CA (Stringer D; Herford A) Statement of the Problem: Transverse palatal discrepancies greater than 5-7 mm have predictably been treated in adult patients with the surgically assisted rapid palatal expansion. Proffit and colleagues have found that as many as 30% of patients seeking orthognathic surgery have transverse maxillary discrepancy. Many of these patients have to undergo both the surgically assisted rapid palatal expansion to expand the maxilla and a secondary Le Fort I osteotomy to reposition the maxilla to the correct dental skeletal relation. Being able to reduce the two stage procedure to one stage would be beneficial in decreasing the morbidity and associated recovery with orthognathic surgery. Recently Cortese et al reported a new technique in which the expansion and advancement were done in a single stage. The authors employed the use of a palatal distraction device fixated to the palate to expand the maxilla and also miniplate fixation of the Le Fort osteotomy. The use of rigid fixation of the Le Fort I osteotomy can hinder the ability to expand the maxilla. We present our experience with one-stage maxillary advancement and/or impaction with concurrent palatal distraction using the traditional hyrax orthodontic appliance and resorbable fixation to allow for unhindered expansion of the maxilla. Materials and Methods: A total of 15 Patients were treated at Loma Linda University Medical Center with one stage transverse expansion and correction of anterior/posterior and/or vertical discrepancy in one stage. All patients had a traditional hyrax appliance and orthodontic brackets in place at the time of the surgery. Of the 10 patients 2 had correction of the dentofacial deformity only in the maxilla and 8 had treatment in both the maxilla and mandible. In treating the maxilla, a standard Le Fort I osteotomy was performed and the maxilla was downfractured. The midpalatal cut was made along the nasal floor lateral to the attachment of the septum and connected at the anterior nasal spine extending through the alveolus between the central incisors. The maxilla was then repositioned into the correct dentofacial position and secured with the use of 2-0 resorbable sutures. Special attention was paid to ensuring that the sutures would be tight in securing the downfractured maxilla to its newly placed position. Interarch elastics were then used to hold the maxilla in its repositioned state. Activation of the hyrax appliance began on post operative day 5 with an expansion of 0.5 mm per day. Each patient was followed closely on a weekly basis with the oral surgeon and orthodontist to AAOMS • 2009
ensure adequate movement of the maxilla. Once the expansion of the palate was complete the hyrax was retained to allow bony consolidation. Method of Data Analysis: Fifteen patients enrolled in the study were followed with lateral cephalograms and clinical exams up to 1 year after the initial surgery. Patients were monitored for complications including relapse, malunion, and nonunion. Results: All patients fixated with the sutures were stable after three weeks. All patients showed good bony consolidation without the use of miniplates that may hinder the transverse movement of maxilla in expansion. The maxilla was found to have more mobility than the standard surgically assisted rapid palatal expansion but the sutures were strong enough to hold the maxilla in position yet loose enough to allow unhindered expansion with the hyrax. Patients treated with one stage two plane surgeries showed no significant relapse postoperatively. Conclusion: In the treatment of two plane maxillary dentoskeletal deformities, one stage treatment is feasible and predictable with the use of loose fixation with sutures. This method of fixation allows the expansion of the palate with a traditional tooth borne hyrax device and more flexibility of movement in the maxilla. References Cortese A, Savastano G, Savastano M, Spagnuolo G, Papa F. New technique: Le Fort I osteotomy for maxillary advancement and palatal distraction in 1 stage. Journal of Oral and Maxillofacial Surgery. 2009; 67(1):223-228 Vandersea B, Ruvo A, Frost D. Maxillary transverse deficiency – surgical alternatives to management. Oral and Maxillofacial Surgery Clinics of North America. 2007;19(3):351-368
POSTER 36 A 10-Year Review of Obstructive Sleep Apnea Surgery Ramtin Amini, DMD, MD, Pittsburgh, PA (Thota G; Dattilo DJ) Statement of the Problem: To measure the effectiveness of obstructive sleep apnea surgery via objective and subjective evaluations. Materials and Methods: Patients who had phase I and phase II surgery by the senior author were mailed a questionnaire. Thirty-eight phase I patients and 25 phase II patients responded to the questionnaire. The questionnaire asked four questions which measured patient satisfaction and three questions which measured improvement in life. The questions regarding satisfaction dealt with the patient’s satisfaction with their surgery, willingness to recommend this treatment to a friend, acceptance of a repeat intervention, and post operative facial appearance. The questions regarding improvement dealt 89
Scientific Poster Session with the ability to sleep through the night, lifestyle improvement, and daytime sleepiness. The patients rated the questions on a scale from 0-8. In addition, a retrospective chart review was performed which measured preoperative and postoperative respiratory disturbance indices (RDI) and Epworth Sleep Scales (ESS). Method of Data Analysis: A mean was taken to compress all data, a t-test and ANOVA were employed, with a p-value less than 0.05 to be statistically significant. Results: Pre- versus postoperative ESS for phase I patients was 12.96 and 7.56. Pre- versus postoperative ESS for phase II patients was 16.29 and 5.47. Pre- versus postoperative RDI for phase I was 38.83 and 18.7. Preversus postoperative RDI for phase II was 67.27 and 10.46. Also, improvement average for phase II versus phase I was 5.80 and 4.16. Satisfaction average for phase II versus phase I was 5.75 and 5.0, p-value .258, not statistically significant. Conclusion: Reduction in the RDI to a value of less than or equal to 10, or of 50% or greater of the original is considered a success. In addition, a ESS value of less than 11 was considered successful. According to this criteria, phase I was 61% (RDI) and 74% (ESS) successful. Also, phase II was 100% (RDI) and 94% (ESS) successful. Overall, both phase I and phase II surgeries have shown increased improvement and satisfaction average, with phase II surgery showing higher averages when compared to phase I. References Dattilo D, Drooger S. “Outcome assessment of patients undergoing maxillofacial procedures for the treatment of sleep apnea: comparison of subjective and objective results. J Oral Maxillofac Surg. 2004;62: 164-168 Prinsell JR. “Maxillomandibular advancement surgery in site-specific treatment approach for obstructive sleep apnea 50 consecutive patients. Chest. 1999;116:1519-1524
Materials and Methods: Nasopharyngoscopy is routinely used to examine the airway before and approximately 4-6 weeks after maxillomandibular advancement. Photographs are taken to document changes in the nasal airway. The photographs of 8 patients status post maxillary and mandibular advancement were used to evaluate the nasal airway for ozena, nasal crusting, perforation, and septal deviation. Method of Data Analysis: A nasopharyngoscopy form was created to evaluate the nasal airway and septum for ozena, nasal crusting, perforation, and septal deviation. Nasopharyngoscopy photographs for 8 cases were reviewed and preoperative and postoperative forms were completed. Results: The mean age of patients is 54 years with a range of 35-74 years. The mean time to post-operative nasopharyngoscopy was 40 days with a range of 27-50 days. At post-operative nasopharyngoscopy, 25% of patients had nasal crusting and 62.5% of patients had a septal perforation; 83.3% of patients with septal deviation prior to surgery were corrected during surgery. No patients demonstrated post-operative ozena. Conclusion: A greater incidence of change in the nasal airway was shown than previously anticipated. A substantial change in the nasal airway was not expected, yet this limited study shows otherwise. Further research is necessary to determine whether the demonstrated septal perforations will close and whether the nasal crusting will resolve. References Lehotay, Göde U, Wigand ME, Neukam FW. Nasal airway changes M. Erbe, M. after Le Fort I—impaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg. 2001;30:123–129 Smith K, Heggie A. Vomero-sphenoidal disarticulation during the Le Fort I maxillary osteotomy. Journal of Oral and Maxillofacial Surgery. 1995;53:465-467
POSTER 37 Evaluation of the Nasal Airway and Septum Before and After Le Fort I Osteotomy Rakesh Shah, MD, DMD, Birmingham, AL (Waite P) Statement of the Problem: Little research has been done to examine the nasal septum after separation from the maxillary crest during Le Fort I procedures. Disruption of the interface between the nasal septum and the maxillary crest can permanently change the nasal anatomy. The changes in the nasal airway could potentially cause ozena, nasal crusting, perforation, or septal deviation. The project was designed to evaluate changes of the nasal airway before and after Le Fort I osteotomy for maxillomandibular advancement in patients with obstructive sleep apnea. 90
POSTER 38 Survey of General Dentist and Oral and Maxillofacial Surgeon Warfarin Protocol for Tooth Extractions Ryan D. Morris, DDS, Iowa City, IA (Morris R; Synan W; Morgan T; Zeitler D; Qian F; Damiano P) Statement of the Problem: Perioperative bleeding risk must be weighed against the risks of thromboembolic events when warfarin anticoagulant therapy discontinuation is considered. Dentists and dental specialists may not be aware of the protocols recommended by current literature that discourage discontinuation of warfarin prior to dental treatment as patients may be placed at unnecessary medical risk. AAOMS • 2009