- Email: [email protected]
Cephalometric Soft Tissue Analysis of Combined Elliptical-Window Genioglossus Advancement and Hyoid Suspension for Obstructive Sleep Apnea
J Oral Maxillofac Surg 70:690-695, 2012
Cephalometric Soft Tissue Analysis of Combined Elliptical-Window Genioglossus Advancement and Hyoid Suspension for Obstructive Sleep Apnea Joseph E. Cillo, Jr, DMD, MPH,* Pankaj Thakker, DDS, MD,† and David J. Dattilo, DDS‡ Purpose: This study sought to determine the changes in cephalometric facial profile soft tissue
measurements after simultaneous elliptical-window genioglossus advancement and hyoid suspension procedures for obstructive sleep apnea. Patients and Methods: A retrospective analysis of preoperative and postoperative lateral cephalometric soft tissue changes in 23 consecutive patients who had undergone combined elliptical-window genioglossus advancement and hyoid bone suspension for polysomnogram-confirmed obstructive sleep apnea. Six cephalometric soft tissue measurements of the lower face were evaluated: pogonion (Pg=-Pg), menton (Me=-Me), gnathion (G=-G), lower lip (LI-L1i), B point (B-B=), and horizontal distance from subnasale perpendicular to the soft tissue chin at the level of pogonion (SN-Pg=). Statistical analysis was conducted with the paired Student t test (with 95% confidence interval of difference between means) and found significant for P ⬍ .05. Post hoc power analysis was conducted. Results: There were no statistically significant differences among all 6 preoperative and postoperative cephalometric, radiographic soft tissue measurements of the lower facial profile. Conclusions: The combined elliptical-window genioglossus advancement and hyoid suspension procedures for obstructive sleep apnea do not significantly change the cephalometric lower facial profile. In patients with an adequate lower facial profile with base-of-tongue obstruction who require surgical management of obstructive sleep apnea without alteration of their lower facial profile, this procedure does not significantly alter the preoperative facial profile. © 2012 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 70:690-695, 2012 Obstructive sleep apnea (OSA) continues to be a pervasive condition contributing to increased morbidity and mortality rates. Phase I surgery has been shown to be successful in alleviating OSA in some situations.1-4 Some procedures for the surgical treatment of OSA significantly change the lower facial profile of the patient. These include the surgical procedures to advance the base of the tongue, such as genioglossus advancement,
which have been shown to enlarge the posterior airway and improve OSA.3,4 However, in the process of enlarging the posterior airway, the genioglossus advancement procedure may also increase and advance the lower facial profile of the patient. In individuals with prominent or normal chin position, this may not be a desired result. The elliptical-window genioglossus advancement procedure is designed to maintain the presurgical facial profile of the patient while advancing the base of the tongue to alleviate nocturnal obstruction during sleep.5 This study was designed to evaluate the cephalometric soft tissue lower facial profile of individuals undergoing the simultaneous elliptical-window genioglossus advancement and hyoid suspension procedures for the correction of polysomnogram-confirmed OSA.
Received from the Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh, PA. *Program Director and Director of Research. †Resident. ‡Division Director. Address correspondence and reprint requests to Dr Cillo: Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, 320 E North Ave, Ste 0107, Pittsburgh, PA; e-mail: [email protected]
Patients and Methods
© 2012 American Association of Oral and Maxillofacial Surgeons
This study had full Institutional Review Board approval from the Allegheny General Hospital/Alle-
0278-2391/12/7003-0$36.00/0 doi:10.1016/j.joms.2011.02.028
690
691
CILLO, THAKKER, AND DATTILO
gheny Singer Research Institute (Pittsburgh, PA), and we had read the Declaration of Helsinki. This was a retrospective cephalometric evaluation of 23 consecutive individuals who underwent simultaneous elliptical-window genioglossus advancement and hyoid suspension procedures for polysomnogramconfirmed OSA under general anesthesia as previously described by Dattilo and Aynechi5 (Figs 1, 2). In brief, through an extraoral incision in the submental region, dissection is performed down to the hyoid bone, where 2 Mitek anchors (Mitek, Westwood, MA) are placed on the body of the hyoid bone. Through the same incision, an elliptical osteotomy is completed in the anterior mandible 15 and 5 mm from the inferior border and connected in an elliptical fashion. After completion of the osteotomy, the segment is rotated, fixated, and reduced in size, and the remaining bone is grafted back to the osteotomy site. The hyoid suspension is then completed and fixated to the mandible. Inclusion criteria for the study were any patient who had undergone the combined elliptical genioglossus advancement and hyoid bone suspension procedures for mild to moderate (respiratory disturbance index ⬎5 and ⬍30) polysomnogram-confirmed OSA with acceptable preoperative and postoperative lateral cephalometric radiographs with at least 6
FIGURE 2. Completed elliptical genioglossus advancement procedure. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
months’ follow-up. Preoperative and postoperative lateral cephalometric radiographs had been obtained with the same panoramic radiography machine (Laser 1000; Panoramic, Fort Wayne, IN) with the patient in centric occlusion and with the lips in a relaxed position. Postoperative radiograph measurements were taken from lateral cephalometric radiographs taken at the 6-month follow-up appointment. Cephalometric measurements were taken manually, repeated 3 times, and averaged for the following radiographic
FIGURE 1. Diagrammatic representation of combined elliptical genioglossus advancement and hyoid suspension procedures. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
692
SOFT TISSUE ANALYSIS IN OSA
soft tissue measurements of the lower face (Fig 3): hard to soft tissue pogonion (Pg=-Pg), hard to soft tissue menton (Me=-Me), hard to soft tissue gnathion (G=-G), hard to soft tissue B point (B-B=), horizontal thickness of lower lip (LI-L1i), and horizontal distance from subnasale perpendicular to Frankfurt horizontal line to soft tissue chin at level of pogonion (SN-Pg=). STATISTICAL ANALYSIS
Standard descriptive statistics were used. Normality of the population was verified with the Shapiro-Wilk test, and statistical significance between the means of the populations was determined with the paired Student t test (with a 95% confidence interval [CI] for the difference between the means of the 2 samples) and found significant for P ⬍ .05. Statistical analysis and post hoc power analysis were conducted with G*Power 3.1 statistical software6 for the paired t test with an effect size of 0.68, ␣ error probability of 0.05, and a sample size of 23.
Results The mean age of the patients was 43 ⫾ 4.3 years, with 21 male and 2 female patients. There were no statistically significant differences between mean preoperative and postoperative cephalometric, radiographic soft tissue measurements of the lower facial profile for any of the measurements taken (Table 1): Pg=-Pg (11.54 ⫾ 1.51 mm vs 11.15 ⫾ 1.63 mm [preoperative vs postoperative, mean ⫾ SD], ⌬ ⫽ ⫺0.39 mm [95% CI, ⫺0.879 to 1.659 mm]; P ⫽ .41), Me=-Me (8.85 ⫾ 2.41 mm vs 9.69 ⫾ 3.04 mm, ⌬ ⫽ ⫹0.84 mm [95% CI, ⫺3.056 to 1.376 mm]; P ⫽ .11), G=-G (10.08 ⫾ 2.25 mm vs 10.69 ⫾ 2.39 mm, ⌬ ⫽ ⫹0.61 mm [95% CI, ⫺2.485 to 1.265 mm]; P ⫽ .09), B-B= (10.11 ⫾ 1.1 mm vs 10.72 ⫾ 1.2 mm, ⌬ ⫽ ⫹0.71 mm [95% CI, ⫺1.425 to 1.562 mm]; P ⫽ .2), LI-L1i mm (13.23 ⫾ 2.17 mm vs 13.31 ⫾ 1.75 mm, ⌬ ⫽ ⫹0.08 mm [95% CI, ⫺1.672 to 1.512 mm]; P ⫽ .08), and SN-Pg= (⫺1.23 ⫾ 1.76 mm vs ⫺0.62 ⫾ 1.88 mm, ⌬ ⫽
FIGURE 3. A, Preoperative lateral cephalometric radiograph. (Fig 3 continued on next page.) Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
693
CILLO, THAKKER, AND DATTILO
FIGURE 3 (Cont’d). B, Lateral cephalometric radiograph 6 months postoperatively after elliptical genioglossus advancement and hyoid suspension procedures. (Pg-Pg=, hard to soft tissue pogonion; Me-Me=, hard to soft tissue menton; G-G=, hard to soft tissue gnathion; B-B=, hard to soft tissue B point; LI-L1i, horizontal thickness of lower lip; SN-Pg=, horizontal distance from subnasale perpendicular to Frankfurt horizontal line to soft tissue chin at level of pogonion.) Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
⫹0.61 mm [95% CI, ⫺2.081 to 0.861 mm]; P ⫽ .12). Post hoc power analysis showed a power of 88%.
Discussion The literature is replete with descriptions of phase I surgical procedures for the treatment of OSA sur-
gery.1-5,7-15 Genioglossus advancement surgery has been successfully used for the treatment of sleepdisordered breathing and has included the traditional genioglossus advancement and genioglossus bone advancement techniques.10-13 The genioglossus advancement procedure has been used alone10-12 and in combination with other upper airway surger-
Table 1. PREOPERATIVE AND POSTOPERATIVE CEPHALOMETRIC MEASUREMENTS
SN-Pg=
Pg-Pg=
Me-Me=
G-G=
B-B=
LI-L1i
Preoperative [mean (SD)] ⫺1.23 (1.76) 11.54 (1.51) 8.85 (2.41) 10.08 (2.25) 10.11 (1.1) 13.23 (2.17) Postoperative [mean (SD)] ⫺0.62 (1.88) 11.15 (1.63) 9.69 (3.04) 10.69 (2.39) 10.82 (1.2) 13.31 (1.75) Difference ⫹0.61 ⫺0.39 ⫹0.84 ⫹0.61 ⫹0.71 ⫹0.08 95% CI ⫺2.081 to 0.861 ⫺0.879 to 1.659 ⫺3.056 to 1.376 ⫺2.485 to 1.265 ⫺1.425 to 1.562 ⫺1.672 to 1.512 P value .12 .41 .11 .09 .2 .08 Abbreviations: SN, subnasale; Pg=, soft tissue pogonion; Pg, pogonion; Me=, soft tissue menton; Me, menton; G=, soft tissue gnathion; G, gnathion; B, B point; B=, soft tissue B point; LI, soft tissue lower lip; Lli, vertical position of incisal edge of mandibular central incisor. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
694 ies, such as uvulopalatopharyngoplasty, hyoid suspension, and radiofrequency treatment, for phase I OSA surgery.5,13,14 Whereas the main purpose of the genioglossus advancement procedure is to improve airflow in the upper airway due to base-of-tongue obstruction, individuals who have normal or prominent chin profiles may have a less-than-desirable cosmetic outcome as a result of undergoing this procedure. Because this procedure advances the hard tissues of the chin, the soft tissues of the chin will also be advanced. Studies on the advancement genioplasty for cosmetic purposes have shown that soft tissue pogonion can predictably follow the underlying hard tissue advancement at a ratio of approximately 0.9:1.15-17 The elliptical genioglossus advancement is designed to advance the genioglossus muscle, thereby allowing for enlargement of the posterior airway while maintaining the soft tissue profile of the patient.5 Currently unpublished research has shown that the combined elliptical genioglossus advancement and hyoid bone suspension procedures are effective in reducing respiratory disturbance index by over 50%.18 Though effective in managing OSA, to our knowledge, no studies have examined whether the combined elliptical genioglossus advancement and hyoid suspension procedures alter the lower facial soft tissue profile. When one is examining patients for the appropriate treatment for OSA, the final cosmetic result may be just as important to some individuals as the surgical correction of OSA. In individuals with OSA due to base-of-tongue obstruction who have a normal or prominent chin profile or in a situation where the patient does not desire a change in chin profile, the traditional genioglossus advancement procedure may not be a viable option because it will make the chin more pronounced (Figs 3, 4). In these situations the elliptical genioglossus advancement and hyoid suspension procedures may be an alternative option. In this study 6 separate lateral cephalometric radiographic measurements were examined preoperatively and 6 months postoperatively to determine any lower facial soft tissues changes. The results of this study show that the combined elliptical-window genioglossus advancement and hyoid suspension procedures for the treatment of OSA do not alter the radiographic lower facial soft tissue profile of the patient. There are several limitations to this study. There are numerous soft and hard tissue measurements and angles that can be used to measure cephalometric facial profile changes associated with surgical manipulation of the facial skeleton. The cephalometric markers in this study were chosen for their simplicity and general representation of the lower facial soft tissue profile. Certainly, a more detailed and exhaus-
SOFT TISSUE ANALYSIS IN OSA
FIGURE 4. A, Preoperative facial profile view. B, Facial profile view 6 months postoperatively after combined elliptical genioglossus advancement and hyoid suspension procedures. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
695
CILLO, THAKKER, AND DATTILO
tive analysis and clinical profile and frontal facial soft tissue evaluation may be conducted in future investigations. The advancement of computer technology may allow for future analysis of changes from these procedures that should involve 3-dimensional computer analysis of both profile and frontal soft tissue changes.19 In conclusion, this study has shown that, by use of lateral cephalometric measurements common in the analysis of the lower facial soft tissue profile, the combined elliptical genioglossus advancement and hyoid suspension procedures do not produce a statistically significant change from preoperative measurements up to 6 months after surgery. This procedure, therefore, may be suitable to be used for the correction of base-of-tongue obstructions in the surgical management of OSA in individuals who have a normal or prominent soft tissue chin profile or when a change in chin profile is not desired, when a traditional genioglossus advancement procedure would likely produce an unesthetic result.
6. 7. 8.
9.
10. 11.
12. 13. 14.
References 1. Woodson BT, Steward DL, Mickelson S, et al: Multicenter study of a novel adjustable tongue-advancement device for obstructive sleep apnea. Otolaryngol Head Neck Surg 143:585, 2010 2. Sorrenti G, Piccin O, Mondini S, et al: One-phase management of severe obstructive sleep apnea: Tongue base reduction with hyoepiglottoplasty plus uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 135:906, 2006 3. Foltán R, Hoffmannová J, Pretl M, et al: Genioglossus advancement and hyoid myotomy in treating obstructive sleep apnoea syndrome—A follow-up study. J Craniomaxillofac Surg 35:246, 2007 4. Dattilo DJ, Drooger SA: Outcome assessment of patients undergoing maxillofacial procedures for the treatment of sleep apnea: Comparison of subjective and objective results. J Oral Maxillofac Surg 62:164, 2004 5. Dattilo DJ, Aynechi M: Modification of the anterior mandibular osteotomy for genioglossus advancement with hyoid suspen-
15. 16. 17. 18.
19.
sion for obstructive sleep apnea. J Oral Maxillofac Surg 65:1876, 2007 Erdfelder E, Faul F, Buchner A: GPOWER: A general power analysis program. Behav Res Methods Instrum Comput 28:1, 1996 Pang KP, Tan R, Puraviappan P, et al: Anterior palatoplasty for the treatment of OSA: Three-year results. Otolaryngol Head Neck Surg 141:253, 2009 Fernández-Julián E, Muñoz N, Achiques MT, et al: Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 140:917, 2009 Cillo JE Jr, Finn R, Dasheiff RM: Combined open rhinoplasty with spreader grafts and laser-assisted uvuloplasty for sleepdisordered breathing: Long-term subjective outcomes. J Oral Maxillofac Surg 64:1241, 2006 Li KK, Riley RW, Powell NB, et al: Obstructive sleep apnea surgery: Genioglossus advancement revisited. J Oral Maxillofac Surg 59:1181, 2001 Santos Junior JF, Abrahão M, Gregório LC, et al: Genioplasty for genioglossus muscle advancement in patients with obstructive sleep apnea-hypopnea syndrome and mandibular retrognathia. Braz J Otorhinolaryngol 73:480, 2007 Lewis MR, Ducic Y: Genioglossus muscle advancement with the genioglossus bone advancement technique for base of tongue obstruction. J Otolaryngol 32:168, 2003 Jacobowitz O: Palatal and tongue base surgery for surgical treatment of obstructive sleep apnea: A prospective study. Otolaryngol Head Neck Surg 135:258, 2006 Thomas AJ, Chavoya M, Terris DJ: Preliminary findings from a prospective, randomized trial of two tongue-base surgeries for sleep-disordered breathing. Otolaryngol Head Neck Surg 129: 539, 2003 Shaughnessy S, Mobarak KA, Hogevold HE, et al: Long-term skeletal and soft-tissue responses after advancement genioplasty. Am J Orthod Dentofacial Orthop 130:8, 2006 Wittbjer J, Rune B: Changes of the profile after advancement genioplasty. Scand J Plast Reconstr Surg Hand Surg 23:65, 1989 Krekmanov L, Kahnberg KE: Soft tissue response to genioplasty procedures. Br J Oral Maxillofac Surg 30:87, 1992 Dalton PS, Cillo JE Jr, Dattilo DJ. Outcome evaluation of the combined mandibular elliptical window genioglossus advancement and hyoid bone suspension for obstructive sleep apnea. J Oral Maxillofac Surg. In press. Jung YJ, Kim MJ, Baek SH: Hard and soft tissue changes after correction of mandibular prognathism and facial asymmetry by mandibular setback surgery: Three-dimensional analysis using computerized tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107:763, 2009
Cephalometric Soft Tissue Analysis of Combined Elliptical-Window Genioglossus Advancement and Hyoid Suspension for Obstructive Sleep Apnea Joseph E. Cillo, Jr, DMD, MPH,* Pankaj Thakker, DDS, MD,† and David J. Dattilo, DDS‡ Purpose: This study sought to determine the changes in cephalometric facial profile soft tissue
measurements after simultaneous elliptical-window genioglossus advancement and hyoid suspension procedures for obstructive sleep apnea. Patients and Methods: A retrospective analysis of preoperative and postoperative lateral cephalometric soft tissue changes in 23 consecutive patients who had undergone combined elliptical-window genioglossus advancement and hyoid bone suspension for polysomnogram-confirmed obstructive sleep apnea. Six cephalometric soft tissue measurements of the lower face were evaluated: pogonion (Pg=-Pg), menton (Me=-Me), gnathion (G=-G), lower lip (LI-L1i), B point (B-B=), and horizontal distance from subnasale perpendicular to the soft tissue chin at the level of pogonion (SN-Pg=). Statistical analysis was conducted with the paired Student t test (with 95% confidence interval of difference between means) and found significant for P ⬍ .05. Post hoc power analysis was conducted. Results: There were no statistically significant differences among all 6 preoperative and postoperative cephalometric, radiographic soft tissue measurements of the lower facial profile. Conclusions: The combined elliptical-window genioglossus advancement and hyoid suspension procedures for obstructive sleep apnea do not significantly change the cephalometric lower facial profile. In patients with an adequate lower facial profile with base-of-tongue obstruction who require surgical management of obstructive sleep apnea without alteration of their lower facial profile, this procedure does not significantly alter the preoperative facial profile. © 2012 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 70:690-695, 2012 Obstructive sleep apnea (OSA) continues to be a pervasive condition contributing to increased morbidity and mortality rates. Phase I surgery has been shown to be successful in alleviating OSA in some situations.1-4 Some procedures for the surgical treatment of OSA significantly change the lower facial profile of the patient. These include the surgical procedures to advance the base of the tongue, such as genioglossus advancement,
which have been shown to enlarge the posterior airway and improve OSA.3,4 However, in the process of enlarging the posterior airway, the genioglossus advancement procedure may also increase and advance the lower facial profile of the patient. In individuals with prominent or normal chin position, this may not be a desired result. The elliptical-window genioglossus advancement procedure is designed to maintain the presurgical facial profile of the patient while advancing the base of the tongue to alleviate nocturnal obstruction during sleep.5 This study was designed to evaluate the cephalometric soft tissue lower facial profile of individuals undergoing the simultaneous elliptical-window genioglossus advancement and hyoid suspension procedures for the correction of polysomnogram-confirmed OSA.
Received from the Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, Pittsburgh, PA. *Program Director and Director of Research. †Resident. ‡Division Director. Address correspondence and reprint requests to Dr Cillo: Division of Oral and Maxillofacial Surgery, Allegheny General Hospital, 320 E North Ave, Ste 0107, Pittsburgh, PA; e-mail: [email protected]
Patients and Methods
© 2012 American Association of Oral and Maxillofacial Surgeons
This study had full Institutional Review Board approval from the Allegheny General Hospital/Alle-
0278-2391/12/7003-0$36.00/0 doi:10.1016/j.joms.2011.02.028
690
691
CILLO, THAKKER, AND DATTILO
gheny Singer Research Institute (Pittsburgh, PA), and we had read the Declaration of Helsinki. This was a retrospective cephalometric evaluation of 23 consecutive individuals who underwent simultaneous elliptical-window genioglossus advancement and hyoid suspension procedures for polysomnogramconfirmed OSA under general anesthesia as previously described by Dattilo and Aynechi5 (Figs 1, 2). In brief, through an extraoral incision in the submental region, dissection is performed down to the hyoid bone, where 2 Mitek anchors (Mitek, Westwood, MA) are placed on the body of the hyoid bone. Through the same incision, an elliptical osteotomy is completed in the anterior mandible 15 and 5 mm from the inferior border and connected in an elliptical fashion. After completion of the osteotomy, the segment is rotated, fixated, and reduced in size, and the remaining bone is grafted back to the osteotomy site. The hyoid suspension is then completed and fixated to the mandible. Inclusion criteria for the study were any patient who had undergone the combined elliptical genioglossus advancement and hyoid bone suspension procedures for mild to moderate (respiratory disturbance index ⬎5 and ⬍30) polysomnogram-confirmed OSA with acceptable preoperative and postoperative lateral cephalometric radiographs with at least 6
FIGURE 2. Completed elliptical genioglossus advancement procedure. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
months’ follow-up. Preoperative and postoperative lateral cephalometric radiographs had been obtained with the same panoramic radiography machine (Laser 1000; Panoramic, Fort Wayne, IN) with the patient in centric occlusion and with the lips in a relaxed position. Postoperative radiograph measurements were taken from lateral cephalometric radiographs taken at the 6-month follow-up appointment. Cephalometric measurements were taken manually, repeated 3 times, and averaged for the following radiographic
FIGURE 1. Diagrammatic representation of combined elliptical genioglossus advancement and hyoid suspension procedures. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
692
SOFT TISSUE ANALYSIS IN OSA
soft tissue measurements of the lower face (Fig 3): hard to soft tissue pogonion (Pg=-Pg), hard to soft tissue menton (Me=-Me), hard to soft tissue gnathion (G=-G), hard to soft tissue B point (B-B=), horizontal thickness of lower lip (LI-L1i), and horizontal distance from subnasale perpendicular to Frankfurt horizontal line to soft tissue chin at level of pogonion (SN-Pg=). STATISTICAL ANALYSIS
Standard descriptive statistics were used. Normality of the population was verified with the Shapiro-Wilk test, and statistical significance between the means of the populations was determined with the paired Student t test (with a 95% confidence interval [CI] for the difference between the means of the 2 samples) and found significant for P ⬍ .05. Statistical analysis and post hoc power analysis were conducted with G*Power 3.1 statistical software6 for the paired t test with an effect size of 0.68, ␣ error probability of 0.05, and a sample size of 23.
Results The mean age of the patients was 43 ⫾ 4.3 years, with 21 male and 2 female patients. There were no statistically significant differences between mean preoperative and postoperative cephalometric, radiographic soft tissue measurements of the lower facial profile for any of the measurements taken (Table 1): Pg=-Pg (11.54 ⫾ 1.51 mm vs 11.15 ⫾ 1.63 mm [preoperative vs postoperative, mean ⫾ SD], ⌬ ⫽ ⫺0.39 mm [95% CI, ⫺0.879 to 1.659 mm]; P ⫽ .41), Me=-Me (8.85 ⫾ 2.41 mm vs 9.69 ⫾ 3.04 mm, ⌬ ⫽ ⫹0.84 mm [95% CI, ⫺3.056 to 1.376 mm]; P ⫽ .11), G=-G (10.08 ⫾ 2.25 mm vs 10.69 ⫾ 2.39 mm, ⌬ ⫽ ⫹0.61 mm [95% CI, ⫺2.485 to 1.265 mm]; P ⫽ .09), B-B= (10.11 ⫾ 1.1 mm vs 10.72 ⫾ 1.2 mm, ⌬ ⫽ ⫹0.71 mm [95% CI, ⫺1.425 to 1.562 mm]; P ⫽ .2), LI-L1i mm (13.23 ⫾ 2.17 mm vs 13.31 ⫾ 1.75 mm, ⌬ ⫽ ⫹0.08 mm [95% CI, ⫺1.672 to 1.512 mm]; P ⫽ .08), and SN-Pg= (⫺1.23 ⫾ 1.76 mm vs ⫺0.62 ⫾ 1.88 mm, ⌬ ⫽
FIGURE 3. A, Preoperative lateral cephalometric radiograph. (Fig 3 continued on next page.) Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
693
CILLO, THAKKER, AND DATTILO
FIGURE 3 (Cont’d). B, Lateral cephalometric radiograph 6 months postoperatively after elliptical genioglossus advancement and hyoid suspension procedures. (Pg-Pg=, hard to soft tissue pogonion; Me-Me=, hard to soft tissue menton; G-G=, hard to soft tissue gnathion; B-B=, hard to soft tissue B point; LI-L1i, horizontal thickness of lower lip; SN-Pg=, horizontal distance from subnasale perpendicular to Frankfurt horizontal line to soft tissue chin at level of pogonion.) Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
⫹0.61 mm [95% CI, ⫺2.081 to 0.861 mm]; P ⫽ .12). Post hoc power analysis showed a power of 88%.
Discussion The literature is replete with descriptions of phase I surgical procedures for the treatment of OSA sur-
gery.1-5,7-15 Genioglossus advancement surgery has been successfully used for the treatment of sleepdisordered breathing and has included the traditional genioglossus advancement and genioglossus bone advancement techniques.10-13 The genioglossus advancement procedure has been used alone10-12 and in combination with other upper airway surger-
Table 1. PREOPERATIVE AND POSTOPERATIVE CEPHALOMETRIC MEASUREMENTS
SN-Pg=
Pg-Pg=
Me-Me=
G-G=
B-B=
LI-L1i
Preoperative [mean (SD)] ⫺1.23 (1.76) 11.54 (1.51) 8.85 (2.41) 10.08 (2.25) 10.11 (1.1) 13.23 (2.17) Postoperative [mean (SD)] ⫺0.62 (1.88) 11.15 (1.63) 9.69 (3.04) 10.69 (2.39) 10.82 (1.2) 13.31 (1.75) Difference ⫹0.61 ⫺0.39 ⫹0.84 ⫹0.61 ⫹0.71 ⫹0.08 95% CI ⫺2.081 to 0.861 ⫺0.879 to 1.659 ⫺3.056 to 1.376 ⫺2.485 to 1.265 ⫺1.425 to 1.562 ⫺1.672 to 1.512 P value .12 .41 .11 .09 .2 .08 Abbreviations: SN, subnasale; Pg=, soft tissue pogonion; Pg, pogonion; Me=, soft tissue menton; Me, menton; G=, soft tissue gnathion; G, gnathion; B, B point; B=, soft tissue B point; LI, soft tissue lower lip; Lli, vertical position of incisal edge of mandibular central incisor. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
694 ies, such as uvulopalatopharyngoplasty, hyoid suspension, and radiofrequency treatment, for phase I OSA surgery.5,13,14 Whereas the main purpose of the genioglossus advancement procedure is to improve airflow in the upper airway due to base-of-tongue obstruction, individuals who have normal or prominent chin profiles may have a less-than-desirable cosmetic outcome as a result of undergoing this procedure. Because this procedure advances the hard tissues of the chin, the soft tissues of the chin will also be advanced. Studies on the advancement genioplasty for cosmetic purposes have shown that soft tissue pogonion can predictably follow the underlying hard tissue advancement at a ratio of approximately 0.9:1.15-17 The elliptical genioglossus advancement is designed to advance the genioglossus muscle, thereby allowing for enlargement of the posterior airway while maintaining the soft tissue profile of the patient.5 Currently unpublished research has shown that the combined elliptical genioglossus advancement and hyoid bone suspension procedures are effective in reducing respiratory disturbance index by over 50%.18 Though effective in managing OSA, to our knowledge, no studies have examined whether the combined elliptical genioglossus advancement and hyoid suspension procedures alter the lower facial soft tissue profile. When one is examining patients for the appropriate treatment for OSA, the final cosmetic result may be just as important to some individuals as the surgical correction of OSA. In individuals with OSA due to base-of-tongue obstruction who have a normal or prominent chin profile or in a situation where the patient does not desire a change in chin profile, the traditional genioglossus advancement procedure may not be a viable option because it will make the chin more pronounced (Figs 3, 4). In these situations the elliptical genioglossus advancement and hyoid suspension procedures may be an alternative option. In this study 6 separate lateral cephalometric radiographic measurements were examined preoperatively and 6 months postoperatively to determine any lower facial soft tissues changes. The results of this study show that the combined elliptical-window genioglossus advancement and hyoid suspension procedures for the treatment of OSA do not alter the radiographic lower facial soft tissue profile of the patient. There are several limitations to this study. There are numerous soft and hard tissue measurements and angles that can be used to measure cephalometric facial profile changes associated with surgical manipulation of the facial skeleton. The cephalometric markers in this study were chosen for their simplicity and general representation of the lower facial soft tissue profile. Certainly, a more detailed and exhaus-
SOFT TISSUE ANALYSIS IN OSA
FIGURE 4. A, Preoperative facial profile view. B, Facial profile view 6 months postoperatively after combined elliptical genioglossus advancement and hyoid suspension procedures. Cillo, Thakker, and Dattilo. Soft Tissue Analysis in OSA. J Oral Maxillofac Surg 2012.
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tive analysis and clinical profile and frontal facial soft tissue evaluation may be conducted in future investigations. The advancement of computer technology may allow for future analysis of changes from these procedures that should involve 3-dimensional computer analysis of both profile and frontal soft tissue changes.19 In conclusion, this study has shown that, by use of lateral cephalometric measurements common in the analysis of the lower facial soft tissue profile, the combined elliptical genioglossus advancement and hyoid suspension procedures do not produce a statistically significant change from preoperative measurements up to 6 months after surgery. This procedure, therefore, may be suitable to be used for the correction of base-of-tongue obstructions in the surgical management of OSA in individuals who have a normal or prominent soft tissue chin profile or when a change in chin profile is not desired, when a traditional genioglossus advancement procedure would likely produce an unesthetic result.
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