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Daytime vigilance in obstructive sleep apnoea: nCPAP-therapy versus maxillomandibular advancement surgery
54 Journal of Cranio-Maxillofacial Surgery Obstructive Sleep Apnoea Syndrome - Results and Conclusions of a Principal Component Analysis
Hierl T.1, Hiimpfner-Hierl H.2, Frerich B.1, Heisgen U.s, Bosse-Henck A. 4, Hemprich A. 1
Departments of j Oral and Maxillofacial Surgery, 2Prosthodontics, 3Orthodontics and 4Internal Medicine Sleep Laboratory, University of Leipzig, Leipzig, Germany Material and Methods: As the obstructive sleep apnoea syndrome (OSAS) can be aggravated or even caused by craniofacial anomalies, the need for interdisciplinary diagnostics and treatment is obvious. Thus 152 patients suffering from OSAS were referred to the Department of Oral and MaxiUofacial Surgery by the Sleep Laboratory of the University from July 1994 to January 1996. The data gained from clinical examination, cephalometry and polysomnography were tested in a principal component analysis to differentiate between several types of patients. Results: Four types could be discriminated: (i) patients with maxillary and mandibular prognathism and brachiofacial growth type suffering from a mild form of OSAS; (ii) patients with a long uvula and an inferiorly positioned hyoid, preferentially elder males; (iii) mandibular retrognathic patients with narrow posterior airway space (in these cases significantly more often than in the other groups an uvulopalatopharyngoplasty had been performed alio loco without success), and (iv) obese patients with cephalometric data in the normal range. Conclusion: The results suggest differentiated therapeutic approaches to the specific subgroups of OSAS patients to guarantee an etiologically orientated treatment in which maxillofacial surgery takes a major part. Thus, the co-operation between oral and maxillofacial surgery and sleep medicine in diagnostics and treatment of OSAS is of high value. Morphometric Evaluation of the Bone-Titanium Interface in an Experimental Animal Bone Graft Model
Hirsch J-M. 1, Liljesten E. 2, Larsson (7.2, Blomqvist GJ, Wedenberg (7.~, Thomsen p.2
1Department of Oral Surgery, Goteborg, and Department of Oral and Maxillofacial Surgery, Uppsala, Sweden 2Institute of Anatomy and Cell Biology, G6teborg, University, G6teborg, Sweden 3Department of Plastic Surgery, Sahlgrens Hospital, Sahlgrens, Sweden 4Department of Oral Pathology, Karolinska Institute, Huddinge, Sweden A defect was made bilaterally in the tibia of rabbits. One defect was grafted with autologous cortical bone, while the other defect was left empty and served as a control. Additional rabbits received demineralized bone matrix (DBM) and plasma-augmented DBM. In all defects, a titanium implant was centrally placed and anchored in the opposite cortex. Specimens were harvested after 6 weeks and 6 months, respectively, and evaluated. Analysis of tissue in the defects, 6 weeks previously grafted with cortical bone, showed that a large proportion (80%) of the implant threads located in the cortical layer was occupied by mineralized bone. Markedly less bone (31%) was found in the DBM group. Control defects and defects with plasma-augmented DBM revealed a similar amount of bone (49% and 53%, respectively). After 6 months, no major quantitative differences were detected between the four experimental groups. In the cortical graft group, the implant
threads contained 78% of mineralized bone. In the other three groups, similar morphometrical values (69-76%) were detected. The present experimental model permits a quantitative evaluation of the bone formation and remodelling at implant surfaces in bone defects. The model therefore allows comparative studies of the effects of modification of both material and biological components on the healing of implants incorporation in grafts.
Comparative Study on the Importance of Bone Scan to the Infiltration of Malignant Turnouts into the Bones of the Cephalocervical Region
Hlawitschka M., John E., Eckelt U.
Department of Maxillo Facial Surgery, University of Dresden, Dresden, Germany Though the functionally stable methods of osteosynthesis and reconstruction have been developed further, partial resection of the maxilla or mandible is a difficult decision for the operating surgeon and may lead to additional complications in the course of treatment if an infiltration of a malignant tumour of the oral soft tissue into the bones is suspected. In preoperative mmour staging, reliable and sensitive investigation methods must supply information about an early involvement of bones. It was our task to investigate whether bone scan as a method of examination, compared with conventional X-ray examinations, represents an aid to decision-making or a critical evaluation has to be made on the basis of a non-specific statement only. We used the clinical findings, Xrays, results of computerized axial tomography, bone scans and medical files of 115 patients with a malignant tumour of the oral soft tissue to investigate retrospectively to what extent the respective method of examination coincided with the histologic diagnosis of the clinical picture. We histologically examined 74 operative bone specimens, 34 of which were pathologically negative. Infiltration of the tumour into the bones could be shown in 40 patients. In all the cases where infiltration of the tumour into the bones was confirmed histologically, bone scan documents the clinical status positively in 100% of cases. All the other methods of examination had a lower hit rate. However, the high proportion of false-positive examination findings (23 patients), where bone infiltration could not be confirmed histologically, has be regarded critically. The specificity of comparative examinations was substantially higher. The exclusive evaluation of a positive bone scan leads to a large number of false-positive results. Reactive granulating and fibrosing medullary cavities as well as the picture of a non-specific chronic osteomyelitis may pretend a malignant bone involvement. Only the obligatory correlation of scintigraphic results with clinical and X-ray data can enhance the specificity and accuracy of high-sensitive bone scan and can restrict misinterpretation. Daytime Vigilance in Obstructive Sleep Apnoea: nCPAP-Therapy versus MaxiUomandibular Advancement Surgery
Hochban W.z, Conradt R. 2, Brandenburg U3, Peter J.H. 2
1Klinik fiir Mund-, Kiefer-, Gesichtschirurgie and 2Schlafmedizinisches Labor, Philipps- Universitat Marburg, Marburg, Germany Excessive daytime sleepiness (EDS) and impaired vigilance are among the most important symptoms of obstructive sleep apnea (OSA). Obstructive sleep apnoea-treatment not only has to improve cardiorespiratory parameters but
Free oral communications 55 also EDS. In this prospective study the effects of conservative nasal continuous positive pressure ventilation (nCPAP) were compared to surgical treatment with maxillomandibular advancement in 14 patients. Cardiorespiratory polysomnography (cPSG) was performed pretreatment, after nCPAP-therapy for at least 3 months and after maxillomandibular osteotomy (MMO) with advancement of 10 mm. At the same time, EDS and vigilance were investigated using a 90 min four choice reaction-time test. R D I could be reduced from mean 53.4 events/h to 2.4 under nCPAP and to 3.6 after MMO, respectively. Sleep stages 3 and 4 improved from mean 9.6% to 22.2% under nCPAP and to 17.2% after MMO. Accordingly, daytime vigilance was improved with nCPAP and MMO in a likewise manner. Mean reaction time was reduced from 1.1 s to 0.8 s under nCPAP and to 0.8 s after MMO, the mean percentage of reactions longer than 1.5 s. decreased from 19.4% to 5.8% under nCPAP and 4.8% after MMO. Significant differences between nCPAP and surgical treatment did not occur, which holds true for the results in cPSG as well as in vigilance testing. We c~nclude that surgical treatment of OSA with MMO in proper selected cases has positive effects on sleep and daytime vigilance, which are different neither statistically nor as regards content obtained by nCPAP.
Acknowledgement: Research supported Forschungsgemeinschaft (DFG).
by
Deutsche
Induction and Prevention of DNA Damage Induced by Tobacco Smoke and Y-Irradiation in Oral Mucosa Cells
Hofele C, 1, Stiihle B.2, Scherf H.R3, Ziiller j.t, Hergenhahn M. 2
IKlinik und Poliklinik ffir Mund-, Kiefer- und Gesichtschirurgie, Universitgit Heidelberg, Heidelberg, Germany 2AbteiIung ToxikoIogie und Krebsrisikofaktoren, Deutsehes Krebsforschungszentrum, Heidelberg, Germany Formation of oral and other head-and-neck (H/N) tumours is mainly due to excessive tobacco use and alcohol consumption. Nitrosamines and polycyclic aromatic hydrocarbons from tobacco smoke are major putative carcinogenic factors involved, but further compounds may contribute to H/N carcinogenesis. Initial D N A damage induced by tobacco smoke or y-irradiation and its possible prevention was studied in human oral mucosa cells. Conditions for short-term cultures of oral mucosa cells were optimized by trypsinization of biopsies from smokers and non-smokers, and isolation of epithelial cells. Appropriate culture conditions allowed growth of cells with normal morphology that could be passaged up to 3 times before terminal differentiation. Cells from the second passage were used for determination of D N A damage induced by tobacco smoke (produced in a cigarette-smoking machine) and y-irradiation used for comparison; D N A damage in oral mucosa cells was detected by single-cell microelectrophoresis (COMET assay). Irradiation damage was readily detectable at doses below 20 Gy; cigarette smoke induced D N A damage in most cells in a time- and concentration-dependent manner. Vitamin C at 1 mM concentration added to the cells concurrently with cigarette smoke could not prevent smoke-induced damage to the cells. We conclude that human oral mucosa cells can be grown in vitro for use in the COMET assay providing a useful tool for studying carcinogen- or toxin-induced DNA damage and the action of cbemopreventive agents.
Impact of Radical Tmnour Resection in Conjunction with Immediate Flap Coverage on the Prognosis of Oral Cancer
Hoffmann jd, Cornelius C-P.1, Kainz M3, Roser Md
1Department of Maxillofacial Surgery, University of Tiibingen, Tiibingen, Germany 2German-Austrian-Swiss Association for Tumours in the Maxillofacial Region [DOSAK], Gieflen Germany Large surgical defects in oral cancer can be primarily closed by means of distant flap transfer without compromise of function and esthetics. Moreover, resectional margins can be extended potentially yielding a more effective locoregional tumour control, only limited by interposed vital anatomic structures. The aim of this study was to determine the prognostic relevance of extensive wide-field tumour resection followed by a free or pedicled flap reconstruction. The effect of this therapeutic strategy on survival rates was evaluated in a series of 140 cases, who underwent treatment in our institution between 1990 and June 1995. Estimates of the overall crude survival at 5 years were obtained using the product-limit method of Kaplan-Meier. The data of this Tiibingen series were compared with matching patients gathered from the prospective multicentric DOSAK study having received conventional surgical therapy. No significant difference in the prognostic outcome between the stratified treatment groups could be demonstrated, so that functional rehabilitation and the resulting enhancement of quality of life have to be considered as the paramount objectives of flap reconstruction in advanced tumour stages. Prognosis in oral cancer rather seems related to complex inherent factors of tumour biology, partially reflected in the type of local invasion, signs of proliferative activity or the degree of differentiation than to the magnitude of clear excision margins.
Long-Term Efficacy of Diskectomy in Treatment of Temporomandibular Joint Internal Derangement
Holmlund A., Gynther G., Axe&son S. Departments of Oral and Maxillofacial Surgery and Clinical Oral Physiology, Karolinska Institute, Huddinge, Sweden The efficacy of temporomandibular joint (TMJ) diskectomy without implants was evaluated clinically in 74 patients with internal derangement. Only patients with unilateral diskectomy were included in the study. For at least 6 months before surgery all patients were treated nonsurgically with full coverage occlusal stabilization splints and physical therapy. Success rates were calculated according to the criteria established in 1984 by the American Association of Oral and Maxillofacial Surgeons. The drop-out rate (that is the number of patients not responding to repeated recall letters) was zero at the 1-year follow-up. The success rate at the 1-year follow-up was 84%. Temporomandibular joint pain was alleviated and mandibular function normalized in 62 patients. Fifty-five of them were also examined 3 and 5 years after surgery. The drop-out rate thus was 11% after 5 years. No patient was classified as unsuccessful at the 3- and 5-year follow-ups. In fact, a slight further improvement of mandibular movements seemed to occur with time. In conclusion, diskectomy without implants is an effective surgical procedure for patients with TMJ internal derangement also in the long term.
Hierl T.1, Hiimpfner-Hierl H.2, Frerich B.1, Heisgen U.s, Bosse-Henck A. 4, Hemprich A. 1
Departments of j Oral and Maxillofacial Surgery, 2Prosthodontics, 3Orthodontics and 4Internal Medicine Sleep Laboratory, University of Leipzig, Leipzig, Germany Material and Methods: As the obstructive sleep apnoea syndrome (OSAS) can be aggravated or even caused by craniofacial anomalies, the need for interdisciplinary diagnostics and treatment is obvious. Thus 152 patients suffering from OSAS were referred to the Department of Oral and MaxiUofacial Surgery by the Sleep Laboratory of the University from July 1994 to January 1996. The data gained from clinical examination, cephalometry and polysomnography were tested in a principal component analysis to differentiate between several types of patients. Results: Four types could be discriminated: (i) patients with maxillary and mandibular prognathism and brachiofacial growth type suffering from a mild form of OSAS; (ii) patients with a long uvula and an inferiorly positioned hyoid, preferentially elder males; (iii) mandibular retrognathic patients with narrow posterior airway space (in these cases significantly more often than in the other groups an uvulopalatopharyngoplasty had been performed alio loco without success), and (iv) obese patients with cephalometric data in the normal range. Conclusion: The results suggest differentiated therapeutic approaches to the specific subgroups of OSAS patients to guarantee an etiologically orientated treatment in which maxillofacial surgery takes a major part. Thus, the co-operation between oral and maxillofacial surgery and sleep medicine in diagnostics and treatment of OSAS is of high value. Morphometric Evaluation of the Bone-Titanium Interface in an Experimental Animal Bone Graft Model
Hirsch J-M. 1, Liljesten E. 2, Larsson (7.2, Blomqvist GJ, Wedenberg (7.~, Thomsen p.2
1Department of Oral Surgery, Goteborg, and Department of Oral and Maxillofacial Surgery, Uppsala, Sweden 2Institute of Anatomy and Cell Biology, G6teborg, University, G6teborg, Sweden 3Department of Plastic Surgery, Sahlgrens Hospital, Sahlgrens, Sweden 4Department of Oral Pathology, Karolinska Institute, Huddinge, Sweden A defect was made bilaterally in the tibia of rabbits. One defect was grafted with autologous cortical bone, while the other defect was left empty and served as a control. Additional rabbits received demineralized bone matrix (DBM) and plasma-augmented DBM. In all defects, a titanium implant was centrally placed and anchored in the opposite cortex. Specimens were harvested after 6 weeks and 6 months, respectively, and evaluated. Analysis of tissue in the defects, 6 weeks previously grafted with cortical bone, showed that a large proportion (80%) of the implant threads located in the cortical layer was occupied by mineralized bone. Markedly less bone (31%) was found in the DBM group. Control defects and defects with plasma-augmented DBM revealed a similar amount of bone (49% and 53%, respectively). After 6 months, no major quantitative differences were detected between the four experimental groups. In the cortical graft group, the implant
threads contained 78% of mineralized bone. In the other three groups, similar morphometrical values (69-76%) were detected. The present experimental model permits a quantitative evaluation of the bone formation and remodelling at implant surfaces in bone defects. The model therefore allows comparative studies of the effects of modification of both material and biological components on the healing of implants incorporation in grafts.
Comparative Study on the Importance of Bone Scan to the Infiltration of Malignant Turnouts into the Bones of the Cephalocervical Region
Hlawitschka M., John E., Eckelt U.
Department of Maxillo Facial Surgery, University of Dresden, Dresden, Germany Though the functionally stable methods of osteosynthesis and reconstruction have been developed further, partial resection of the maxilla or mandible is a difficult decision for the operating surgeon and may lead to additional complications in the course of treatment if an infiltration of a malignant tumour of the oral soft tissue into the bones is suspected. In preoperative mmour staging, reliable and sensitive investigation methods must supply information about an early involvement of bones. It was our task to investigate whether bone scan as a method of examination, compared with conventional X-ray examinations, represents an aid to decision-making or a critical evaluation has to be made on the basis of a non-specific statement only. We used the clinical findings, Xrays, results of computerized axial tomography, bone scans and medical files of 115 patients with a malignant tumour of the oral soft tissue to investigate retrospectively to what extent the respective method of examination coincided with the histologic diagnosis of the clinical picture. We histologically examined 74 operative bone specimens, 34 of which were pathologically negative. Infiltration of the tumour into the bones could be shown in 40 patients. In all the cases where infiltration of the tumour into the bones was confirmed histologically, bone scan documents the clinical status positively in 100% of cases. All the other methods of examination had a lower hit rate. However, the high proportion of false-positive examination findings (23 patients), where bone infiltration could not be confirmed histologically, has be regarded critically. The specificity of comparative examinations was substantially higher. The exclusive evaluation of a positive bone scan leads to a large number of false-positive results. Reactive granulating and fibrosing medullary cavities as well as the picture of a non-specific chronic osteomyelitis may pretend a malignant bone involvement. Only the obligatory correlation of scintigraphic results with clinical and X-ray data can enhance the specificity and accuracy of high-sensitive bone scan and can restrict misinterpretation. Daytime Vigilance in Obstructive Sleep Apnoea: nCPAP-Therapy versus MaxiUomandibular Advancement Surgery
Hochban W.z, Conradt R. 2, Brandenburg U3, Peter J.H. 2
1Klinik fiir Mund-, Kiefer-, Gesichtschirurgie and 2Schlafmedizinisches Labor, Philipps- Universitat Marburg, Marburg, Germany Excessive daytime sleepiness (EDS) and impaired vigilance are among the most important symptoms of obstructive sleep apnea (OSA). Obstructive sleep apnoea-treatment not only has to improve cardiorespiratory parameters but
Free oral communications 55 also EDS. In this prospective study the effects of conservative nasal continuous positive pressure ventilation (nCPAP) were compared to surgical treatment with maxillomandibular advancement in 14 patients. Cardiorespiratory polysomnography (cPSG) was performed pretreatment, after nCPAP-therapy for at least 3 months and after maxillomandibular osteotomy (MMO) with advancement of 10 mm. At the same time, EDS and vigilance were investigated using a 90 min four choice reaction-time test. R D I could be reduced from mean 53.4 events/h to 2.4 under nCPAP and to 3.6 after MMO, respectively. Sleep stages 3 and 4 improved from mean 9.6% to 22.2% under nCPAP and to 17.2% after MMO. Accordingly, daytime vigilance was improved with nCPAP and MMO in a likewise manner. Mean reaction time was reduced from 1.1 s to 0.8 s under nCPAP and to 0.8 s after MMO, the mean percentage of reactions longer than 1.5 s. decreased from 19.4% to 5.8% under nCPAP and 4.8% after MMO. Significant differences between nCPAP and surgical treatment did not occur, which holds true for the results in cPSG as well as in vigilance testing. We c~nclude that surgical treatment of OSA with MMO in proper selected cases has positive effects on sleep and daytime vigilance, which are different neither statistically nor as regards content obtained by nCPAP.
Acknowledgement: Research supported Forschungsgemeinschaft (DFG).
by
Deutsche
Induction and Prevention of DNA Damage Induced by Tobacco Smoke and Y-Irradiation in Oral Mucosa Cells
Hofele C, 1, Stiihle B.2, Scherf H.R3, Ziiller j.t, Hergenhahn M. 2
IKlinik und Poliklinik ffir Mund-, Kiefer- und Gesichtschirurgie, Universitgit Heidelberg, Heidelberg, Germany 2AbteiIung ToxikoIogie und Krebsrisikofaktoren, Deutsehes Krebsforschungszentrum, Heidelberg, Germany Formation of oral and other head-and-neck (H/N) tumours is mainly due to excessive tobacco use and alcohol consumption. Nitrosamines and polycyclic aromatic hydrocarbons from tobacco smoke are major putative carcinogenic factors involved, but further compounds may contribute to H/N carcinogenesis. Initial D N A damage induced by tobacco smoke or y-irradiation and its possible prevention was studied in human oral mucosa cells. Conditions for short-term cultures of oral mucosa cells were optimized by trypsinization of biopsies from smokers and non-smokers, and isolation of epithelial cells. Appropriate culture conditions allowed growth of cells with normal morphology that could be passaged up to 3 times before terminal differentiation. Cells from the second passage were used for determination of D N A damage induced by tobacco smoke (produced in a cigarette-smoking machine) and y-irradiation used for comparison; D N A damage in oral mucosa cells was detected by single-cell microelectrophoresis (COMET assay). Irradiation damage was readily detectable at doses below 20 Gy; cigarette smoke induced D N A damage in most cells in a time- and concentration-dependent manner. Vitamin C at 1 mM concentration added to the cells concurrently with cigarette smoke could not prevent smoke-induced damage to the cells. We conclude that human oral mucosa cells can be grown in vitro for use in the COMET assay providing a useful tool for studying carcinogen- or toxin-induced DNA damage and the action of cbemopreventive agents.
Impact of Radical Tmnour Resection in Conjunction with Immediate Flap Coverage on the Prognosis of Oral Cancer
Hoffmann jd, Cornelius C-P.1, Kainz M3, Roser Md
1Department of Maxillofacial Surgery, University of Tiibingen, Tiibingen, Germany 2German-Austrian-Swiss Association for Tumours in the Maxillofacial Region [DOSAK], Gieflen Germany Large surgical defects in oral cancer can be primarily closed by means of distant flap transfer without compromise of function and esthetics. Moreover, resectional margins can be extended potentially yielding a more effective locoregional tumour control, only limited by interposed vital anatomic structures. The aim of this study was to determine the prognostic relevance of extensive wide-field tumour resection followed by a free or pedicled flap reconstruction. The effect of this therapeutic strategy on survival rates was evaluated in a series of 140 cases, who underwent treatment in our institution between 1990 and June 1995. Estimates of the overall crude survival at 5 years were obtained using the product-limit method of Kaplan-Meier. The data of this Tiibingen series were compared with matching patients gathered from the prospective multicentric DOSAK study having received conventional surgical therapy. No significant difference in the prognostic outcome between the stratified treatment groups could be demonstrated, so that functional rehabilitation and the resulting enhancement of quality of life have to be considered as the paramount objectives of flap reconstruction in advanced tumour stages. Prognosis in oral cancer rather seems related to complex inherent factors of tumour biology, partially reflected in the type of local invasion, signs of proliferative activity or the degree of differentiation than to the magnitude of clear excision margins.
Long-Term Efficacy of Diskectomy in Treatment of Temporomandibular Joint Internal Derangement
Holmlund A., Gynther G., Axe&son S. Departments of Oral and Maxillofacial Surgery and Clinical Oral Physiology, Karolinska Institute, Huddinge, Sweden The efficacy of temporomandibular joint (TMJ) diskectomy without implants was evaluated clinically in 74 patients with internal derangement. Only patients with unilateral diskectomy were included in the study. For at least 6 months before surgery all patients were treated nonsurgically with full coverage occlusal stabilization splints and physical therapy. Success rates were calculated according to the criteria established in 1984 by the American Association of Oral and Maxillofacial Surgeons. The drop-out rate (that is the number of patients not responding to repeated recall letters) was zero at the 1-year follow-up. The success rate at the 1-year follow-up was 84%. Temporomandibular joint pain was alleviated and mandibular function normalized in 62 patients. Fifty-five of them were also examined 3 and 5 years after surgery. The drop-out rate thus was 11% after 5 years. No patient was classified as unsuccessful at the 3- and 5-year follow-ups. In fact, a slight further improvement of mandibular movements seemed to occur with time. In conclusion, diskectomy without implants is an effective surgical procedure for patients with TMJ internal derangement also in the long term.