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Obstructive sleep apnoea following orthognathic surgery: 10-year follow up
Int. J. Oral Maxillofac. Surg. 2005; 34 (Supplement 1): $ 1 - $ 1 8 1
64
033. Sleep Apnoea
[O•]
CHANGING OF VENTILATION PARAMETERS DURING SLEEP AFTER ORTHOGNATHIC SURGERY - A PILOT LIMITED SLEEP STUDY
R. Foltan 1 , F. Donev 1 , J. Hoffmannova 1 , M. VIk 1 , M. Pretl 2, R. Kufa 3
1Dep. Oral & Maxillofacial Surgery, 1st Medical Faculty Hospital of Charles University, Czech Republic, Prague; 2Dep. of Neurology, 1st Medical Faculty Hospital of Charles University, Czech Republic, Prague; 3Dep. of Plastic Surgery, 2nd Medical Faculty Hospital of Charles University, Czech Republic The obstructive sleep apnea syndrome is often associated with narrowing of the upper airways. Orthognathic surgery is changing the position of the jaws in relation not only to each other but also to the cervical spine. There is a risk of narrowing of the upper airway, especially in the mandibular setbacks. Direct scientific proof of the risk of orthognathic surgery causing obstructive sleep apnea is still missing. Only polysomnographic sleep study measurements may prove these risks. We designed a prospective pilot study with 3 groups of 6 patients each (3 male, 3 female). The 1st st group of patients (aged average 18.6, range 17.3-22) underwent treatment of their class III skeletal malocclusion by mandibular BSSO set back and Le Fort I maxillary advancement. The 2nd group were patients (aged average 17.2, range 16.4-21.2)with class II malocclusion treated only by mandibular advancement. The 3rd group are patients (aged average 15.7, range 15.5-19.1) who needed a surgically assisted rapid maxillary expansion (SARME) because of bilateral cross bite. We measure parameters such as air flow, P,DI, ODI, snoring, micro-arousal, P 02, ECG, position of the body. The 1st measurement was done before surgery and the second measurement after a certain period (average 6.5 month, ranging from 5.35 to 8.65) at the time of P,IF plate removal. We correlated the results with the type of operation and the size of movements. In the 1st group there was a statistically significant increase in ODI (2.6 to 6.25, p 0.005) and there seems to be a positive correlation with the size of mandibular set-back. The 2nd group of patients showed a statistically significant improvement in almost all polygraphic parameters, but we didn't found any correlation with the size of the movement. SAP, ME also shows improvement in all polygraphic parameters, but they aren't statistically significant. Our results indicate that there is a positive correlation between a bi-maxillary surgery of class III malocclusion with mandibular BSSO set-back and an increase of hypopnoea periods during sleep, which may be a sign of possible risk. SAP, ME and mandibular advancement seem to have a positive effect on the ventilation parameters during sleep, as we expected. This is a pilot study so the number of patients is small. There is a need for longer period of observation and possibly for a multi-centric study. Acknowledgement: The study was supported by grant NP,-8038/3 of the Czech Ministry of Health.
between the groups were compared. The results were compared with the current literature on this topic. Six of 42 patients who underwent isolated MS and 6 of 81 patients who underwent isolated MA completed and returned their questionnaire. Mean ESS for the study group (9.0) was significantly different than for the control group (4.8; P < 0.05). Mean years since surgery (14.5 and 12.7), age at surgery (27.0 and 25.3), and gender (4 males and 2 females each group) were not significantly different. The current report represents a long-term follow-up evaluation of patient 10 years or longer since surgery using a screening questionnaire. Patients who undergo MS for surgical correction of Class III skeletal malocclusion may develop signs and symptoms of OSAS as they age. Further study is needed to determine whether these patients would have developed OSAS without surgical correction and whether specific clinical markers (body mass index, neck circumference, degree of overjet, etc) can predict those at risk. Patients may be informed that adjunctive procedures may be needed later in life if OSAS symptoms develop.
[-0-~
FACIAL WIDTH OF SLEEP APNOEA PATIENTS
O. Yelegin, A. Goss, R. Antic, S. Krishnan. Royal Adelaide Hospital &
Adelaide Dental Hospital, Australia The study was undertaken to characterize the hard and soft tissue morphology of the upper airway of the South Australian sleep apnoea population with particular reference to the hard and soft tissue width. Patient's who are selected on medical grounds for an overnight sleep laboratory study in the Royal Adelaide Hospital formed the basis of the study. Patient's with OSA proven by overnight sleep study were included. A series of 100 consecutive patients were included into the study. Sleep apnoea have a number of hard and soft tissue varations of their head and neck, involving their upper airway. Some variations are also seen in the coronal plane with narowness of the maxilla and nose with soft tissue enlargement of the turbinates and tonsils. These changs can be demonstrated by lateral and PA head cephalograms. Published studies show marked variation in incidence of these features in the different sleep apnoea populations. This study demonstrates that there is similar variations in the incidence of these features in the South Australian Sleep Apnoea population. The data is still currently being analsyed. The conclusion will be made once the results are fully available. This should be well before the conference. References [1] Cistulli PA et al. Maxillary morphology in obstructive sleep apnoea syndrome. E J Orthodontics. 2001; 23:703-714. [2] Guilleminault C, Partinen M, Hollman K et al. Familial aggregates in OSA syndrome. Chest 1995; 107: 1545-51.
I-0-~-~
MULTI POINT ELECTRODE VERSUS INDIVIDUAL MOUTH FLOOR ELECTRODE FOR ELECTROMYOSTIMULATION THERAPY IN OBSTRUCTIVE SLEEP APNEA
A. Ludwig. Department of Cranio-Maxillofacial Surgery, University of
Goettingen, Germany [-0-'~-'~ OBSTRUCTIVE SLEEP APNOEA FOLLOWING ORTHOGNATHIC SURGERY: 10-YEAR FOLLOW UP M. Baltensperger 1, R. Lebeda 1,2, R. Alcalde 2, D. Bloomquist 2. 1Center
for Jaw Surgery, Winterthur/Zurich, Switzerland; 2Dept. of OMFS, University of Washington, Seattle, USA The increased incidence of Obstructive sleep apnea syndrome (OSAS) following mandibular setback (MS) has been reported in the immediate postoperative period. However, contrary results have also been described, showing onset of latent OSAS after a several year period without symptoms in patients who underwent MS. The purpose of this paper is to compare the Eppworth Sleepiness Scores (ESS) in patients who underwent mandibular setback at least 10 years ago and ESS in a control group to see whether their surgery increased their risk for airway obstruction. Surgical records were reviewed retrospectively identifying a total of 240 patients who underwent Orthognathic surgery for Class III skeletal malocclusion prior to 1994. Those who underwent isolated mandibular setback (MS; study group) or isolated maxillary advancement (MA; control group) were sent a copy of the ESS and asked to answer for themselves. Returned completed surveys were included in the study. Mean ESS, years since surgery, age at surgery, and gender differences
During the last years, innovative muscle stimulation techniques have became alternatives for therapy of OSAS breathing disorders. In this study, it therefore was of interest whether optimized intraoral electrodes had influence on efficiency of the EMS-therapy. In group l an individually shaped mouth floor electrode (IME) and in group II an also individually adaptable multi point silicon electrode (MPE) have been used for electromyostimulation therapy in patients with obstructive sleep apnea. The enoral-cutaneous EMS was carried out with the low frequency stimulation apparatus I-pulse over a period of eight weeks, two times daily for thirty minutes during daytime hours, only. The stimulation intensity in both groups could individually be influenced by the patient himself. For achievement of an efficient recruitment of the muscles, patients were instructed to choose treatment with maximum intensity. Before and after stimulation treatment 3D-volumetric sonographical measurement of the geniohyoid muscle has been carried out by B-scan sonography in combination with a 3D-workstation. All patients (n = 14, average age 52.1 years) totally applied the EMS-therapy. As well under IME as under MPE application after four weeks of EMS-therapy a volume increase in median of 19.6% (minimum 9.5%, maximum 27.6%) was registered, the median after eight weeks IME was 27.6% and in MPE 24%). No significant difference (ANOVA type: p<0.05) between both electrodes
64
033. Sleep Apnoea
[O•]
CHANGING OF VENTILATION PARAMETERS DURING SLEEP AFTER ORTHOGNATHIC SURGERY - A PILOT LIMITED SLEEP STUDY
R. Foltan 1 , F. Donev 1 , J. Hoffmannova 1 , M. VIk 1 , M. Pretl 2, R. Kufa 3
1Dep. Oral & Maxillofacial Surgery, 1st Medical Faculty Hospital of Charles University, Czech Republic, Prague; 2Dep. of Neurology, 1st Medical Faculty Hospital of Charles University, Czech Republic, Prague; 3Dep. of Plastic Surgery, 2nd Medical Faculty Hospital of Charles University, Czech Republic The obstructive sleep apnea syndrome is often associated with narrowing of the upper airways. Orthognathic surgery is changing the position of the jaws in relation not only to each other but also to the cervical spine. There is a risk of narrowing of the upper airway, especially in the mandibular setbacks. Direct scientific proof of the risk of orthognathic surgery causing obstructive sleep apnea is still missing. Only polysomnographic sleep study measurements may prove these risks. We designed a prospective pilot study with 3 groups of 6 patients each (3 male, 3 female). The 1st st group of patients (aged average 18.6, range 17.3-22) underwent treatment of their class III skeletal malocclusion by mandibular BSSO set back and Le Fort I maxillary advancement. The 2nd group were patients (aged average 17.2, range 16.4-21.2)with class II malocclusion treated only by mandibular advancement. The 3rd group are patients (aged average 15.7, range 15.5-19.1) who needed a surgically assisted rapid maxillary expansion (SARME) because of bilateral cross bite. We measure parameters such as air flow, P,DI, ODI, snoring, micro-arousal, P 02, ECG, position of the body. The 1st measurement was done before surgery and the second measurement after a certain period (average 6.5 month, ranging from 5.35 to 8.65) at the time of P,IF plate removal. We correlated the results with the type of operation and the size of movements. In the 1st group there was a statistically significant increase in ODI (2.6 to 6.25, p 0.005) and there seems to be a positive correlation with the size of mandibular set-back. The 2nd group of patients showed a statistically significant improvement in almost all polygraphic parameters, but we didn't found any correlation with the size of the movement. SAP, ME also shows improvement in all polygraphic parameters, but they aren't statistically significant. Our results indicate that there is a positive correlation between a bi-maxillary surgery of class III malocclusion with mandibular BSSO set-back and an increase of hypopnoea periods during sleep, which may be a sign of possible risk. SAP, ME and mandibular advancement seem to have a positive effect on the ventilation parameters during sleep, as we expected. This is a pilot study so the number of patients is small. There is a need for longer period of observation and possibly for a multi-centric study. Acknowledgement: The study was supported by grant NP,-8038/3 of the Czech Ministry of Health.
between the groups were compared. The results were compared with the current literature on this topic. Six of 42 patients who underwent isolated MS and 6 of 81 patients who underwent isolated MA completed and returned their questionnaire. Mean ESS for the study group (9.0) was significantly different than for the control group (4.8; P < 0.05). Mean years since surgery (14.5 and 12.7), age at surgery (27.0 and 25.3), and gender (4 males and 2 females each group) were not significantly different. The current report represents a long-term follow-up evaluation of patient 10 years or longer since surgery using a screening questionnaire. Patients who undergo MS for surgical correction of Class III skeletal malocclusion may develop signs and symptoms of OSAS as they age. Further study is needed to determine whether these patients would have developed OSAS without surgical correction and whether specific clinical markers (body mass index, neck circumference, degree of overjet, etc) can predict those at risk. Patients may be informed that adjunctive procedures may be needed later in life if OSAS symptoms develop.
[-0-~
FACIAL WIDTH OF SLEEP APNOEA PATIENTS
O. Yelegin, A. Goss, R. Antic, S. Krishnan. Royal Adelaide Hospital &
Adelaide Dental Hospital, Australia The study was undertaken to characterize the hard and soft tissue morphology of the upper airway of the South Australian sleep apnoea population with particular reference to the hard and soft tissue width. Patient's who are selected on medical grounds for an overnight sleep laboratory study in the Royal Adelaide Hospital formed the basis of the study. Patient's with OSA proven by overnight sleep study were included. A series of 100 consecutive patients were included into the study. Sleep apnoea have a number of hard and soft tissue varations of their head and neck, involving their upper airway. Some variations are also seen in the coronal plane with narowness of the maxilla and nose with soft tissue enlargement of the turbinates and tonsils. These changs can be demonstrated by lateral and PA head cephalograms. Published studies show marked variation in incidence of these features in the different sleep apnoea populations. This study demonstrates that there is similar variations in the incidence of these features in the South Australian Sleep Apnoea population. The data is still currently being analsyed. The conclusion will be made once the results are fully available. This should be well before the conference. References [1] Cistulli PA et al. Maxillary morphology in obstructive sleep apnoea syndrome. E J Orthodontics. 2001; 23:703-714. [2] Guilleminault C, Partinen M, Hollman K et al. Familial aggregates in OSA syndrome. Chest 1995; 107: 1545-51.
I-0-~-~
MULTI POINT ELECTRODE VERSUS INDIVIDUAL MOUTH FLOOR ELECTRODE FOR ELECTROMYOSTIMULATION THERAPY IN OBSTRUCTIVE SLEEP APNEA
A. Ludwig. Department of Cranio-Maxillofacial Surgery, University of
Goettingen, Germany [-0-'~-'~ OBSTRUCTIVE SLEEP APNOEA FOLLOWING ORTHOGNATHIC SURGERY: 10-YEAR FOLLOW UP M. Baltensperger 1, R. Lebeda 1,2, R. Alcalde 2, D. Bloomquist 2. 1Center
for Jaw Surgery, Winterthur/Zurich, Switzerland; 2Dept. of OMFS, University of Washington, Seattle, USA The increased incidence of Obstructive sleep apnea syndrome (OSAS) following mandibular setback (MS) has been reported in the immediate postoperative period. However, contrary results have also been described, showing onset of latent OSAS after a several year period without symptoms in patients who underwent MS. The purpose of this paper is to compare the Eppworth Sleepiness Scores (ESS) in patients who underwent mandibular setback at least 10 years ago and ESS in a control group to see whether their surgery increased their risk for airway obstruction. Surgical records were reviewed retrospectively identifying a total of 240 patients who underwent Orthognathic surgery for Class III skeletal malocclusion prior to 1994. Those who underwent isolated mandibular setback (MS; study group) or isolated maxillary advancement (MA; control group) were sent a copy of the ESS and asked to answer for themselves. Returned completed surveys were included in the study. Mean ESS, years since surgery, age at surgery, and gender differences
During the last years, innovative muscle stimulation techniques have became alternatives for therapy of OSAS breathing disorders. In this study, it therefore was of interest whether optimized intraoral electrodes had influence on efficiency of the EMS-therapy. In group l an individually shaped mouth floor electrode (IME) and in group II an also individually adaptable multi point silicon electrode (MPE) have been used for electromyostimulation therapy in patients with obstructive sleep apnea. The enoral-cutaneous EMS was carried out with the low frequency stimulation apparatus I-pulse over a period of eight weeks, two times daily for thirty minutes during daytime hours, only. The stimulation intensity in both groups could individually be influenced by the patient himself. For achievement of an efficient recruitment of the muscles, patients were instructed to choose treatment with maximum intensity. Before and after stimulation treatment 3D-volumetric sonographical measurement of the geniohyoid muscle has been carried out by B-scan sonography in combination with a 3D-workstation. All patients (n = 14, average age 52.1 years) totally applied the EMS-therapy. As well under IME as under MPE application after four weeks of EMS-therapy a volume increase in median of 19.6% (minimum 9.5%, maximum 27.6%) was registered, the median after eight weeks IME was 27.6% and in MPE 24%). No significant difference (ANOVA type: p<0.05) between both electrodes