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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
Miniscrew-Assisted Maxillary Expansion Techniques forTreatment ofObstructive Sleep Apnea
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Implant Location
Measurement
11.9mm 4.7mm5.8mm
Red – 10mm Screws
Blue – 12mm Screws
12.3mm
. Fig. 20.5 DOME virtual planning. Using 3-D technology, custom- fabricated miniscrew-assisted maxillary expander is designed and ideal
sites and length of miniscrews are identied to achieve optimal results and minimize side effects and failure for OSA
lary expansion should be achieved to resolve obstructive
sleep apnea medical conditions. Once the planned
expansion is completed, orthodontic treatment is initiated to close the existing diastema and expand lower
the orthodontist guides the teeth into proper position to
correct the occlusion. Longer consolidation period with
the device in place increases greater long-term stability
of the skeletal expansion.
arch to achieve normal occlusion.
20.4.5 Determining theAmount
20.4.4 Consolidation Phase
Typically, the consolidation phase is 3 months [15, 17,
18] for typical craniofacial distraction osteogenesis, but
the ideal recommended consolidation period is
6–8months in order to allow maximal bone ll and minimize relapse. The miniscrew-assisted rapid palatal
expander technique does not interfere with tooth movement and allows the expander to remain in place while
Dening the amount of necessary skeletal expansion
for improvement of OSA has not yet established.
Typical orthodontic measurements are based on arch
width differences between maxillary and mandibular
intermolar width. However, in order to achieve the
greatest possible skeletal maxillary expansion for OSA
improvement, the most important areas of consider-
ofExpansion
300
A. J.-S. Yoon et al.
20
. Fig. 20.6 Limited Le-Fort I and mid-sagittal split without down- fracture. (Courtesy of Dr. Stanley Liu)
ation are the width of nasal oor and palatal oor.
Depending on location of screws and application of
forces, dentoalveolar response and teeth angulation
changes after expansion are quite different than con-
alveolar bone needs to be calculated for both maxillary
and mandibular dentition. In some cases, uprighting of
the lower posterior teeth rst (i.e., mandibular dental
decompensation) can be helpful.
ventional tooth-anchored expander. For example, if
you use only miniscrews on oor of palate close to midpalatal sutures, palatal crown tipping of molars will
20.4.6 Retention andRelapse
occur after expansion, which is the opposite phenomenon to tooth-anchored maxillary expander. Therefore,
the design of expander, location of screws, and basal
bone width and angulation all need to be considered.
The orthodontist needs to evaluate the skeletal and
Following the active phase of any expansion, a retainer
is needed even after bone ll seems complete. The expan-
sion must be maintained passively by xed or removable
appliance to aid in transverse retention.
dental relationships in the transverse plane using dental casts and/or coronal cross-section views of 3-D
images.
20.5 Case Result ofDOME
In many cases of constricted maxilla, the compensated lower teeth are more lingually inclined, camouaging the maxillary constriction. Uprighting the posterior
teeth to a normal inclination over the supporting basal
. Figures 20.7, 20.8, 20.9, and 20.10 illustrate pre-
DOME and post-DOME results. For most patients
using a proper DOME technique, 8–9mm expansion of
ab
cd
Miniscrew-Assisted Maxillary Expansion Techniques forTreatment ofObstructive Sleep Apnea
301
20
e f
. Fig. 20.7 Pre-DOME (left) and post-DOME (right). a Pre-
DOME occlusal view. b Post-DOME occlusal view. 14mm diastema
presented after 9mm of jackscrew expansion. c Pre-DOME frontal
view d Post-DOME frontal view. Note 14mm diastema e Pre-DOME
transverse view of palate of CBCT f) Post-DOME transverse view
of palate of CBCT.Note 12mm expansion at anterior nasal spine,
4.5mm expansion at posterior nasal spine after 9mm of transpalatal
expansion at jackscrew level
the appliance jackscrew equates to approximately
10–14 mm dental diastema present. This patient presented 14 mm diastema, 12 mm expansion at anterior
nasal spine, 4.5mm expansion at posterior nasal spine,
and 8 mm expansion on nasal oor after 9 mm of
transpalatal expansion at jackscrew level. Internasal
width, intermolar width, and internal nasal valve are all
signicantly increased after DOME. This patient’s
Apnea Hypopnea Index dropped from 13.8 to 4, Nasal
Obstruction Symptom Evaluation Scale dropped from
17 to 3, and Epworth Sleepiness Scale improved from 23
to 6 after DOME procedure.
20.6 Discussion
There are many studies that show maxillary expansion
as an effective treatment modality for OSA in children
[5, 6, 19]; however, there are very limited published data
available for adult OSA population [20].
302
A. J.-S. Yoon et al.
20
. Fig. 20.8 Pre-DOME (left) and post-DOME (right): coronal view at nasopalatine canal level. Nasal oor was expanded 8mm and nasal
cavity became more patent after expansion
. Fig. 20.9 Pre-DOME (left) and post-DOME (right): coronal view at palatal cusp of rst molar level. Nasal oor was expanded 6mm and
nasal cavity become more patent after expansion
Miniscrew-Assisted Maxillary Expansion Techniques forTreatment ofObstructive Sleep Apnea
. Fig. 20.10 Pre-DOME (left) and post-DOME (right): 3-D surface rendering from CBCT
303
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Orthodontic miniscrews, which are used for absolute
orthodontic anchorage, have been incorporated into
bone-anchored maxillary expander designs (i.e., xed
maxillary expander attached directly to palatal bone
using miniscrews) and clinical research has attempted to
validate the theory that direct transfer of expansion
energy to the palatal bone should result in greater skeletal expansion rather than alveolar bone bending [9].
Miniscrew-assisted palatal expanders allow for greater
physiologic suture expansion, reduces negative dentoalveolar effects, achieves the maximum nasal and oral cavity volume compared to conventional RME [9, 10], and
contribute to more predictable stable management of
OSA.Recently, randomized-controlled trial showed that
signicantly higher post-expansion nasal airow values
for bone-anchored maxillary expander (hybrid type,
average age 10.2years) compared with tooth- anchored
expander (average age 9.7years) [21]. Many studies have
demonstrated that miniscrew-assisted maxillary expander
can be a better treatment option than conventional
tooth-anchored maxillary expander for increasing skeletal expansion and airway volume without osteotomy but
these patient’s age were mostly for late teenagers [22] and
has not been studied yet in the OSA patient pool.
The separation of sutures using DOME becomes
much more predictable and reliable in adult OSA
patients, thus the author advocates the continued augmentation of minimal osteotomy during maxillary
expansion using miniscrew-assisted RME appliances for
older population of OSA. It still remains to be determined whether mandibular expansion is possible
although there are some individual case reports [23].
Skeleton-borne maxillary expansion using palatal miniscrews offers a new treatment alternative for a multidisciplinary approach to adult sleep apnea syndrome.
References
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7. Persson M, Thilander B.Palatal suture closure in man from 15
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HS.Comparison of transverse changes during maxillary expansion with 4-point bone-borne and tooth-borne maxillary expanders. Am J Orthod Dentofac Orthoped. 2015;148(4):599–607.
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14. Landes CA, Laudemann K, Schubel F, etal. Comparison of
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segmental inclination, dental tipping, and vestibular bone
resorption. J Craniofac Surg. 2009;20(4):1132–41.
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B.Transpalatal distraction using bone-borne distractor: clinical
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C.Craniofacial distraction osteogenesis: a review of the literature: part 1: clinical studies. Int J Oral Maxillofac Surg.
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FV. Effects of surgically assisted rapid maxillary expansion on
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21. Bazargani F, Magnuson A, Ludwig B.Effects on nasal airow
and resistance using two different RME appliances: a randomized controlled trial. Eur J Orthod. 2017;
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Orthognathic Surgical
Considerations forObstructive
Sleep Apnea
Yong-IlKim, KiBeomKim, andRezaMovahed
Contents
21.1 Assessment ofthePosterior Airway Space – 306
21.2 Visualization oftheAirway Space forVolumetric
Analysis–309
21.3 Airway Space Change andStability Related toOrthognathic
Surgery – 309
21.3.1 Mandibular Setback andBimaxillary Surgery – 309
21.3.2 Vertical Movement oftheMaxillomandibular Complex – 314
21.3.3 Maxillomandibular Setback – 316
21.3.4 Maxillomandibular Advancement (MMA) – 317
21
References – 319
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_21
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21
In 1978, Bell and Epker [1] recognized that preoperative orthodontic treatment helps improve the outcome
of orthognathic surgery. Bell etal. [2, 3], Epker and Fish
[4], and Prott and White [5] all concluded improved
stability and outcomes could be achieved via close
cooperation between maxillofacial surgeons and orthodontists. Although orthognathic surgery was initially
conned to the treatment of sagittal discrepancy before
1975, its scope gradually widened thereafter to include
treatment of transverse discrepancy and various forms
of skeletal discrepancies. In the 1990s, rigid xation was
generally used to achieve precise surgical results and to
reduce patient discomfort (e.g., typically 6–8weeks of
intermaxillary xation characterized by a liquid diet,
the inability to brush teeth, and reported psychological
complaints similar to claustrophobia).
In 1985, Wolford et al. [6] published the Surgical
Treatment Objective (STO), which predicted outcome
of orthognathic surgery. Prott etal. [7, 8] constructed
a treatment plan based on a hierarchy of stability of
outcomes of orthognathic surgical procedures, rendering it possible to obtain a more stable outcome [9,
10]. In patients with severe skeletal discrepancy, skel-
etal improvements result in an improved aesthetic outcome with better functionality and stability. Prior to the
advent of orthognathic surgery, practitioners attempted
to resolve malocclusion using a compensatory treatment; however, the patient and the practitioner were
less satised with the treatment outcome because of
suboptimal aesthetic improvements. With the development of orthognathic surgical methods, it is possible to
overcome the limitations of compensatory treatment
and relatively easier to eliminate skeletal discrepancies.
However, orthognathic surgery signicantly changes the
anteroposterior or vertical position of the maxilla or the
mandible. This skeletal modication inevitably induces
alterations in the soft tissue that may lead to changes in
the upper airway space.
In the early 1950s, Drs. King [11] and Brodie [12] separately reported that the nasopharynx’s anteroposterior
size is nearly fully formed in the rst and second years
of life. In 1976, Handelman and Osborne [13] suggested
the growth of the nasopharynx is complete at 18years
of age, but noted growth patterns differ according to sex.
In adults, structural changes do not occur in the upper
airway space after maturation and there is no structural
change in the airway space except for specic pathological conditions or a long-term aging effect [14, 15].
Clinicians should consider these inevitable changes in the
airway space when performing orthognathic surgery [16].
It is well known that the upper airway space and skeletal movement of the maxilla and mandible interact closely
with each other [17]. Therefore, orthognathic surgery,
including maxillomandibular advancement (MMA), is
one of the effective treatments for obstructive sleep apnea
(OSA) in severe skeletal Class II patients with sleep apnea.
MMA is a relatively straightforward intervention for
Caucasian patients who have a large nose and a retruded
mandible, whereas the procedure is more difcult to perform for Asian patients who have a small nose and at
facial prole. Because orthognathic surgery improves the
upper airway space and causes aesthetic changes, both
race and facial pattern need to be considered.
It is also important to note that positional changes
of the hyoid bone and tongue in concert with mandibular movement are also closely related to the spatial
change in the upper airway [18, 19]. The upper airway
space includes the nasal and oral cavity and consists of
the nasopharynx, the posterior region of the nose, posterosuperior region of the soft palate, oropharynx, posterior region of the mouth and mandible, hypopharynx,
and the third and fourth cervical vertebrae regions. The
upper airway space is surrounded by hard tissues such as
the maxilla, mandible, palatine bone, vomer, and cervical vertebrae. The muscles consist of the tongue and soft
palate. The mucosa originates from the oral, nasal, and
laryngopharyngeal cavity.
In mandibular prognathism and a skeletal class
III malocclusion, mandibular setback is performed to
resolve the skeletal discrepancy. However, space reduction may cause snoring and OSA in some patients [20].
In most studies that report change in the upper
airway after mandibular setback, results consistently
demonstrate that the upper airway space is reduced
immediately after surgery. However, it remains controversial whether the reduced space recovers due to physiological adaptation [21, 22], remains reduced after the
surgery [23–27], or continues to decline when observed
after a certain period of time [28, 29].
Because orthognathic surgery inevitably changes
the position of the skeleton, more accurate and stable
results should be obtained by accurately analyzing functional characteristics of the upper airway space, soft
palate, uvula, the position of the hyoid bone, as well as
achieving the aesthetic goal set forth in planning [9].
21.1 Assessment ofthePosterior Airway
Space
Because the upper airway space cannot be directly visualized, it can be challenging to evaluate. Various imaging
modalities have been used to evaluate the upper airway
space, peripheral soft tissues, and skeletal structure, such
as acoustic rhinometry, uoroscopy, nasopharyngoscopy, magnetic resonance imaging (MRI), cephalometry, and tomography, among others [30]. Each method
has its inherent advantages and disadvantages; thus, the
selected method of imaging should be based on the goal
of the assessment.
Orthognathic Surgical Considerations forObstructive Sleep Apnea
307
21
. Fig. 21.1 Comparison of the lateral cephalogram and cephalogram extracted from cone beam computed tomography
The results from cephalometric radiography are
commonly used as data for establishing the orthodontic treatment plan, whereas most studies of the upper
airway employ cephalometric measurements. However,
cephalometric radiography is obtained by projecting
a three-dimensional (3D) structure in two dimensions
(2D) and presents a disadvantage in accurately elucidating size and complexity of the upper airway. Various
imaging modalities have been used to evaluate the upper
airway space, peripheral soft tissues, and skeletal structure, such as acoustic rhinometry, uoroscopy, nasopharyngoscopy, magnetic resonance imaging (MRI),
cephalometry, and tomography, among others [30].
Each method has inherent advantages and disadvantages and the selection of imaging modality should be
based on the goal of the analysis.
Cone-beam computed tomography (CBCT) has
recently been used widely and can acquire the 3D volumes of all structures in the maxillofacial complexes.
The 3D volume data can be reconstructed into a more
detailed image by converting it into a multiplanar reconstruction image using commercially available 3D imaging software, which facilitates measurements of not only
the soft tissue and the upper airway space, but also the
skeletal structure, all in 3D [24].
The 3D raw image data reconstruction allows visualization of a multilayered cross-section, and this 2D
image of the pharynx can be evaluated in all directions
(most common of which are sagittal, coronal, and axial;
see . Fig.21.1). Various commercially available imaging software programs are capable of observing the
upper airway space from various angles. Unlike hard
and soft tissues, the void space of the upper airway
allows for a sharper and clearer spatial analysis. Specic
tools can be used to distinguish tissues of different densities. Software capable of using transparency allows
observation of the hard tissue covered by the soft tissues. A linear measurement tool is also available, allowing measurement of height, width, and depth of the
entire pharynx (.
Owing to variation in the conditions at the time of
image acquisition, images obtained from the CBCT are
not always acquired using a consistent head position.
Therefore, the patient’s 3D image needs to be realigned
with the reference plane to facilitate image analysis (a
process similar to that in lateral cephalometric image
analysis). This means the Frankfort horizontal plane
should be parallel to the axial plane and the midsagittal plane should coincide with the patient’s midline,
and, in the same way, the coronal plane should contact
the lower margins of the orbit (. Figs.21.3 and 21.4).
If an asymmetry is detected, the reorientation process
should be carefully performed. This virtual position
allows for appropriate head rotation, which helps to
Fig.21.2).
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Y.-I. Kim et al.
. Fig. 21.2 3D image to multiplanar reconstruction image
21
. Fig. 21.3 Establish the boundaries for pharyngeal airway
ensure that structures present bilaterally correspond
with each other [31].
To accurately compare and analyze the airway space
before and after treatment, the head posture of the
CBCT should be reconstructed with reproducibility, and
the upper airway space needs to be evaluated in each section using a tool for evaluating the airway space. Because
CBCT provides information in 3D, clinicians may effectively evaluate the airway space and surrounding structures and analyze the narrowest areas and volume of the