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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
330
S. O. Hong et al.
b
between two
two groups
between two
groups
groups
p-value
b
p-value
b
p-value
a
Comparison of
∆T1−T2
Comparison
of T2 between
of T1
SD
T1 T2 p-value
a
22
SD mean SD mean SD mean
Group 1 (conventional MMA) Group 2 (modied MMA) Comparison
. Table 22.3 Comparison of the polysomnogram (PSG) results and cephalometric measurements between modied MMA and MMA
T1 T2 p-value
mean
2
) 21.3 2.0 21.3 2.8 1.000 21.9 2.5 21.6 1.2 0.715 1.0000 1.0000 1.0000
PSG results BMI (kg/m
AHI (n/h) 44.9 6.0 7.6 5.6 0.068 35.8 28.7 5.7 2.2 0.068 1.0000 1.0000 1.0000
RDI (n/h) 50.7 6.8 11.0 7.4 0.109 41.6 25.5 10.8 4.5 0.068 1.0000 1.0000 0.629
LSAT (%) 84.5 4.9 88.3 5.5 0.066 86.8 4.8 91.5 1.0 0.066 0.4860 0.2000 0.886
78.5 3.5 82.5 3.1 0.068 81.0 5.3 80.8 4.1 0.715 0.4860 0.6860 0.057
SNA
Cephalometric
71.9 1.7 76.4 2.6 0.068 76.7 4.9 77.6 4.3 0.144 0.2000 1.0000 0.029*
38.6 10.7 36.5 11.6 0.144 30.1 5.5 28.8 5.0 0.465 0.3430 0.3430 0.686
(81.43°±3.10°)
SNB
(79.48°±2.85°)
FMA
measurements
(Korean
norm)
102.9 4.4 104.1 3.7 0.465 110.5 7.5 104.4 7.8 0.144 0.2000 1.0000 0.114
102.6 8.1 98.9 12.9 0.465 90.2 8.1 88.2 9.5 0.144 0.1140 0.3430 0.343
(22.51°±3.80°)
U1 to FH
(116.0° ±5.60°)
Nasolabial angle
(91.11°±8.12°)
, SNA sella to nasion to subspinale, SNB angle from sella to nasion to supramentale, Nasolabial angle angle formed by the columella-subnasale-labrale superioris, U1 to FH angle of
2
the maxillary incisor inclination to Frankfort horizontal line (FH), FMA Frankfort mandibular plane angle
SD standard deviation, MMA maxillomandibular advancement, BMI body mass index, AHI apnea–hypopnea index, RDI respiratory disturbance index, LSAT lowest saturation rate of
O
p<0.05aWilcoxon signed ranks test was performed
*
Mann-Whitney test was performed
b
Individualized Treatment Planning for OSAS
a
b
331
22
. Fig. 22.3 Case 1 (patient number #2) treated with conventional
maxillomandibular advancement (con-MMA), which consisted of
Le Fort I osteotomy with counterclockwise rotation of the maxilla,
sagittal position of the mandible (SNB, 76.7 to 77.6°,
. Table22.3).
In summary, patients with relatively retrusive maxilla, obtuse nasolabial angle, and normal maxillary incisor inclination can be treated with con-MMA procedure.
However, patients with relatively forward positioned
maxilla, acute nasolabial angle, and labioversed maxillary incisors can be treated with seg-MMA procedure.
22.4 Cases
22.4.1 Case 1 (Patient #2): Con-MMA
Procedure withCounterclockwise
Rotation andGA
A nonobese OSAS patient (23-year-old male; BMI,
23.7; . Table22.2) was referred from the ENT department for MMA surgery. The results of initial PSG
showed severe OSAS (AHI, 42.9 events/hour; RDI, 42.9
events/hour, . Table 22.2). He had skeletal Class II
facial pattern, relatively large nose, 3.5mm overjet, and
3.0mm maxillary incisal showing at the resting position
bilateral sagittal split ramus osteotomy (BSSRO), and genioglossus
advancement. a Initial status, b after con-MMA
Fig. 22.3 and . Table22.2). Lateral cephalogram
(.
showed a hyperdivergent facial pattern, retrusive maxilla and mandible, and obtuse nasolabial angle (FMA,
42.1°; SNA, 75.6°, SNB, 69.9°; NLA, 105.4°; . Fig.22.3
and . Table22.2).
Con-MMA procedure with counterclockwise rotation of the maxilla to improve the steep occlusal plane
[Le Fort I osteotomy (anterior impaction: 3mm, posterior impaction: 0 mm, maxillary advancement, 7 mm)
and BSSRO advancement of the mandible (mandibular
advancement, 8mm)] was planned (.
Table22.1). The
amount of maxillary advancement was determined by
allowing the maxilla to stay in the normal range of
cephalic measurements. In addition, 5.0 mm GA was
performed to maximize improvement of the OSAS
parameters and chin projection (. Table 22.1 and
. Fig.22.3).
There was signicant improvement in the OSAS
parameters (AHI, 42.9 to 5.5 events/hour; RDI, 42.9 to
16.6 events/hour, . Table 22.2). Cephalometric measurement also showed signicant increase in SNA (75.6
to 81.1°) and SNB (69.9 to 76.4°) and decrease in nasolabial angle (105.4 to 98.2°) (. Fig.22.3 and . Table22.2).
332
S. O. Hong et al.
22.4.2 Case 2 (Patient #5): Seg-MMA
Procedure
A nonobese patient (40-year-old male; BMI, 18.9;
. Table 22.2) was referred for OSAS treatment.
Although nCPAP therapy was initially tried, the patient
could not tolerate it. The initial PSG results showed
severe OSAS (AHI, 60 events/hour; RDI, 61 events/hour;
LSAT, 80%, . Table22.2). He had labioversed maxillary
and mandible anterior teeth, skeletal Class II facial pattern, 1mm maxillary incisor showing, and 2.5mm overjet (. Fig. 22.4 and . Table 22.2). Cephalometric
measurement showed a relatively normodivergent facial
pattern, protrusive maxilla and mandible, and slight
obtuse nasolabial angle (FMA, 27.7°; SNA, 85.7°; SNB,
82.1°; NLA, 98.8°; . Fig.22.4 and . Table22.2).
Excessive maxillomandibular advancement in this
patient would lead to bimaxillary protrusion and/or
labioversion of the maxillary and mandibular incisors,
resulting in unfavorable facial esthetics. Therefore, segMMA procedure without counterclockwise rotation
was planned to maintain the original sagittal position of
the anterior parts of maxilla and mandible. After the
dental arches were aligned with presurgical orthodontic
treatment (3months), the posterior segment of the maxilla was advanced 6mm to close the extraction space of
the maxillary rst premolars (.
Table22.1). The ante-
rior segment of the mandible was moved backward to
close the extraction space of the mandibular rst premolars and the total mandible was advanced 4.5 mm
(. Table 22.1). The CAD-CAM made condylar jigs
were used to position the condylar segments in a stable
position when xating the plates and screws. The osteotomized segments were xed by ligating stainless steel
wires onto the brackets of the adjacent teeth.
There was signicant improvement of OSAS param-
eters (AHI, 60 to 6 events/hour; RDI, 61 to 11 events/
hour; LSAT, 80 to 92%, . Table22.2) without signicant change in cephalometric measurement (SNA, 85.7
to 84.7°; SNB, 82.1 to 82.9°; nasolabial angle, 98.8 to
99°; . Fig.22.4 and . Table22.2).
22.4.3 Case 3 (Patient #7): Seg-MMA
Procedure withCounterclockwise
Rotation
A nonobese patient (21-year-old male; BMI, 21.1;
. Table22.2) was referred due to the chief complaint of
OSAS.The initial PSG results showed mild-to-moderate
OSAS (AHI, 14.2 events/hour; RDI, 28.9 events/hour;
LSAT, 87%, . Table 22.2). He had normal maxillary
incisal inclination, labioversed mandible anterior teeth,
skeletal Class II facial pattern, large nose, short chin
22
a
b
. Fig. 22.4 Case 2 (patient number 5) treated with modied MMA
with segmental osteotomy (seg-MMA), which consisted of extraction of #14, #24, #34, #44, Le Fort I osteotomy and advancement
of the posterior segment of the maxilla, and anterior segmental osteotomy and total advancement of the mandible. a Initial status, b
after con-MMA
Individualized Treatment Planning for OSAS
a
b
333
22
. Fig. 22.5 Case 3 (patient number 7) treated with seg-MMA,
which consisted of extraction of #14, #24, #34, #44, Le Fort I osteotomy with advancement of the posterior segment and counter-
length, gummy smile, 2mm maxillary incisor showing,
and 3.5 mm overjet (. Fig. 22.5 and . Table 22.2).
Cephalometric measurement showed a slight vertical
pattern, retrusive maxilla and mandible, and normal
nasolabial angle (FMA, 32.8°; SNA, 78.5°; SNB, 73.6°;
NLA, 94.0°; . Fig.22.5 and . Table22.2).
Although he had a retrusive maxilla, he refused to
undergo advancement of the maxilla. Therefore, segMMA procedure with counterclockwise rotation was
planned to minimally advance the anterior part of the
maxilla and increase the amount of mandibular
advancement. After the dental arches were minimally
aligned with presurgical orthodontic treatment (half
months), the posterior segment of the maxilla was
advanced 9mm to close the extraction space of the maxillary rst premolars and the maxilla was impacted
(anterior, 2mm; post, 1.5mm; .
Table22.1). The ante-
rior segment of the mandible was moved backward to
close the extraction space of the mandibular rst premolars and the total mandible was advanced 10.5 mm
(. Table 22.1). The CAD-CAM made condylar jigs
were used to position the condylar segments in a stable
clockwise rotation of the maxilla, and anterior segmental osteotomy
and total advancement of the mandible. a Initial status, b after conMMA.Note the change in the upper airway space (arrow)
position when xating the plates and screws. The osteotomized segments were xed by ligating stainless steel
wires onto the brackets of the adjacent teeth.
The OSAS parameters showed signicant improve-
ment (AHI, 14.2 to 7.9 events/hour; RDI, 29 to 8.3
events/hour, . Table 22.2). Although cephalometric
measurement did not show signicant change in SNA
(78.5 to 79.2°), SNB (82.2 to 82.9°), and nasolabial angle
(98.8 to 99°) (. Fig.22.5 and . Table22.2), there was
a signicant enlargement of the posterior airway space
Fig.22.5).
(.
22.5 Discussion
Caucasians usually have a convex prole, obtuse nasolabial angle, and large nose with high dorsums. On the contrary, East Asians (i.e., Korean, Chinese, and Japanese)
have a tendency of protrusive lip, acute nasolabial angle,
and small nose with low dorsums. Con-MMA procedure
can improve facial esthetics in middle-aged obese OSAS
patients with convex prole and obtuse nasolabial angle,
334
S. O. Hong et al.
22
because large amount of advancement can somewhat
rejuvenate their face and give a younger looking impression [26]. However, 5–10mm advancement in young nonobese OSAS patients with protrusive maxilla and acute
nasolabial angle should be compromised for conserving
facial esthetics. Therefore, it is needed to set up proper
consensus on the surgical method and amount of
advancement for simultaneous improvement of the
OSAS parameters as well as facial esthetics.
When the amounts of change in the cephalometric
parameters were compared with the con-MMA group,
the seg-MMA group revealed marginally signicant
changes in SNA and signicant change in SNB
(∆SNA, 0.2° vs. 4°, P=0.057 and ∆SNB, 0.9° vs. 4.5°,
P < 0.05; . Table 22.3). In addition, patients who
underwent the seg-MMA procedure exhibited a tendency of close-to- normal values and a tendency of
relatively forward positioned maxilla and mandible
(SNA; 81.0° vs. 78.5°, Korean norm, 81.4°; and SNB;
76.7° vs. 71.9°, Korean norm, 79.5°), less hyperdivergency (FMA, 30.1° vs. 38.6°, Korean norm, 22.5°),
greater maxillary incisor inclination (110.5° vs. 102.9°,
Korean norm, 116.5°), and smaller nasolabial angle
(90.2° vs. 102.6°, Korean norm, 91.1°) (.
Table22.3).
These cephalometric ndings can be used a reference
for differential diagnosis between con-MMA and segMMA.
Since the seg-MMA procedure did not produce signicant differences in the amounts of change in the
cephalometric parameters (. Table 22.3), it can be
considered to produce minimal alteration of facial
esthetics by minimization of protrusion of the upper
lip or maxilla as well as effective enlargement of the
upper airway space and improvement of the OSAS
parameters.
Surgical treatment plan for adult OSAS patients
must be individualized to provide favorable changes in
the respiratory function and facial esthetics [2, 4]. An
individualized ow chart to plan the con-MMA or segMMA procedure, which is based on cephalometric analysis of the vertical and horizontal skeletal pattern,
denture pattern, and soft tissue prole, can be set up
using a step-by-step approach (. Fig.22.6).
5 Step 1. Evaluation of the TMJ status
If OSAS patients have skeletal Class II facial pattern
and show centric relation-centric occlusion (CR-CO)
discrepancy or degenerative TMJs, too much advancement of the mandible may cause TMJ overload and lead
to condylar resorption. In that case, since relapse is inevitable, the status of TMJ should be checked as the rst
step.
5 Step 2. Evaluation of the anteroposterior position of
the maxilla, upper lip, and nose
When evaluating the cephalometric parameters such
as SNA, A-N perpendicular, nasolabial angle, nose
height (projection), upper lip to Ricketts’ esthetic line,
and U1-FH, we have to look at the horizontal position of the maxilla, acuteness of the nasolabial angle,
and inclination of the maxillary incisors. If the conMMA procedure has a possibility of compromising
the facial esthetics, the seg-MMA procedure should
beconsidered.
5 Step 3. Evaluation of the vertical position of the
maxillary incisor and steepness of the maxillary
occlusal plane
If the amount of the maxillary incisor showing at the
resting position is excessive, impaction of the maxilla
can be considered. In skeletal Class II patients with
steep maxillary occlusal planes, allowing more impaction of the anterior part than the posterior part of the
maxilla can be an effective way to produce counterclockwise rotation of the maxilla and to increase the amount
of mandibular advancement.
5 Step 4. Evaluation of the anteroposterior position of
the mandible, lower lip, and chin
Once the maxillary position is set up, the mandible can be
positioned using SNB, Pog-N perpendicular, ANB, and
overbite/overjet. If the con-MMA procedure has a possibility of compromising the facial esthetics, the segMMA procedure should be considered. Arpornmaeklong
etal. [27] stated that patients with steep mandibular plane
angle and more than 10mm advancement of the mandible experienced signicant relapse due to remodeling
and/or resorption of the condyle. Therefore, reduction of
the amount of mandibular advancement and/or adjunctive treatment such as genioglossus advancement can be
performed to minimize TMJ overloading.
5 Step 5. Evaluation of the vertical height of the lower
1/3 of face
The lower 1/3 facial height should be in proportion with
the upper and mid 1/3facial height. If the lower 1/3 is
vertically excessive, adjunctive surgical methods such as
reduction genioplasty with or without GA can be
applied. However, we have to consider that impaction of
the maxilla and counterclockwise rotation of the mandible can also affect the amount of decrease in the vertical height of the lower 1/3.
Individualized Treatment Planning for OSAS
335
22
. Fig. 22.6 Individualized
owchart for surgical treatment
planning of con-MMA or
seg-MMA for Asian adult OSAS
patients
Step 1 Evaluation of TMJ
Degenerative change / CR-
CO discrepancy
* Consider the TMJ overloading and
pathologic resorption after excessive
mandible advancement.
Step 2
Upper lip, Max. incisor
Nose height / projection
Step 3
AP position of the Maxilla, Upper lip, Max. Incisor, and Nose
SNA, A-N perp,
Protrusive or
Nasolabial angle
Vertical position of the Max. incisor / Steepness of the Max. occl. plane
No
Yes
Retrusive
normal
obtuse
acute
high
low
Con-MMA or Seg-MMA
Tx. for TMJ disease
Adjunctive procedure
(Genioglossus Advancement)
Total advancement of the
maxilla using
Le Fort I osteotomy
Minimization of advancement of
the maxilla
using Le Fort I osteotomy and
Segmental osteomy with
advancement of post. segment
Max. incisor showing
at the resting position
* Consider the vertical dimension of the
anterior and posterior parts of maxilla.
Step 4
SNB, Pog-N perp,
ANB, APDI, Overjet, Lower
lip, and Chin
* Do not advance the mandible too much to
prevent TMJ overloding.
Step 5
AP position of the Mandible, Lower Lip and Chin
TMJ status
Vertical height of the Lower 1/3 (Mandible and Chin)
excessive
steepMaxillary Occlusal plane
Retrusive
Protrusive or
normal
DJD etc.
Total impaction
of Maxilla
Differential impaction of the
maxilla (Ant > Post):
counterclockwise rotation
Counterclockwise rotation of
Mandible
Total advancement of the
mandible with or without
Genioglossus Advancement
Total advancement of the
mandible and Segmental
osteotomy with
setback of the ant. segment
Reduction of the amount of
Mandibular advancement /
Genioglossus Advancement
Facial Height Proportion:
Lowe 1/3
* Consider the effect of impaction of the
maxila and counterclockwise rotation of the
mandible on increase in the chin projection.
Excessive
Impaction of the maxilla and
counterclockise rotation of the
mandible
Reduction Genioplasty
336
S. O. Hong et al.
22
22.5.1 Worsening oftheSymptoms ofOSAS
During Preoperative Orthodontic
Treatment
If clinicians try to close the extraction spaces of the
maxillary and mandibular rst premolars with orthodontic treatment only, the tongue space can be
decreased due to constriction of the dental arch during
pre surgical orthodontic treatment [28]. For example,
patient # 6 demonstrated worsening of the OSAS symptoms during 10months of presurgical orthodontic treatment due to partial closure of the extraction space and
narrowing of the tongue space. Therefore, in most segMMA cases of this study, surgery-rst approach with
minimal presurgical orthodontic treatment was performed (. Table22.1). Also, notice about worsening of
OSAS symptoms during presurgical orthodontic treatment was given to the patients. The use of nCPAP can
be recommended to the patients, who complained of
worsening of OSAS symptoms during presurgical orthodontic treatment.
22.5.2 Proposition forIncreasing
theSuccess Rate
Holty and Guilleminault [18] suggested that younger
age, lower preoperative AHI and BMI, and larger
amount of maxillary advancement were positive predictors for the successful outcome of MMA.Liu etal. [21]
reported 83.3% of success rate in 5–10mm advancement
cases, which was similar with the result of this study
(87.5%; con-MMA group, n=4/4 and seg-MMA group,
n=3/4). Although the surgical outcome was successful
in the seg-MMA approach, several patients refused to
take a postoperative PSG.Therefore, further investigation of the success rates of seg-MMA procedure with a
larger sample size is needed in the future. In addition, it
is necessary to accurately estimate the amount of airow
change per certain amounts of MMA using computational uid dynamics, thus deciding an optimum amount
of advancement satisfying both functional and esthetic
aspects [3].
22.6 Conclusion
The seg-MMA procedure with or without counterclockwise rotation can effectively expand the upper airway by advancement of the posterior segment of the
maxilla and the total mandible and obtain the facial
esthetics by minimizing the forward movement of the
maxilla and upper lip. Therefore, in adult OSAS cases
with relatively forward positioned maxilla, acute naso-
labial angle, and labioversed maxillary incisors, the
seg-MMA procedure can be regarded as an effective
alternative to the con- MMA procedure for simultaneous improvement of the respiratory function and facial
esthetics.
Conicts of Interest The authors declare no conicts of
interest and source of funding.
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Maxillomandibular
Advancement for OSA
Contents
Chapter 23 Clinical, Occlusal, and Cephalometric Analyses
of the OSA Patient–341
Larry Wolford
Chapter 24 MRI Evaluation for Patients with TMJ Disorders
and Obstructive Sleep Apnea–361
Larry Wolford
Chapter 25 Maxillary Surgical Procedures for Correction
of Obstructive Sleep Apnea–381
Will R. Allen and Matt J. Madsen
339
V
Chapter 26 Mandibular Surgical Procedures–393
Larry Wolford
Chapter 27 Counterclockwise Rotation of the Maxillomandibular
Complex for the Correction of Dentofacial Deformities
and Sleep Apnea–415
Larry Wolford
Chapter 28 Maxillomandibular Advancement–437
Reza Movahed
Chapter 29 Virtual Surgical Planning and Digital Workow for
Concomitant Temporomandibular Replacement and
Maxillomandibular Advancement Surgery–467
Reza Movahed and Joseph W. Ivory
Chapter 30 Postoperative Management of the Maxillomandibular
Advancement Patient–497
Zachary Brown and Daniel E. Perez
Chapter 31 Post-surgical Myofunctional Therapy and Physical
Therapy–507
Joy L. Moeller, Cynthia Peterson, Licia Coceani Paskay,
Samantha D. Weaver, and Soroush Zaghi
Chapter 32 Complications Associated with Maxillomandibular
Advancement–515
Reza Movahed, Joseph W. Ivory, and Frank Delatour
Chapter 33 Virtual Surgical Planning for Osseous Surgery to
Manage Obstructive Sleep Apnea–545
Christopher Viozzi
Chapter 34 Temporomandibular Joint Reconstruction–563
Louis G. Mercuri
Chapter 35 Maxillomandibular Advancement Using Total Joint
Replacement for the Treatment of Obstructive
Sleep Apnea–571
Daniel E. Perez, Zachary Brown, and Edward Ellis III
Chapter 36 Computational Fluid Dynamics and Morphometric
Changes in OSA–615
Ki Beom Kim, Reza Movahed, and Mark McQuilling