Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
Mean Dierence
Does Not
02
Cochran Q=61.26; p<0.00001; I2=76%
Mean Dierence
Does Not
Cochran Q=4.20; p=0.94; I2=0%
Maxillomandibular Advancement
445
28
Study Weight
Abramson Z et al., 2011
Bettega G et al., 2000
Blumen MB et al., 2009
Boyd SB et al., 2013
Cohen-Levy J et al., 2013
Fairburn SC et al., 2007
Goh YH et al., 2003
Li KK et al., 2000a
Li KK et al., 2000b
Li KK et al., 2001a
Li KK et al., 2001b
Li KK et al., 2002
Liao YF et al., 2015
Lin CH et al., 2011
Liu SY et al., 2015
Serra MM et al., 2012
Overall
. Fig. 28.5 Forest plot for lowest oxygen saturation (LSAT). (John etal. (2018) [129])
5.4%
6.2%
6.3%
6.3%
5.4%
6.6%
4.4%
5.9%
4.7%
7.9%
7.3%
4.6%
6.8%
7.0%
7.3%
7.9%
100%
95% CI Favors MMA
9.46 [2.41, 16.51]
8.00 [2.29, 13.71]
13.50 [7.80, 19.20]
9.40 [3.81, 14.99]
2.70 [-4.42, 9.82]
7.35 [2.14, 12.56]
25.30 [16.36, 34.24]
14.80 [8.58, 21.02]
22.10 [13.81, 30.39]
11.60 [8.45, 14.75]
10.90 [6.82, 14.98]
12.70 [4.28, 21.12]
8.70 [3.92, 13.48]
7.60 [3.05, 12.15]
8.10 [4.02, 12.18]
1.00 [-2.14, 4.14]
10.20 [7.57, 12.83]
Favor MMA
-20 -10 10
0
Study
Bettega G et al., 2000
Bumen MB et al., 2009
Buttereld KJ et al., 2015
Cohen-Levy J et al., 2013
Fairburn SC et al., 2007
Goh YH et al., 2003
Li KK et al., 2000b
Li KK et al., 2002
Lin CH et al., 2011
Liu SY et al., 2015
Vicini C et al., 2010
Overall
. Fig. 28.6 Forest plot for body mass index (BMI). (John etal. (2018) [129])
28.3.1 Counterclockwise Rotation,
Weight
11.5%
21.8%
8.0%
13.3%
2.2%
5.8%
7.4%
3.7%
14.4%
6.3%
5.6%
100%
Genioplasty, andOther
Interventional Options
While various operative modications have been proposed to minimize aesthetic disharmony post-MMA,
95% CI Favors MMA
-1.50 [-3.88, 0.88]
-0.50 [-2.23, 1.23]
-0.28 [-3.13, 2.57]
-2.41 [-4.62, -0.20]
0.80 [-4.69, 6.29]
-2.20 [-5.55, 1.15]
-2.00 [-4.95, 0.95]
-1.20 [-5.41, 3.01]
-0.80 [-2.92, 1.32]
0.20 [-3.01, 3.41]
-1.30 [-4.71, 2.11]
-1.10 [-1.91, -0.30]
counterclockwise rotation of the maxillomandibular
complex and alteration to the occlusal plane is likely the
best mitigating measure in this regard. It is always
important to discuss the potential risks with patients in
terms of potentially unfavorable aesthetic outcomes. Li
et al. emphasized the importance of communication
4
-2 024
Favor MMA
446
R. Movahed
28
. Table 28.3 Risk of treatment failure (Vigneron etal.,
2017 [143])
Risk parameter Odds ratio 95% CI
Preoperative BMI
>24.8 vs. <24.8kg/m
Preoperative age
>45.01 vs. <45.01years
Gender
Men vs. women
Preoperative AHI
>44.5 vs <44.5 events/hour
Preoperative SNB
>75% vs <75%
Maxillary advancement
>11 vs <11mm
Postoperative MRBL
>8 vs <8mm
BMI body mass index, AHI apnea-hypopnea index, SNB
Sella-nasion-sub chin point angle measured on a cephalogram, MRBL minimal retrobasilingual distance measured on
a cephalogram
2
14.00 1.43; 137.32
14.00 1.43; 137.32
33.33 2.83; 392.60
6.25 1.03; 38.08
14.17 1.83; 109.86
11.00 1.06; 114.09
6.25 1.03; 38.08
with all patients undergoing MMA, but were keen to
note that there are patient subgroups who appear to be
at greater risk of being dissatised with the aesthetic
outcome: younger patients, patients with pre-existing
bimaxillary protrusion, and nonobese patients [145].
However, employing counterclockwise rotation in lieu
of a full-forward 10mm movement has provided surgeons a viable tool to negotiate these hurdles, even in
these patient populations.
By dropping the occlusal plane in a counterclockwise fashion to 8 degrees or less, a surgeon may not only
achieve better airway, but also prevent a negative aesthetic outcome, such as upward tip of the nose and/or a
highly protrusive looking upper and/or lower jaw [80,
146]. The aesthetic risk of a full, direct advancement of
the upper and lower jaw may result in an excessively
increased nasolabial angle and the patient’s nares may
become more visible in the frontal view and lips may
appear more highly protrusive. In the prole view, excessive prognathism of the entire maxillomandibular complex could cause the nose to tip up and the jaws to be
unaesthetically protrusive. The benets of counterclockwise rotation are especially advantageous in some ethnic
populations, such as Asians, who have more concave
facial proles [147].
To lessen or minimize advancement, other options
could be explored in select cases, such as expanding the
transverse dimensions of the dental arch to allow the
tongue to extend superiorly toward the palate. Another
option is to perform a concomitant transoral base-oftongue resection to achieve the same degree of airway
expansion, though it is important to note the caveats to
this approach can potentially prolong recovery and the
patient will need to remain intubated for up to 36hours.
28.4 The Patient Evaluation Prior toMMA
28.4.1 Preoperative Medical Assessment
When a patient arrives to the ofce, a thorough comprehensive evaluation of the head and neck is conducted
for these patients prior to planning of the surgery and its
preparation. After the initial arrival of a patient to the
ofce, a cone-beam computed tomography (CBCT) is
performed. A nasal obstruction screener NOSE scale is
lled out by the patient. From the CBCT scan, numerous radiographs are extracted, including the lateral
cephalogram, assessment of the nasal sinuses, and volumetric analyses (including minimal cross-sectional evaluation, which is the most relevant 3D evaluation of the
airway), and a panoramic radiograph should be performed to evaluate dentition. In addition, a nasal evaluation is performed to ascertain septal morphology,
including turbinate morphology. Clinically, the patient’s
nares are visualized using a nasal speculum. A beroptic
evaluation of nasal tissue, hypopharyngeal, and lateral
pharyngeal wall collapse is performed during druginduced sleep endoscopy (DISE). This will also allow
assessment of the base of the tongue and correlate with
CBCT evaluation. Sinuses are screened for any pathologic abnormalities. Intra-orally, the shape of the arch,
crowding of the dentition, and width of the arch are
noted and evaluated.
Clinical manipulation of the upper lip tissue is also
performed to gain an understanding of maximal
advancement that can be achieved and to determine the
potential effects of this on the nasolabial angle. The
patient’s myofascial tissue is palpated due to the fact
that excessive advancement in the maxilla could potentially have a negative effect on nasal structure and extensive lip protrusion. In case the situation is considered to
be a problem for already-orthognathic patients, future
need for rhinoplasty should be discussed with the
patient. Any areas of tenderness are noted on a scale of
0–10. Presence of headaches/migraines, severity, and site
are also noted. A very important anatomical landmark
that is often ignored in MMA candidates is the temporomandibular joint (TMJ). TMJs are the foundation
for jaw position, occlusion, facial balance, jaw function,
growth and development, and airway function. TMJ
pathology can adversely affect any of these factors.
Maxillomandibular Advancement
447
28
Because MMA movements are signicant, a thorough evaluation of TMJ stability is paramount to assure
future stability. For a patient symptomatic in the TMJ
region and having tinnitus and earache, a thorough evaluation of the bony and soft tissue structures of the TMJ
are deemed necessary. MRI of the TMJ can allow visualization of the articular disc. It is important to note
that for a subsection of patients diagnosed with weak
and arthritic joints who require signicant MMA/counterclockwise rotation, a combination surgery with total
joint prosthesis is recommended. This will allow the
patient to have a long-lasting and stable position of the
mandible to maintain the airway open and prevent
future relapse.
28.4.2 Guidelines andIndications forMMA
The rst indication for MMA is an accurate diagnosis
of OSA based on polysomnography and AHI ≥15
events per hour. Early guidelines for OSA surgery are
presented below, as proposed by Prinsell in 2000 [148]:
1. Surgical prerequisites.
(a) Clinically signicant OSAS (AHI>15 or AI >5,
LSAT <90%, and EDS)
(b) Conservative treatments (e.g., CPAP) nonappli-
cable/unsuccessful/nontolerable
(c) Medically/psychologically stable
(d) Willing to proceed with surgery (i.e., informed
consent)
2. For specic site(s)/segmental area(s) that are dis-
tinctly identiable
(a) Treat with appropriate procedures that address
these specic sites
(b) If a staged approach is recommended/desired,
treat the most severe/critical site/area rst
3. For diffusely complex or multiple sites that are not
readily distinguishable.
(a) Skeletal advancement procedures rst to enlarge/
stabilize the pharyngeal airway
(i) Primary single-stage denitive treatment; or
(ii) Minimize risk of postoperative edema-
induced airway embarrassment associated
with subsequent pharyngeal surgery
(b) Pharyngeal soft tissue procedures second, if still
necessary, for clinically signicant residual OSAs
It should be noted that these guidelines do not apply to
all patients, their expectations, quality of life, and their
ability to adhere to CPAP therapy. For certain patients,
CPAP is not an option because of claustrophobia and
other reasons for nonadherence. Ultimately, for these
patients, surgery is the ideal solution, but it must be tailored to each specic patient. Indications for MMA
include patients who have severe OSA without signicant pharyngeal tissue redundancy, patients with signicant maxillomandibular deciency, young patients who
require long-term resolution of OSA, and patients who
desire the most effective single-stage surgery [142].
Young patients who are in good clinical health and cardiovascular status are the best candidates for this procedure. Patients who have multiple comorbidities require
proper optimization and need to undergo thorough risk
assessment prior to surgery. However, it has been proposed that oxygen desaturation and morbid obesity are
valid secondary factors that could indicate MMA intervention.
The risk of blood loss and need for hypotensive anesthesia place a signicant amount of pressure on the
body. Multiple referrals for systemic evaluation are necessary for these patients with comorbidities. Even
though the risks and complications of these cases are
not high, communication is of utmost importance
between the surgeon, anesthesiologist, and primary and
secondary care physicians, to tailor the best intraoperative procedure plan and optimal post-procedure care for
the patients.
Intraoperatively, use of arterial lines for expedient
evaluation of arterial blood oxygen and cardiac function also allows the anesthesiologist better ability to
control the mean arterial pressure while also monitoring
kidney function via urine output. Lowering mean arterial pressure allows the team to minimize blood loss during surgery. Cardine, propofol infusion, and nitroglycerin
may be used, among other modalities.
28.4.3 Contraindications forMMA Surgery
MMA may not be the surgery of choice for certain subsets of patients who have numerous comorbidities (also
known as multimorbidity) and are at high risk for having the procedure. While the complexity of the case varies from patient to patient, MMA can last anywhere
between 4 and 7hours. Procedure duration should be
weighed against the patient’s medical history and physiological reserve.
While many patients who suffer from OSA may
already have compromised cardiac and multiorgan decits due to OSA pathology and high levels of cortisol
from poor sleep hygiene, these sequelae must be weighed
and considered for each individual patient to determine
recovery resilience. In elderly patients (older than
65years of age), it must be noted that longer anesthesia
times could cause postoperative amnesia that could last
for 3–4days. Again, a comprehensive anesthesia history
can help predict many of these types of events and have
a plan in place.
448
R. Movahed
28
Patients taking anticoagulants are at high risk for
excessive hemorrhage and, in the case of a LeFort I osteotomy, they are particularly at high risk for epistaxis,
which could potentially compromise the airway. The
airway of morbidly obese patients is at higher risk for
complications and collapse, and in cases may be contraindicated. Patients with poor kidney function are typically
not candidates for the procedure because of the higher
risk of anesthetic complications and further renal damage. Heavy smokers are also at high risk for necrosis following LeFort I osteotomy, particularly if it is a segmented
procedure, which can have a high risk of ap failure.
Smokers are also at high risk for treatment failure in
terms of risk of segment vascularity and healing, as well
as to achieve successful intraoperative pulmonary function; therefore, preoperative smoking cessation is mandated. Diabetic patients with HBA1c>7 are at higher risk
for myocardial infarction (MI), stroke, and postoperative
infections. These patients would need to be maintained
on antibiotics signicantly longer; therefore, their procedures should be delayed until HBA1c is well controlled.
28.5 Procedure
Orthognathic surgery has been used for decades to correct dentofacial deformities. The number of orthognathic procedures had somewhat declined in the 1980s and
1990s, but its practice has been revitalized in the past
two decades due its modication to MMA and its resultant surgical successes, particularly in OSA patients, but
also in temporomandibular disorder (TMD) patients
requiring temporomandibular joint reconstruction
(TMJR), some of whom also have OSA.
operatively. In addition, the rigid xation achieved by
securing plates would allow for healing. This is due to
the heavy interface of bony contact of the proximal and
distal segments. Before the application of plates for rigid
xation, positional screws were used to stabilize the
proximal and distal segments. However, use of plates
has allowed surgeons to bypass extra-oral stab incisions
that are traditionally used to introduce bicortical screws.
In our practice, we place screws and position plates
intraorally.
Modications of the sagittal split were then proposed
by Dal Pont in 1961 and Hunsuck in 1968. In 1977, a
seminal article by Bell and Schendel was published
exploring the biologic basis for modifying the sagittal
ramus split. This informed Epker’s new modication,
who published his paper later that same year. In 1987,
Wolford, Bennett, and Rafferty [151] introduced important modications of the sagittal split osteotomy of the
mandibular ramus, which allowed for more controlled
segment splits and greater control of the proximal segment. Later in 1990, Wolford and Davis [152] introduced
the inferior border split for the mandible, which
employed a new customized saw specially designed for
inferior border cuts with the aim of achieving a low lingual split while also preserving the IAN. This was an
important advancement because it reduced the likelihood that the IAN would be found in the proximal segment where it is more susceptible to procedural trauma.
For the maxillary step osteotomy, Bennett and
Wolford [153] described their improvement in 1985.
Traditional Le Fort I maxillary osteotomy is inclined
anteroposteriorly. The maxillary step osteotomy’s primary advantage allows for “pure” anteroposterior
movement by obviating incline effects of the traditional
technique.
28.5.1 Sagittal andLeFort IOsteotomies
28.5.1.1 Advancement Limitations ofSagittal
Osteotomy
Originally pioneered by Trauner and Obwegeser in 1957
[149] (after its initial introduction by Schuchardt in 1942
[150]), their modied bilateral sagittal split osteotomy
(BSSO) revolutionized maxillofacial surgery by introducing it as a safe and standardized procedure that is
still performed globally with few modications from
their described approach. Their modication of
Schuchardt’s technique consisted of widening the gap
between horizontal cuts to 25mm to accommodate the
inferior alveolar nerve (IAN) by connecting two horizontal cortical cuts on the lateral oblique ridge (avoiding
the ramus’s posterior border), and then the chiseling of
the lateral cortex would lead to fracturing the ramus.
This procedure allows the surgeon to correct most
asymmetries and allows jaw function immediately post-
28.5.1.2 Plates Vs. Screws
The two most common xation devices used for BSSO
are either a monocortical miniplate or bicortical titanium screws (See . Fig.28.7). A 2016 systematic review
and meta-analysis by Al-Moraissi and Al-Hendi [154]
found no signicant difference in postoperative stability
when comparing use of a monocortical plate (n=67) or
bicortical screws (n=60) pooled from three studies for
xation post-BSSO.Bicortical screws may be useful for
cases that require more than 6 mm of advancement to
achieve postoperative stability and plate xation is useful to stabilize fragments in cases where there is not
enough bone overlap between the proximal and distal
segments for bicortical screw placement. Use of mandibular locking plates can allow the head of the screws
to be fully stabilized to the plate, which can prevent
future loosening and infection.
These plates are bent to a passive t of the bony
structure. The combination of the passive t and lock-
Maxillomandibular Advancement
449
28
. Fig. 28.7 Fixation achieved with implanted L-plates and Z-plates
on a sagittal split
ing screws prevents future hardware failure and infection. After xation of the bilateral sagittal split and use
of intermediate splints, incision lines are irrigated and
incisions are closed. Next, a LeFort I osteotomy is completed, and segmental osteotomies are performed with a
piezosurgery unit using prefabricated splints.
When necessary, it is important to employ maxillary
expansion to achieve greater width and proper occlusion. This can be achieved by segmental osteotomy or,
prior to MMA, with surgically assisted rapid palatal
expansion (SARPE). Skeletal stability of SARPE for
large expansions has been shown to be modest but stable, though operators should expect late loss of roughly
one-third of the expansion [155, 156]. Based on clinician
experience, either route may be taken, either SARPE
performed prior to MMA or expansion during the
advancement procedure, effectively consolidating both
interventions in a single procedure. To ensure stability
of the segmental osteotomy, a palatal splint is xated to
the maxilla with interdental wires to serve as a cast-like
mechanism throughout bone healing and removed after
3–4months (.
Fig.28.8).
Throughout LeFort I osteotomy, the anesthesia team
is notied to maintain the mean arterial pressure at
50mm Hg. Any necessary modications to the septum
and turbinates are performed during this portion of the
procedure with caution to not remove excess turbinate
tissue and ensuring reduction of one-half to two-thirds
of the turbinate at maximum [157].
In continuum, paramedian cuts are performed for
segmental surgery. Grafting of the maxilla is important
when rigidly xating. The grafting in the anterior aspect
of the maxilla will facilitate long-term stability of maxillary movement, which is particularly important in
patients with extensive counterclockwise rotation of the
occlusal plane. Lastly, if indicated, a genioglossal
advancement with proper rigid xation is performed.
. Fig. 28.8 After segmental osteotomy and maxillary expansion, a
palatal splint is inserted and stabilized with interdental wire xation.
This splint will remain in the palate for 3–4months post-surgery
This advancement can be shaped to meet the aesthetic
requirements of the case as the advanced bone can be
modied by reduction.
28.6 Total Joint/TMJ Considerations
inAdvancing theMandible
28.6.1 TMJ Pathology andIndications
forSurgery
The TMJ is an anatomic centerpiece that determines jaw
position and function, occlusion, growth and development, facial balance, and airway function. The pathology
of the TMJ can adversely affect any of these factors. A
range of TMJ pathology has been documented, including
CT disorder and various forms of arthritis, disc displacement, ankylosis (or trauma resulting in ankylosis), symptomatic TMJ, facial asymmetry (which may be caused by
a TMJ tumor), and agenesis, all of which may be indications for the procedure. The diagnosis and treatment
planning for TMJ pathology and dentofacial deformities
consist of the usual steps of a complete clinical evaluation
consisting of a medical history, dental model analysis,
and CBCT and MRI scans. For TMJ, MRI is a very
important tool in diagnostic and treatment planning by
evaluating both hard and soft tissues. It has been estimated that approximately 40%–60% of TMJ MRIs are
improperly read. TMJ surgery may be needed for a majority of OSA patients with dentofacial deformities and
should be performed only when necessary. In 2008,
Goncalves etal. [158] described the relationship between
joint pathology, disc displacement, and relapse.
In modern day practice, a combination of both TMJ
surgery and orthognathic surgery has proven to be successful with long-term follow-up [159]. A more accurate
450
R. Movahed
28
result has been made possible by the digital workow
that has been rened over the past decade. This signies
the importance of evaluating the joint prior to embarking upon MMA.
28.7 Post-MMA Follow-Up Care
The majority of patients are extubated after surgery
when criteria are met. When extubated, the patient is
transferred to the postanesthesia care unit (PACU).
During this portion of the recovery, the patient has
bilateral nasal trumpets in place to maintain a patent
airway. When vital signs and pain control meet criteria,
the patient is transferred to the intensive care unit (ICU)
for one-on-one monitoring by a nurse. The head-of-bed
will be maintained at 45 degrees and ice will be applied
for the following 3days postsurgery. A humidied oxygen tent is provided for the patient and pulse oximetry is
continually monitored. The day after surgery, the Foley
catheter and arterial lines are discontinued, and the
patient is transferred to a transitional care unit. While in
the transitional care unit, goals are set to meet ambulation needs, general and oral pain control, and uid and
protein intake. Nutrition and physical therapy consults
are initiated. Oral hygiene is maintained to prevent
infection. Intravenous antibiotics, steroids, and antiemetics are used as necessary. On average, patients are
discharged 2–3days post-MMA and followed in private
practice 2–3 times a week for the rst 2–3weeks to help
the patient change dental elastics as well as to monitor
intraoral and extraoral wounds.
At week 3, physical therapy is initiated to allow the
patient to achieve muscle release good incisal opening.
Postsurgical orthodontics is initiated at 6 weeks after
surgery. After the initial month, the patient is then seen
at the 3- to 4-month mark to remove the palatal splint
(if a segmental osteotomy is performed). These timelines may vary from patient to patient. Most patients
are recommended to take 3–4weeks off work for acceptable recovery, though this could be shortened or
extended due to the patient’s physiologic status and
healing progress.
28.7.1 Relapse andRisks Leading
toReoperation
As noted above, a relapse of OSA could be attributable
to postoperative weight gain and the natural history of
other comorbidities and changes in medication [160].
However, various other problems could lead to instability, such as condylar resorption and its related skeletal
instability, implant device failure, and postoperative
trauma. However, relapse may occur and defy explanation. However, several structural factors have been associated with relapse, including changes attributable to
any excess bone movement and/or rotation, changes of
the teeth, and any unresolved malocclusion during preprocedure orthodontic treatment, any change in position of the condyles, and any signicant changes in
ramus inclination and the mandibular plane [161, 162].
28.7.2 Case 1: 38-Year-Old Female
Intolerant ofCPAP
A 38-year-old female referred by a pulmonologist presented with a history of OSA and a prior turbinectomy
and was not taking any medications at the time. The
patient was subsequently diagnosed with OSA and
referred to my practice. The patient had been treated
with CPAP since 2011 but reported it to be intolerable
and became nonadherent. After thorough patient evaluation and discussion of risks and benets, the patient
opted for MMA and began presurgical orthodontics.
MMA was performed with counterclockwise rotation.
The patient began orthodontic treatment 5weeks after
surgery. AHI before (2013 sleep study) and after (2015
postoperative study) was 53 and 0.3, respectively. Her
sleep efciency improved to 91% with a lowest O
92%. Upon 4-year follow-up, the patient reported no
signicant evidence of OSA (See . Figs. 28.9, 28.10,
28.11, and 28.12).
28.7.3 Case 2: 59-Year-Old Female
sat of
2
withScleroderma
A 59-year-old female presented to my practice with a
history of scleroderma and multiple TMJ procedures
since her rst in the early 1990s (hypoplastic maxilla
and mandible), as well as TMJ arthroscopy, discectomy, and placement of silicone spacers and bilateral
rib grafts in the late 1990s. She had been on oxygen via
nasal cannula since 1993 and had been reportedly
adherent in her use of CPAP for sleep. CBCT or cephalometric imaging of TMJs revealed ankylosis of joints
with oating bone particles in both TMJ fossae. Her
maximal incisal opening was only 5mm. A sleep study
was performed in 2016 and revealed an AHI of 28 and
conrmed the diagnosis of OSA.The patient opted for
MMA with simultaneous TMJR with new TMJ prostheses. Presurgical preparation began with orthodontics. The 2016 procedure was a planned reconstruction
with total joint prosthesis and MMA.The rib harvest
that was previously completed in 1999 was removed
and the maxilla was grafted at the time of LeFort I
Maxillomandibular Advancement
451
28
. Fig. 28.9 Dolphin airway imaging showed minimum axial area improvement from 29.8mm3 preoperatively to 206.1mm3 postoperatively
. Fig. 28.10 Pre- and postoperative prole cephalometry comparison shows increased area of middle posterior airway space (MPAS) from
2mm to 9mm and an increased inferior posterior airway space (IPAS) from 3mm to 11.5mm
osteotomy in 2016. Postoperative follow- up was performed weekly, then bimonthly for 1 year. At 1-year
follow-up, the airway minimum axial area improved
from 88mm
the patient’s pulmonary and renal function tests. The
patient reported a decrease in polypharmacy, as medi-
2
to 186mm2 (see . Fig.28.16 below) in
cations decreased from 9 to 4. Postoperatively, the
patient no longer required a nasal cannula or CPAP,
and was evaluated to be ostensibly cured of OSA.The
patient’s function improved as her maximal incisal
opening improved from 5mm to 38 mm without pain
(See . Figs.28.13, 28.14, 28.15, and 28.16).
28
452
R. Movahed
. Fig. 28.11 Pre- and postoperative prole photographs (prole and oblique) show improved craniofacial harmony and disappearance of
the dorsal hump of the nose
Maxillomandibular Advancement
453
28
. Fig. 28.12 Pre- and postoperative dental photographs show improved dental alignment, improved arch, preservation of occlusion, and
satisfactory esthetic outcome
28.7.4 Case 3: Severe OSA andPronounced
Retrognathia
A 52-year-old male presented to our practice with
severe OSA and pronounced retrognathia, hypertension, and polypharmacy. The patient was on CPAP,
which was ineffective to manage his OSA.A prior sleep
study showed an AHI of 57. After obtaining CBCT
and airway analysis prior to DISE, it was appreciated
that he had an above-average airway, which was likely
collapsible. MMA was cautiously recommended as a
solution since his airway did not radiographically
appear constricted upon 3D analysis. The other challenge that was met during his case was the mechanics
of MMA movement due to excessive proclination of
his lower incisors. To solve this problem, subapico
osteotomy and extraction of the rst lower premolars
was recommended to facilitate further mandibular
advancement. The subapico osteotomy setback also
allowed us to resolve the extensive of curve of spee.
Following MMA, the patient’s maxilla was advanced
by 7 mm and pogonion by 22 mm. The maxilla was
expanded by 12 mm to meet the demands of the
uprighted posterior teeth. The pterygoid plates were
advanced 11mm on the left and 9 mm on the right.
The patient’s minimal cross-sectional area increased
from 169mm
impacted the uid dynamics adequately to decrease the
collapsibility of the soft tissue in his airway, subsequently curing him of OSA.
2
to 308 mm2. This volumetric increase
28
454
R. Movahed
. Fig. 28.13 Presurgical and postsurgical photographs
. Fig. 28.14 Sagittal view of TMJs reveal ankylosis of joints with oating bone particles in the fossae. Maximal incisal opening was 5mm