Abstract
A new monitoring protocol for orthognathic surgery for addressing obstructive sleep apnea syndrome in adult patients using bilateral internal ramus distraction (BIRD) followed by Lefort I osteotomy and monitored by HRP is presented. This strategy is part of an outpatient major surgery protocol and includes preoperative 3d virtual planning, followed by surgery under general anesthesia with endoscopic assistance.
Following the procedure, patients are typically discharged on the same day, with the vertical lengthening of the mandibular ramus starting after a 5-day period and progressing at a speed of 0.5–1 mm per day over a period of 10–50 days. The process carries on until the negative dental overjet exceeds 10 mm or the apnea-hypopnea index falls beneath 15 events per hour, demonstrating a curative level.
Mandibular advancement monitorization based on clinical, polygraphic, or polysomnographic criteria enables the surgeon to meet the individual needs of each patient. The distractors are typically maintained in position for six months following elongation of 10–25 mm to ensure proper consolidation.
BIRD followed by LeFort I osteotomy, has demonstrated significant efficacy as a treatment for obstructive sleep apnea syndrome in adult patients, irrespective of the presence of retrognathia. Furthermore, this approach may offer particular advantages for patients with severe cardiovascular disease or diabetes.
Highlights
- •
Innovative approach combining BIRD and LeFort I osteotomy for obstructive sleep apnea.
- •
Mandibular ramus distraction leads to significant airway volume expansion.
- •
Home respiratory polygraphy guides personalized mandibular advancement.
- •
Technique improves severe OSA outcomes in patients intolerant to CPAP.
- •
Multistage surgery demonstrates improvements in AHI, ODI, and metabolic conditions.
1
Introduction
Obstructive sleep apnea (OSA) is a widespread chronic sleep-related breathing disorder characterized by repeated episodes of partial or complete upper airway collapse during sleep. This condition results in oxygen desaturation, sleep fragmentation, and excessive daytime sleepiness. OSA is linked with several serious health issues, including diabetes mellitus, cardiovascular disease, cerebrovascular events, and cognitive impairment, contributing to a diminished quality of life and increased mortality risk [ ].
Polysomnography (PSG) is regarded as the gold standard for diagnosing OSA. PSG provides detailed information about sleep stages and comprehensive data on various physiological parameters, including body position, heart rate, respiratory rate, and muscle tone [ ]. Due to the high cost of PSG and the increasing prevalence of OSA, there is a pressing need for more accessible and cost-effective diagnostic alternatives. Home respiratory polygraphy (HRP) has emerged as a viable option. HRP measures key parameters such as airflow, respiratory effort, and blood oxygen saturation, and many systems now include postural movement detectors and microphones for snoring detection. Ideally, HRP should incorporate biosensors similar to those used in PSG, such as oronasal thermal sensors, nasal pressure transducers, inductance plethysmography, and pulse oximetry [ ].
Craniofacial anatomical abnormalities, such as an under-positioned hyoid, retrognathic maxilla or mandible, and a narrow hard palate, are commonly associated with OSA, either as causative factors or exacerbating elements [ , ]. Although obesity is often cited as a primary cause, these craniofacial abnormalities also play a significant role in the development of the conditions.
Surgical interventions aimed at correcting craniofacial anatomical issues have been utilized to treat OSA. Maxillomandibular advancement (MMA) orthognathic surgery has long been a standard approach for expanding the upper airways [ ]. Recent studies suggest that mandibular advancement alone can also be effective in treating OSA [ ]. Mandibular distraction osteogenesis, a technique for mandibular advancement, has proven successful in both pediatric [ ] and adult [ , ] patients.
Mandibular distraction osteogenesis differs from conventional MMA by allowing for gradual reduction in negative overjet. While most studies on this technique rely on pre- and post-distraction PSG [ , ], few have explored HRP for monitoring during distraction.
The aim of this article is to present a novel management strategy for the complete cure of the disease. This new, customized protocol of bilateral internal ramus distraction (BIRD), monitored by HRP and followed by a LeFort I osteotomy, could offer a novel perspective in the definitive, and even primary, management of this prevalent chronic disease, which is associated with extremely high healthcare costs.
1.1
Case presentation
The 54-year-old male patient was referred to the Maxillofacial Surgery Department of the Hospital Universitario de la Princesa (Madrid, Spain) with chronic intolerance to CPAP therapy, after being diagnosed with severe obstructive sleep apnea syndrome (OSA) with an apnea-hypopnea index (AHI) of 80.7, oxygen desaturation index (ODI) of 87.7, time under 90 % oxygen saturation (T90) of 60, and an Epworth Sleepiness Scale (ESS) score of 19. The volume of the upper airways, measured using CT, was 8756 mm³ ( Table 1 ) and the patient presented with bimaxillary skeletal retrusion ( Fig. 1 A).
| T0 | T1 | T2 | |
|---|---|---|---|
| AHI | 80.7 | 44.6 | 18.5 |
| ODI | 87.7 | 34 | 17.4 |
| T90 | 60 | 2 | 4.2 |
| ESS | 19 | 8 | 6 |
| BMI | 31.94 | 31.5 | 29 |
| UA volume (mm³) | 8756.0 | 19977.0 | 20046.0 |
The patient had previously undergone an unsuccessful uvulopalatopharyngoplasty, rhinoplasty and tonsillectomy, and participation in CPAP adaptation workshops had yielded minimal benefit. Additionally, the patient presented with metabolic syndrome, including arterial hypertension and type II diabetes mellitus. After a multidisciplinary clinical review in the Sleep Unit, surgical intervention via non-reductive dilator surgery was unanimously recommended.
Following comprehensive clinical and radiographic evaluation, which included facial analysis based on the Arnett protocol [ ], model analysis, maxillomandibular computed tomography (CT) imaging with 3D reconstruction, and virtual surgical planning using specialized software (Timeus®, CD Ortosan, Madrid, Spain), bilateral internal ramus distraction (BIRD) was identified as the initial treatment approach. The patient presented unstable occlusion, with incomplete bilateral Class II canine and molar relationships, mandibular retrognathia, increased overjet, and moderate crowding in both arches ( Fig. 2 A. Orthodontic treatment was planned after the LeFort I osteotomy to achieve long-term occlusal stability. Due to the anticipated occlusal instability and the potential for skeletal relapse following a significant advancement of both jaws, the patient was not deemed a suitable candidate for conventional MMA. The surgical procedure was thoroughly explained, and informed consent was obtained from the patient
Stay updated, free dental videos. Join our Telegram channel
VIDEdental - Online dental courses
