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DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY RUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCH KOHKA, BHILAI PRESENTED BY DR. SHEETAL KAPSE 3 rd YEAR, P.G. STUDENT MODERATORS - DR. D. A. DARAWADE DR. M. SATISH DR. MANISH PANDIT DR. DEEPAK THAKUR

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DEPARTMENT OF

ORAL & MAXILLOFACIAL SURGERYRUNGTA COLLEGE OF DENTAL SCIENCES & RESEARCH

KOHKA, BHILAI

PRESENTED BY –

DR. SHEETAL KAPSE

3rd YEAR, P.G. STUDENT

MODERATORS -

DR. D. A. DARAWADE

DR. M. SATISH

DR. MANISH PANDIT

DR. DEEPAK THAKUR

Distraction osteogenesis for management of obstructive sleep apnoea

Yadav R, Bhutia O, Shukla G, Roychoudhury A. Distraction osteogenesis for management of obstructive sleep apnoea in temporomandibular joint ankylosis patients before the release of joint. Journal of Cranio-Maxillo-Facial Surgery.2014;42 (5): 588–594.

JOURNAL CLUB

in temporomandibular joint ankylosis patients before the release of joint

Authors

1. Dr. Rahul Yadav, Senior Resident, Department of Oral & Maxillofacial Surgery, AIIMS, New Delhi, India.

2. Dr. Ongkila Bhutia, Associate Professor, Department of Oral & Maxillofacial Surgery, AIIMS, New Delhi, India.

3. Dr. Garima Shukla, Department of Neurology, AIIMS, New Delhi, India.

4. Dr. Ajoy Roychoudhury, BDS, MDS, Prof & Head, Department of Oral & Maxillofacial Surgery, AIIMS, New Delhi, India.

KEY WORDS :

• Obstructive sleep apnoea• Temporomandibular joint

ankylosis• Blood oxygen saturation• Retrognathia

CONTENTS

Abstract

Introduction

Material and methods

Results

Discussion

Conclusion

References

Abstract • Authors have evaluated the effects of distraction osteogenesis in

management of obstructive sleep apnoea patients secondary to temporomandibular joints ankylosis.

• 15 patients were included in study. Preoperatively the patients were worked up for polysomnography and CT scans. Only those patients with Apnoea-hypopnoea index >15 events/h denoting moderate to severe obstructive sleep apnoea were included in the study.

• Distraction osteogenesis was followed with 5 days latency period in adult patients and 0 days for children.

• Rate of distraction was 1 mm/day for adults and 2 mm/day for children till the mandibular incisors were in reverse overjet.

• After 3 months post distraction assessment was done using polysomnography and CT scan.

• TMJ ankylosis was released by doing gap arthroplasty after distraction osteogenesis.

• Post distraction improvement was seen in clinical features of OSA like daytime sleepiness and snoring.

• Epworth sleepiness scale improved from a mean of 10.25 to 2.25. Polysomnographic analysis also showed improvement in all cases with apnoea-hypopnoea index from 57.03 to 6.67 per hour.

• Lowest oxygen saturation improved from 64.47% to 81.20% and average minimum oxygen saturation improved from 92.17% to 98.19%.

• Body mass index improved from a mean of 18.26 to 21.39 kg/m2.

• By this they concluded that Distraction osteogenesis is a stable and beneficial treatment option for temporomandibular joint ankylosis patients with obstructive sleep apnoea.

INTRODUCTION• Retrognathia whether acquired or congenital leads to reduced

posterior airway space and may cause obstructive sleep apnoea.

• Acquired retrognathia may occur due to temporomandibular joint ankylosis.

• Obstructive sleep apnoea is a sleep-related disorder defined as absence of breathing for 10 or more seconds despite the effort to breathe (Kushida et al).

• Besides having immediate effects of hypoxia, arousal during sleep, snoring and daytime sleepiness, long term repetitive nocturnal upper airway obstruction has a risk of the development of hypertension, stroke and myocardial infarction.

Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman Jr J, et al: Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 28(4): 499e521, 2005 Apri1

• Exposure to intermittent hypoxia leads to oxidative stress, inflammation, atherosclerosis and endothelial dysfunction (Prabhakar).

• Intermittent hypercapnia and hypoxia may be the mechanism responsible for cardiovascular effects of obstructive sleep apnoea due to sustained activation of the sympathetic nervous system (Patel et al).

Prabhakar NR: Physiological and genomic consequences of intermittent hypoxia:invited review: oxygen sensing during intermittent hypoxia: cellular and molecular

mechanisms. J Appl Physiol 90(5): 1986e1994, 2001 May

Patel SR, White DP, Malhotra A, Stanchina ML, Ayas NT: Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive

sleep apnoea: results of meta-analysis. Arch Intern Med 163(5): 565e571,2003 Mar 10

• Obstructive sleep apnoea in retrognathic patients can be treated successfully by mandibular advancement procedures.

• The mandible can be advanced up to 10-12 mm by orthognathic surgery. This advancement is useful only for mild to moderate obstructive sleep apnoea.

• Obstructive sleep apnoea secondary to severe acquired retrognathia usually requires extensive advancement.

• This is easily achieved by using distraction osteogenesis.

• Distraction induces histogenesis of blood vessels, muscles, nerves, cartilages, ligaments, skin and mucosa.

• Mandibular lengthening by distraction osteogenesis is now a commonly used technique to correct congenital and acquired retrognathia (Rao et al., 2004; Shang et al., 2012).

• Distraction osteogenesis is less invasive, can be applied to children and due to histogenesis there is less chance of relapse (Iatrou et al., 2010; Miloro, 2010).

• This study reports the experience in the treatment of obstructive sleep apnoea with distraction osteogenesis in severely retrognathic patients’ secondary temporomandibular joint ankylosis.

MATERIAL AND

METHODS

MATERIAL AND METHODS

• A prospective study including 15 patients with retrognathia were enrolled in the study.

• Retrognathia followed by release of temporomandibular joint ankylosis was done in all 15 cases.

• Mean age was 18.2 years with a range of 2-46 years.

• Male: female ratio was 3:2.

• Institutional review board approval was obtained prior to commencement of the study.

• Preoperatively the patients underwent polysomnography and CT scans.

• Only those patients with an apnoea-hypopnoea index (AHI) >15

events/h, denoting moderate to severe obstructive sleep apnoea

(OSA),were included in the study.

• The distraction vector was planned by computer simulation.

Distraction was done using a stainless steel linear distractor

manufactured by Synthes (GmBh Oberdorf, Switzerland.) in all 15

cases.

• The distractors were placed using a submandibular incision and the

activation arm was taken out through a stab incision in the mental

foramen region.

MATERIAL AND METHODS

a) Pre operative CT.

b) Planning phase pre operative CT showing the 2 possible osteotomy cut in horizontal and vertical ramus.

c) Planning phase pre operative CT showing the desired cut at angle of mandible to have the desired vector for distraction.

d) Planning phase pre operative CT showing computer simulation of planned distraction.

e) Post operative CT showing amount of distraction achieved as proposed in planning phase.

• The standard procedure for distraction

osteogenesis (DO) was followed with a 5 day

latency period in adult patients and 0 day for

children.

• The rate of distraction was 1 mm/day for

adults and 2 mm/ day for children until the

mandibular incisors were in reverse overjet or

edge to edge position.

• The consolidation period was calculated using

3 days for 1 mm of distraction in all cases.

• Patients had polysomnography and CT scan 3 months after

distraction osteogenesis. Further surgery to remove the distractor

was performed after the completion of consolidation period.

• TMJ ankylosis was released 6 months after the removal of

distractors.

MATERIAL AND METHODS

Statistical analysis

RESULTS

• Bilateral advancement was carried out in all cases except one.

• The range of advancement was from 15 to 30 mm, with a mean of 22.4 mm on right side and 23.16 mm on left side.

1. Mandibular advancement

(a) Pre distraction orthopantomogram. (b) Post distraction orthopantomogram showing amount of bone formed.

(b) Post distraction lateral cephalogram.

(a) Pre distraction lateral cephalogram.

• BMI was calculated in all the patients preoperatively and postoperatively after the consolidation period.

• 10 patients were underweight i.e. BMI was less than 18.5. Post-operatively BMI improved from a mean of 18.26 pre operative to 21.39 kg/m2 postoperatively.

2. Body mass index (BMI)

• There was improvement in ESS which decreased from a mean of 10.25 pre distraction to 2.25 post distraction osteogenesis.

• ESS ranged from 3 to 17 and 6 patients had ESS >10 i.e. which indicates that they required some intervention for impaired sleep.

3. Epworth sleepiness scale (ESS)

• Post distraction osteogenesis analysis showed improvement in all 15 cases. • Out of 15 patients, 9 had severe OSA i.e. AHI >30 events/h and 6 had

moderate OSA (AHI 15-30 events/h).

• Post distraction osteogenesis polysomnography showed that all patients were free of OSA i.e. AHI <5 events/h.

4. Polysomnographic analysis

• Mean AHI improved from 57.03 to 6.67 events/h.

• Average minimum oxygen saturation improved from a mean of 92.17 to 98.19% post distraction osteogenesis.

• Mean minimum O2 saturation was 64. 47% pre distraction and improved to a mean of 81.20% post distraction.

• Number of desaturation episodes less than 90% also showed improvement.

• All the patients who were subjected to distraction osteogenesis had a skeletal class II malocclusion. Post distraction osteogenesis all patients were brought to an edge to edge position or even class III.

• After release of ankylosis by gap arthroplasty there was backward positioning of mandible leading to an overjet and overbite of around 2-4 mm.

(a) Pre distraction lateral profile. (b) Post distraction lateral profile.

(a) Occlusion pre distraction. (b) Occlusion post distraction.

• Infection at rod/pin site was noted in 4 patients, infection was managed by oral antibiotics. There was no need for premature removal of distractor in any case.

• In 2 children a tracheostomy was done. One patient had difficult intubation and thus tracheostomy was done as an emergency procedure at the operation table. Another patient had severe hypoxic episode while admitted in ward. Patient aspirated and cyanosed as oxygen saturation fell to 59%. Immediate needle cricothyroidotomy was done to maintain oxygen saturation. This was followed by tracheostomy and distractor placement.

Aspiration pneumonitis was managed by intravenous antibiotics and chest physiotherapy. In both the patients bilateral distraction osteogenesis was done and they were decannulated successfully after the consolidation period and removal of distractors.

• Non-union was encountered in one patient after consolidation period. This was managed with an iliac crest bone graft.

5. Complications

DISCUSSION

• In this study the cause of the retrognathic mandible in all patients was post traumatic, long standing, temporomandibular joint (TMJ) ankylosis. In this situation due to fusion of the condyle to the temporal bone the growth of the mandible was retarded.

• In severe retrognathia the space available for the tongue is diminished and as the tonicity of muscles decreases during sleep the tongue falls back which causes obstruction of the upper airway, resulting in episodes of apnoea.

• Repeated bouts of transient hypoxaemia occur leading to high sympathetic nervous system activity which results in complications like hypertension, angina, stroke, myocardial infarction and cardiac failure (Somers et al., 2008).

• Distraction osteogenesis was performed in all patients before the

release of the TMJ ankylosis, because if TMJ ankylosis is released

before doing distraction osteogenesis then the already diminished

posterior airway space will be further compromised and will pose

problems in the post operative period (tracheostomy may be

needed).

• In all the cases a linear distractor was used for lengthening the

mandible as the only movement required was in the horizontal

ramus.

• The amount of mandibular advancement

required in this study was more than 1.5 cm

(mean 2.2 cm) and in such cases distraction

osteogenesis would be considered as the better

option rather than standard osteotomies.

1. Mandibular advancement

(a) Pre distraction orthopantomogram. (b) Post distraction orthopantomogram showing amount of bone formed.

(a) Pre distraction lateral cephalogram. (b) Post distraction lateral cephalogram.

• In all the adult patients ESS, and in 3 children pediatric sleep

questionnaires, were used (Chervin et al., 2000).

• In all adult patients pre operative ESS values ranged from 3 to 17,

6 patients had an ESS score >10, suggesting that these patients require

some intervention for impaired sleep.

2. Epworth sleepiness scale (ESS)

Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545.

The Epworth sleepiness

scale has been

frequently

recommended as a

standard measure of

daytime sleepiness in

the clinical evaluation

of obstructive sleep

apnoea (Pouliot et al.,

1997; Johns, 2000).

The proposed range for

normal sleep

propensity is 0-10.

(ESS)

• All these patients had apnoea-hypopnoea index 22 on

polysomnography, suggesting that all of them had moderate to severe

obstructive sleep apnoea.

• After distraction there was significant improvement in Epworth

sleepiness scale readings which ranged from 1 to 3.

• This correlates with the study done by Ishikawa et al. (2006).

• In children pre distraction, the pediatric sleep questionnaire score was

more than 10 in all patients and showed significant improvement post

distraction with a maximum score of 5.

Average minimum blood oxygen saturation :• The average minimum oxygen saturation pre distraction was within a range of

74.09-98%. Post distraction average minimum oxygen saturation was found to be in a range from 97 to 99.6%.

• The mean improvement in average minimum blood oxygen saturation was from 92.17% in the pre operative period to 98.19% after distraction osteogenesis.

• Improvement in average minimum oxygen saturation levels after distraction osteogenesis was also shown by Anantanarayanan et al. (2008).

3. Effect on blood oxygen saturation

Minimum blood oxygen saturation:

• The improvement in blood oxygen saturation is because of reduced episodes

of transient hypoxaemia because of the increased space for the tongue, with

no fall back of the tongue to cause obstruction of airway.

• Improvement in mean apnoea-hypopnoea index was seen in all cases.

• Mean apnoea-hypopnoea index in pre distraction cases was 57.03 which improved significantly to 6.67 per hour post distraction.

• This shows that advancement of mandible increases space for tongue and prevents fall back during sleep, thus reducing the episodes of apnoea and hypopnoea.

• This is in correlation with a study done by Wang et al. (2003).

4. Apnoea-hypopnoea Index (AHI)

• In this study they found that number of desaturation episodes of less than 90% oxygen was in the range from 13 to 682 pre distraction and from 2 to 48 in post.

• Improvement was seen in the mean number of desaturation episodes less than 90% pre distraction from 213.4 to 24.13 post distraction.

• There was significant improvement in all cases (p-value is 0.001).

• Improvement in desaturation in turn reduces the chances of transient hypoxaemia and thus reduces chances of complications associated with obstructive sleep apnoea.

5. Number of desaturation episodes less than 90% oxygen

• According to World Health Organization classification any person with a body mass index less than 18.5 is underweight.

• In the present study 10 patients were underweight. Post distraction osteogenesis there was significant improvement in body mass index in these patients (p-value is 0.001), with a mean body mass index pre distraction of 18.26 to a post distraction of 21.39.

• This could be because as obstructive sleep apnoea was relieved after distraction osteogenesis, there was increased delivery of oxygen to tissues, which leads to improved metabolism in all patients, hence improved body mass index.

6. Body mass index

• They noted that improvement in facial profile, snoring and daytime

sleepiness can be achieved by distraction osteogenesis in retrognathic

patients and in patients like those in the present study, where the

amount of advancement needed is more than 10 mm, distraction

osteogenesis can be considered as it causes tension across the

osteotomy and induces bone formation and histogenesis of blood

vessels, muscles, nerves, cartilages, ligaments, skin and mucosa

(Aronson et al., 1990, 1988, 1989). Thus there is less chance of

relapse as compared to orthognathic surgery.

7. Clinical features

• In the study 4 patients had infection at rod/pin site and this was managed by daily dressings and oral antibiotics. This may be due to the long consolidation period and less compliance on the patient’s part.

• In 2 children tracheostomy was done prior to distraction osteogenesis and post distraction osteogenesis both patients were decannulated successfully.

• This again was due to reduced airway space and frequent upper respiratory tract infections in the children, further compromising the already diminished airway space leading to severe apnoea and drastic falls in blood oxygen saturation, requiring emergency tracheostomy to improve blood oxygen saturation by bypassing the upper airway.

8. Complications

• Mandibular distraction osteogenesis increases the airway space, allowing successful removal of tracheostomy (Iatrou et al., 2010).

• Non-union was seen in one of the patient even after the completion of consolidation period this may be due to poor patient compliance because of lengthy treatment period.

CROSS REFERENCES

2510 North Frontage RoadDarien, IL 60561(630) 737-9700www.aasmnet.org ©AASM 2008

Types

• Mild OSA: AHI of 5-15

Involuntary sleepiness during activities that require little

attention, such as watching TV or reading

• Moderate OSA: AHI of 15-30

Involuntary sleepiness during activities that require some

attention, such as meetings or presentations

• Severe OSA: AHI of more than 30

Involuntary sleepiness during activities that require more

active attention, such as talking or driving

A. Moderate to severe obstructive sleep apnoea secondary to temporomandibular joint ankylosis can be successfully treated by distraction osteogenesis of the mandible followed by the release of temporomandibular joint ankylosis after 6 months of distraction osteogenesis.

B. Improvement in facial profile, BMI and ESS scores can be achieved by doing distraction osteogenesis in retrognathic patient secondary to temporomandibular joint ankylosis associated with obstructive sleep apnoea.

C. Drawbacks of distraction osteogenesis include the need more patient compliance, second surgery for removal of the distractors and frequent visits to hospital. Noncompliant patients result in unfavourable outcomes.

CONCLUSION

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