The external devices were used initially because theinternal devices were not available at the time we startedthis work. The average movement was 15mm of maxil-lary advancement. All patients have maintained the dis-traction advancment with excellent clinical results. Dis-traction osteogenesis techniques should be consideredto use for the patients that require large advancements ofthe maxilla due to cleft related skeletal deformities toincrease stability of the movements as well as use as astaging procedure in the younger teen population toimprove function and psychosocial acceptance earlier.

References

Figueroa A, Polley J, Ko W-C: Maxillary distraction for the manage-ment of cleft maxillary hypoplasia with a rigid external distractionsystem. Semin Orthod 5:46, 1999

Samchukov, Cope, Cherkashin: Molina maxillary distraction osteo-genesis craniofacial distraction osteogenesis. 494, 2001

Bell GC: Intraoral distraction. Distraction of the Craniofacial Skele-ton, McCarthy, 1999, pp 219-248

Pre-surgical Nasoalveolar Molding(PNAM) Therapy for the Treatment ofUnilateral Cleft Lip and Palate: APreliminary StudyJaime Gateno, DDS, MD, 6550 Fannin Street, Ste.2237,Houston, TX 77030 (Teichgraeber JF; Chavarria C;Ezzat CF; Stratmann R; Chen AJW; Xia JJ)

Statement of the Problem: The purpose of this studywas to evaluate the outcome of presurgical nasoalveolarmolding (PNAM) therapy in the treatment of patientswith non-syndromic unilateral cleft lip and palate.

Materials and Methods: PNAM therapy was used in thetreatment of 12 patients with unilateral cleft lip andpalate. The average age of the patients at initial impres-sions was 26 days. Intraoral and extraoral casts weremade before and after the therapy and digitized into acomputer. All images were calibrated and processedusing image processing software. The images were mea-sured for columellar deviation, bialar width, nostrilheight, nostril width, columellar width, intersegmentalveolar cleft distance, and posterior maxillary width.

Method of Data Analysis: The measurements weretabulated in Microsoft Excel. The SPSS 10.0 softwarepackage (SPSS Inc, Chicago, IL) was used to performstatistical analyses. Two-tail paired t-tests were used totest the differences of the measurements between pre-and post-therapy. Finally, multiple linear regressionswere performed.

Results: After PNAM therapy, there was a statisticallysignificant decrease in the intersegment alveolar cleftdistance, and the columellar deviation (P � 0.05).There was also a statistically significant increase in cleftnostril height, maxillary width, and columellar (P �

0.05). A statistically significant approximation in heightand width of the affected cleft nostril and the nonaf-fected nostril was also noted (P � 0.05). The length ofthe time the patient utilized the appliance and post-molding nostril height were found to have a statisticallysignificant positive correlation (P � 0.05).

Conclusion: PNAM therapy decreases intersegment al-veolar cleft distance while permitting an increase inposterior maxillary arch width. It also increases nasalsymmetry by decreasing columellar deviation, increasingnostril height on the affected side, maintaining bialarwidth of nose, increasing columellar width, creatingmore symmetrical nostril heights / widths. The improve-ment of the height of the cleft nostril is correlated to thetime when the appliance was applied.

References

Matsuo K, Hirose T: Preoperative non-surgical over-correction ofcleft lip nasal deformity. Br J Plast Surg 44:5, 1991

Grayson BH, Santiago P, Brecht L, et al: Presurgical naso-alveolarmolding in infants with cleft lip and palate. Cleft Palate Craniofac J36:486, 1999

Intubation Difficulties Associated WithObstructive Sleep Apnea SyndromeChad Robertson, DDS, MD, 1278 Tower Road, Halifax,Nova Scotia B3H 2Y9, Canada (Morrison A;Goodday R)

Statement of the Problem: There have been severalreports in the literature regarding anesthetic complica-tions associated with obstructive sleep apnea syndrome(OSAS) patients. Intubation has been cited as one of thedifficulties associated with OSAS patients undergoinggeneral anesthetic. Obesity is thought to be a risk factorfor difficulty during intubation. The purpose of thisstudy was: 1. To compare intubation difficulties betweena group of patients undergoing maxillomandibular ad-vancement (MMA) surgery for OSAS and a group ofpatients undergoing the same surgical procedure for thetreatment of dentofacial deformities. 2. To compare pa-tients’ Body Mass Index (BMI) with intubation difficul-ties.

Materials and Methods: The anesthetic records of pa-tients who received MMA surgery for the treatment ofOSAS and of patients who received maxillary and man-dibular osteotomies for the treatment of a dentofacialdeformity between January 2002 and Febuary 2004 werereviewed. A difficult intubation was defined as: 1. Theuse of any intubation technique other than direct laryn-goscopy. 2. Failure to properly place the endotrachealtube using direct laryngoscopy. Inclusion criteria for theOSAS group was any patient with an AHI greater than 10who received MMA surgery under general anestheticbetween the specified dates. A total of 40 patients wereincluded (34 male; 6 female). The control group con-

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sisted of the 40 most senior of the 590 patients who hadorthognathic surgery for the treatment of a dentofacialdeformity during the same time period (11 males and 29females). All 40 patients in the control group had max-illary and mandibular advancement surgery to correcttheir deformity.

Method of Data Analysis: A t-Test was calculated tocompare the two groups with respect to age and BMI.Fisher’s Exact Test was used to compare intubation dif-ficulties between the two groups. A relative risk ratio forintubation difficulty in relation to BMI was calculated.

Results: The two groups were found to be statisticallydifferent with respect to age and BMI (p � 0.05). Theaverage age in the OSAS group was 45 years (range 33 to58). The average age in the orthognathic group was 35(range 22 to 54). The average BMI in the OSAS groupwas 34.3 (range 24.4 to 62.4). The average BMI in theorthognathic group was 23.8 (range 17.9 to 39.2). Fiveof the 40 OSAS patients (12.5%) were found to have haddifficult intubations. One of the 40 orthognathic patients(2.5%) had a difficult intubation. The Fisher Exact Testwas calculated and there was no statistically significantdifference with respect to intubation difficulties be-tween the two groups (p � 0.201). A 5 unit increase inBMI resulted in a relative risk of 1.6 (1.1-2.1) for diffi-culty during intubation in this patient population.

Conclusion: In this patient population:1. There was no statistically significant difference

found between the OSAS and the orthognathicgroup with respect to intubation difficulties.

2. A high Body Mass Index is associated with in-creased risk for intubation difficulties.

References

Benumof JL: Obstructive sleep apnea in the adult obese patient:Implications for airway management. J Clin Anesth 13:144, 2001 (re-view)

Brio P, Kaplan V, Bloch KE: Anesthetic management of a patientwith obstructive sleep apnea syndrome and difficult airway access.J Clin Anesth 7:417, 1995

The Effect of MaxillomandibularAdvancement Surgery on ControlledPositive Airway Pressure (CPAP) Use inPatients With Obstructive Sleep ApneaCurtis Gregoire, BSc, DDS, 1278 Tower Road, Halifax,Nova Scotia B3H 2Y9, Canada (Goodday R; Robertson C)

Statement of the Problem: CPAP is currently consid-ered the gold standard for treatment of ObstructiveSleep Apnea Syndrome (OSAS). Unfortunately, becauseof physical discomfort associated with wearing the unit,drying of the nasal and oral mucous membranes, dis-lodgement during sleep, noise, and the social conse-quences of its use, long-term compliance on a nightlybasis can be as low as 25%. This has led to the develop-

ment of many alternative treatments for OSAS. Maxillo-mandibular Advancement Surgery (MMA) is one of thesurgical alternatives and has demonstrated good successalong with high levels of patient satisfaction. It is impor-tant for patients looking for alternatives to knowwhether or not MMA can eliminate the need for CPAP.The purpose of this study was to determine what effectMMA surgery has on post-operative CPAP use.

Materials and Methods: A retrospective study was car-ried out on patients who underwent MMA surgery forthe treatment of OSAS between March 1997 and Octo-ber 2004. Information was gathered concerning pre-operative CPAP use and post-operative CPAP use 6 to 12months after MMA surgery.

Method of Data Analysis: The pre and post-operativedata were compared and analyzed using McNemar’sTest.

Results: Complete data regarding CPAP use was avail-able for 76 of 106 patients who underwent MMA surgerybetween the specified dates. This included 62 males and14 females ranging in age from 29 to 67 years. Of thisgroup, 59 patients used CPAP as treatment for OSASprior to MMA surgery. All patients experienced dissatis-faction with using CPAP. Thirty patients (51%) said CPAPwas difficult to tolerate and as such they rarely used it.Twenty-six patients (44%) reported they used CPAP reg-ularly but did not like using it. Three patients toleratedCPAP but wished to seek a treatment alternative thatwould eliminate the inconvenience of using the appara-tus. Fifty-five of the 59 patients (93%) did not require itsuse following surgery. Four of the 59 patients (7%) re-quired continued use of CPAP following surgery. Thereduction in CPAP use following MMA surgery wasfound to be statistically significant (p � 0.001).

Conclusion: In this OSAS patient population:1. Dissatisfaction with CPAP was a major factor in

seeking MMA surgery.2. MMA surgery reduced the need for CPAP use

post-operatively by 93%.

References

Collard P, Pieters T, Aubert G, et al: Compliance with nasal CPAP inobstructive sleep apnea patients. Sleep Med Rev 1:33, 1997

Souter MA, Stevenson S, Sparks B, et al: Upper airway surgerybenefits patients with obstructive sleep apnoea who cannot toleratenasal continuous positive airway pressure. J Laryngol Otol 118:270,2004

Mid-Maxillary Internal DistractionOsteogenesis: Ideal Surgery for theMature Cleft PatientChristopher Kang, DDS, MD, 1 Linden Place, Apt 309,Hartford, CT 06106 (Ritoli EL; Mabry K; CastiglioneCL; Bevilacqua RG)

Statement of the Problem: Distraction osteogenesis isa technique for bone lengthening where gradual separa-

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48 AAOMS • 2005