Skeletal surgery for obstructive sleep apnea (OSA) aims to provide more space for the soft tissue in the oropharynx to prevent airway collapse during sleep. Conventional surgical techniques include genioglossus advancement (GA), hyoid myotomy/suspension (HMS), and maxillomandibular advancement (MMA). GA and HMS are usually performed with soft tissue surgery and/or other skeletal surgery in a combined manner. These combined procedures seem to have a higher success rate. MMA employs a different conceptual approach, so called whole upper airway reconstruction, because MMA can widen the entire upper airway with one procedure. Various modifications of skeletal surgery have been reported. Surgical techniques, efficacy and complications of skeletal surgery with my opinions and comments are introduced in this review. Furthermore, limitations and considerations in skeletal surgery that sleep surgeons have to realize and overcome will be discussed in this review.
Mandibular Advancement ; Oropharynx ; Sleep Apnea Syndromes ; Sleep Apnea, Obstructive*

BACKGROUND: The Mandibular advancement device (MAD) was known to be one of the effective treatments for the broad spectrum of sleep related breathing disorders. The aim of the present study was to evaluate the therapeutic effects and the determinants of success or failure of MAD in patients with sleep-related breathing disorders (SRBD). METHODS: We enrolled 20 patients with SRBD confirmed by overnight polysomnography. All patients were fitted with temporary MAD. Apnea-hypopnea index (AHI) and risk index (RI) were measured by a portable respiratory- monitoring device (MESAM IV) before and after temporary MAD use. RESULTS: Overall, MAD significantly reduced AHI (18.9+/-11.6/hr to 13.8+/-11.9/hr, p=0.029), but Epworth sleepiness scale was not improved (10.9+/-3.9 to 9.8+/-3.9, p=0.086). More than 50% of reduction in AHI was observed in 6 patients (30%, 6/20). When subjects were divided into patients who were satisfied with the temporary MAD and decided to keep wearing permanent MAD during the night (good response, GR, N=12) and patients who refuse to wear permanent MAD because they could not get accustomed to the temporary MAD (poor response, PR, N=8), There were no differences in age, body mass index, and pre-treatment AHI during the overnight polysomnography between both groups. There were significant reductions in AHI, and ESS were observed in GR, not in PR. Seven patients in GR group decided to apply the permanent MAD (two-piece Herbst type). CONCLUSIONS: These findings suggested that having good response to MAD determined the improvement of SRBD and daytime sleepiness. However, it is uncertain whether other factors affected the patients' compliance to MAD.
Body Mass Index ; Compliance ; Humans ; Mandibular Advancement* ; Polysomnography ; Respiration*

OBJECTIVES: The purpose of this study was to estimate the safety and efficacy of a mandibular advancement device (MAD), 'Bioguard,' for the treatment of obstructive sleep apnea (OSA). METHODS: In this 5-week prospective, multi-center, single group, and non-inferiority trial, patients who chose 'Bioguard' as their treatment option were evaluated using both questionnaires (Pittsburgh Sleep Quality Index (PSQI), Epworth sleepiness scale (ESS)) and polysomonography (PSG) (apnea hypopnea index (AHI), oxygen saturation). All patient data, including clinical records, PSG studies (both pre- and post-treatment), and adverse events (AEs), were reviewed and analyzed. RESULTS: Results were obtained for 59 of 62 patients (95.16%). No significant difference in success rate was found between the MAD treatment and surgical treatment (95% CI). AHI, PSQI, ESS and oxygen saturation demonstrated significant improvement (p < 0.001) after MAD treatment, and 39 of 62 patients (62.9%) reported 85 AEs. 79 of the 85 AEs (91.8%) were mild cases, and there were no severe AEs related to the MAD treatment. CONCLUSION: The MAD 'Bioguard' should be considered as an alternative treatment option for OSA patients.
Humans ; Mandibular Advancement* ; Oxygen ; Prospective Studies* ; Sleep Apnea, Obstructive*

The purpose of this study was to evaluate the resistant force of medial pterygoid muscles against the mandibular advancement and distraction to anterior, and inquire into the relationship between medial pterygoid muscles and cephalometric variables. Sixty six patients with class III malocclusion underwent bilateral sagittal splitting of ramus with intraoralvertico-sagittal ramus osteotomy for mandibular set-back. The spring scale was used to measure the resistance of medial pterygoid muscles after splitting of ramus. Skeletaldental cephalometric analysis was made and statistic package was used for correlation between resistance and cephalometric variables. The resistant force of the right medial pterygoid muscle was greater than the left one in Koreans with class III malocclusion, and the force had a linear regression relationship with facial depth. The results suggested that facial depth has significant correlation with the resistance of medial pterygoid muscle, which can be acquired from patient's cephalometric analysis.
Humans ; Linear Models ; Malocclusion ; Mandibular Advancement ; Osteotomy ; Pterygoid Muscles*

Humans ; Mandibular Advancement ; Osteogenesis, Distraction ; Sleep Apnea, Obstructive ; diagnosis ; surgery

OBJECTIVEThis study investigated the reconstructed mandibular condylar cartilage and the ultrastructural variations in mandibular condylar cartilage in adult rats as a result of mandibular advancement.

METHODSThirty 9-week-old male Sprague-Dawley rats were randomly divided into experimental and control groups. Rats in the experimental group were subjected to mandibular advancement. Rats were sacrificed on days 3, 7, 14, 21, 30. Sections were cut from condyles, and bone morphogenetic protein-2 (BMP-2) expression in condylar cartilage was examined through immunohistochemical analysis. Condylar cartilage samples were harvested, and ultrastructural changes in these samples were observed under Micro-CT and transmission electron microscope.

RESULTSCompared with the control group, the experimental group obviously displayed cartilage hyperplasia in the middle and rear of the condyle. Moreover, the number of BMP-2-positive cells in condylar cartilage and the gray value gradually increased in the experimental group on day 7 of the intervention. Ultrastructural changes, such as karyopyknosis, reduced microfilaments around the nucleus, reduction in size or even disappearance of lipid droplets, swelling of endoplasmic reticulum compartments, broadened and increased extracellular matrix, were observed in the condylar hypertrophic chondrocytes. Micro-CT revealed that the trabecula and the newly formed bone gradually thickened.

CONCLUSIONSHypertrophic remodeling of the condylar cartilage and high BMP-2 expression are observed in adult rats as a result of continuous mandibular advancement.

OBJECTIVETo investigate the changes in expression of gelatinase (MMP-2, MMP-9) in young rat condylar cartilage during functional mandibular advancement.

METHODSSixty male 5-week old SD rats were divided into experimental and control groups. The mimic functional appliances were used in experimental group rats. The animals were sacrificed after 1, 2, 4 weeks. The immunoreactivity of gelatinase was detected by immunohistochemistry.

RESULTSIn normal mandibular condylar cartilage, the immunoreactivity of MMP-2 was rather strong, the immunoreactivity of MMP-9 was very weak. Following functional mandibular advancement, the expression of MMP-9 was significantly increased (P < 0.01), but immunoreactivity of MMP-2 had no significant changes.

CONCLUSIONGelatinase plays an important role in the adaptive remondling of young rat condylar cartilage during functional mandibular advancement.

mandibular retrognathism is represented by two methods, distraction osteogenesis (DO) and mandibular osteotomy surgery. The DO is mostly preferred when the degree of advancement of mandible is large. However, the postoperative stability of mandibular advancement using DO have not been actively investigated. Therefore, in the present study we have compared the postoperative stability between DO and bilateral sagittal split ramus osteotomy (BSSRO) in mandibular retrognathism.METHODS: Seven patients who had been treated by DO and thirteen patients with BSSRO were included in this study. Serial lateral cephalograms were analyzed by manual tracing and the amount of the mandibular elongation was measured. To evaluate the postoperative stability, positional changes of the condylar position and B point were analyzed.RESULTS: Mean amount of mandibular advancement was 6.51+/-3.57 mm for BSSRO group and 12.43+/-4.35 mm for DO group, respectively. There was no significant difference in age between the two groups (P>0.05). Mean follow up periods were 10.77 months for BSSRO group and 11.28 months for DO group, respectively. After mandibular advancement, mean positional changes in the condyle were 0.56+/-1.43 mm horizontally and 0.72+/-1.61 mm vertically for BSSRO group and 0.53+/-1.56 mm horizontally and 0.56+/-1.75 mm vertically for DO group, respectively. Mean change of distance from B point to Y-axis was -1.76+/-0.83 mm for BSSRO group and -2.14+/-1.82 mm for DO group, respectively. According to the condylar position and B point, there were no significant differences in postoperative stability between the two groups (P>0.05).CONCLUSION: There was no significant difference in postoperative stability between DO and BSSRO group according to condylar position and B point. Based on the results of the present study, it is hypothesized that DO would be a good treatment choice for severe mandibular retrognathism because DO could achieve more mandibular advancement and concurrent soft tissue elongation.]]>
Follow-Up Studies ; Humans ; Mandible ; Mandibular Advancement ; Mandibular Osteotomy ; Osteogenesis, Distraction ; Osteotomy, Sagittal Split Ramus ; Retrognathia

Mandibular retrusion showing the facial problem with a marked maxillarry incisors protrusion and chin deficiency, resulting in a highly convex profile is uncommon in Korea.. The large incisor overjet and deep-bite create functional limitations and unpleasing esthetic result. The majority of theses cases are susceptible to correction by orthodontic therapeutic methods. But severe Class II retrognathic cases in which orthodontic treatment alone has not been capable of achieving good results. Orthognathic surgery offers several approaches. In this case, mandibular advancement by bilateral sagittal split ramus osteotomy and augmentation genioplasty has a special surgical problems. The suprahyoid muscle gorup are lengthened if the body of the mandible is surgically repositioned anteriorly. Instability of results and relapse return to original position shoud predicted during post-surgical muscular readjustment.. To maintain maximum correction with this technique, it is suggested that the mandibular body be well rotated forward at time of surgical intervention and overcorrected anteriory as much as possible. So, the authors report the case with review of concerned literature.
Chin ; Genioplasty ; Incisor ; Korea ; Mandible ; Mandibular Advancement ; Orthognathic Surgery ; Osteotomy, Sagittal Split Ramus ; Overbite ; Recurrence ; Retrognathia*

OBJECTIVES: The aim of this study was to investigate the effects of advancement magnitude and changes in mandibular plane angle on the stability of mandibular advancement. MATERIALS AND METHODS: This retrospective cohort study evaluated the postoperative stability of mandibular advancement in class II skeletal subjects who underwent bilateral sagittal split osteotomy. Radiographs taken preoperatively, immediately postoperatively and 1 year postoperatively were traced and analyzed using linear and angular measurements. To determine horizontal and vertical relapse, an X-Y coordinate system was established in which the X-axis was constructed by rotating S-N downward by 7° (approximation of the Frankfort horizontal plane) and the Y-axis was defined as a line perpendicular to the X-axis and passing through the point Sella. For certain reference points including point A, point B, pogonion and menton, the perpendicular distance between each point and both axes was determined and cephalometric variables were recorded as X and Y coordinates. RESULTS: Twenty-five subjects were studied. A significant correlation between the amount of mandibular advancement and relapse in the B point (vertical and horizontal) and the pogonion point was observed (vertical and horizontal, P<0.001). Evaluation of data demonstrated a positive correlation between the mandibular plane angle (SN/ML) change and vertical relapse in the B point (P<0.05). A simple regression model demonstrated that 74% of horizontal relapse and 42.3% of vertical relapse in the B point was related to the amount of mandibular advancement. The receiver operating characteristic test showed that 8.5 mm mandibular advancement is related to a relapse rate of 1 mm or more in the pogonion, vertically or horizontally. CONCLUSION: The magnitude of mandibular advancement is a stronger surgical predictor for horizontal rather than vertical relapse at the B point. Changes in mandibular plane angle (SN/ML) during surgery affect vertical, but not horizontal relapse at the B point.
Cohort Studies ; Mandible ; Mandibular Advancement* ; Orthognathic Surgery ; Osteotomy ; Recurrence ; Retrospective Studies ; ROC Curve