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BILATREAL INTRABILATREAL INTRA--ORAL DISTRACTION ORAL DISTRACTION OSTEOGENESIS FOR THE OSTEOGENESIS FOR THE
MANAGEMENT OF OBSTRUCTIVE SLEEP MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA IN EARLY CHILDHOODAPNEA IN EARLY CHILDHOOD
By
Amgad A. Farhat*Amgad A. Farhat*; Abd El-Fattah A. ; Abd El-Fattah A. Sadakah** & Mohammad A. ElshalSadakah** & Mohammad A. Elshal****
*Chest Department, Faculty of Medicine and **Oral & Maxillofacial Department, Faculty of Dentistry ;
Tanta University.
الرحيم الرحمن الله بسم
Sleep apnea may frequently occur in early childhood, but it is usually unnoticed.
The potential for airway obstruction is further increased by supine positioning, neck flexion and increased secretions during sleep.
Sleep apnea is one of the most frequent manifestations of respiratory obstruction.
Historically this clinical entity has stimulated the production of numerous valuable contributions with one purpose in mind: the improvement of airway patency.
In 1937, Callister used a pediatric neurosurgical back-brace with a halo, with the infant imprisoned in this device.
Longmire and Sanford, 1949, used orthopedic weight hangers and pulleys attached to the patient with circum-mandibular wire.
Complications:
Frequent cutting through the symphysis &TMJ ankylosis.
Children born with a diminutive mandible present a challenge to pediatric specialists, because of the potential for airway obstruction.
(Schaefer et al., 2004).
Pierre Robin sequence:
Mandibular deficiency.Glossoptosis.With or without cleft palate.
(Schaefer et al., 2004)
Recent literature has suggested that facial skeletal advancement using distraction
osteogenesis might be beneficial in those children with obstructive sleep apnea
secondary to midface hypoplasia or retromicrognathia and lack of tongue support.
(Burstein et al., 1995).
Introduction
Early distraction
procedures used extra oral devices that caused facial scarring with the
potential for facial nerve damage.
(Chris et al., 1999).
Introduction
More recently, intra oral subperiosteal appliances have been developed with the advantages of:
Lack of external scars. Less soft tissue trauma. Near total concealment of the device. Superior psychological tolerance.
Introduction
However, in infants and young children, there is no enough room subperiosteally to accommodate the whole distractor.
In this article, we report our In this article, we report our experience in correcting mandibular experience in correcting mandibular
micrognethia accompanying micrognethia accompanying obstructive sleep apnea syndromeobstructive sleep apnea syndrome
(Pierre Robin sequence)(Pierre Robin sequence) by bilateral by bilateral DO using a modified technique for DO using a modified technique for
submucosalsubmucosal intra-oral distractor intra-oral distractor placement. placement.
Aim of the workAim of the work
Patients and MethodsPatients and Methods
Patients and Methods
During the last five years, a total of 7 patients with mandibular micrognethia (diagnosed with isolated Pierre Robin sequence) accompanying obstructive sleep apnea syndrome were treated with bilateral mandibular distraction osteogenesis, using an intraoral unidirectional submucosal unburied distractor (MARTIN DISTRACTOR).
Patients and Methods
Patients and Methods
Sex: 3 M & 4 F
Age range: 7 mo – 7.5 yr
Follow-up: 2 – 5 yr (range)
Patients were:Neurologically free.Without associated syndromes.
Pt. NoAgeSexPathology
17 moMale
Severe bilateral mandibular hypoplasia.Sleep apnea.
Difficult feeding.
220 moFemale
Severe bilateral mandibular hypoplasia.Sleep apnea.
Difficult feeding.Cleft palate.
37.5 yrFemale
Severe bilateral mandibular hypoplasia.Sleep apnea.
Disturbed occlusion and difficult mastication.
420 moMale
Severe bilateral mandibular hypoplasia.Sleep apnea.Cleft palate.
Difficult feeding
54.5 yrMale
Severe bilateral mandibular hypoplasia.Sleep apnea.
Disturbed occlusion and difficult mastication.
65 yrFemale
Severe bilateral mandibular hypoplasia.Sleep apnea.
Disturbed occlusion and difficult mastication.
76 yrFemale
Severe bilateral mandibular hypoplasia.Sleep apnea.
Disturbed occlusion and difficult mastication.
Limitation of jaw movement.
Previous failed managementPrevious failed management::
PositioningPositioning… in all patients.… in all patients.
Tongue/lip adhesionTongue/lip adhesion… in 2 … in 2 patients.patients.
Criteria for diagnosis of obstructive Criteria for diagnosis of obstructive sleep apnea OSAsleep apnea OSA
1.1. SnoringSnoring. .
2.2. DayDay--time somnolence and reduced time somnolence and reduced activitiesactivities..
3.3. Less than 85% oxygen saturationLess than 85% oxygen saturation..
4.4. Apnea/hypoapnea index > 5.Apnea/hypoapnea index > 5.
The criteria for cure:The criteria for cure: Disappearance of clinical symptoms.Disappearance of clinical symptoms.Absence of apneic attacks during sleep Absence of apneic attacks during sleep hours.hours.Lowest oxygen saturation more than 85 %.Lowest oxygen saturation more than 85 %.Apnea/hypoapnea index < 5.Apnea/hypoapnea index < 5.
Patient Examination:Patient Examination: Clinical.Clinical.
Maxillo-Mandibular Maxillo-Mandibular discrepancy discrepancy
> 8 mm.> 8 mm.
Patient Examination:Patient Examination:
Radiographiclly;Radiographiclly; lateral lateral cephalometry and cephalometry and panoramic views.panoramic views.
Patients and Methods
Radiographic analysisRadiographic analysis::
Airway obstruction at the Airway obstruction at the tongue-base level.tongue-base level.
Required length of Required length of distraction:distraction:
Range, 14 -20 mm.Range, 14 -20 mm.
Average, 17.4 mm. Average, 17.4 mm.
Over-correction by about Over-correction by about 2-3 mm. 2-3 mm.
Airway measurements
Patient Examination:Patient Examination:
All patients were subjected to diagnostic sleep All patients were subjected to diagnostic sleep study at night for at least 7 hours in sleep study at night for at least 7 hours in sleep laboratory, Chest Department, Tanta laboratory, Chest Department, Tanta University, EgyptUniversity, Egypt
Polygraphic examination.. Before, at Polygraphic examination.. Before, at the end of activation and 3 months the end of activation and 3 months after consolidation.after consolidation.
Surgical ProcedureSurgical ProcedureThe modified technique for distractor application
(unburied device)
Distraction ProtocolDistraction Protocol
Latency.. Latency.. 3 days3 days. .
Rate .. Rate .. 0.5 mm twice/ 0.5 mm twice/ dayday. .
Period .. Period .. 17-24 days17-24 days..
Consolidation.. Consolidation.. 4 weeks4 weeks..
ResultsResults
Results
The subjective symptoms of all patients had disappeared completely or had been alleviated after completion of mandibular distraction osteogenesis.
No infection.
No permanent nerve injury.
No facial scaring
No psychological problems to parents
Pre-Distraction Post-Distraction
Mean 70.5% , Range 31-125%
Mean values ofMean values ofPredistractionPredistractionPostdistractionPostdistraction
Posterior airway space (mm)Posterior airway space (mm) 6.66.6 14.514.5
SNB angle (degrees)SNB angle (degrees) 6868 7979
Apnea hypoapnea indexApnea hypoapnea index 60 (9.8-126.5)60 (9.8-126.5) 1.57 (0-16.4)1.57 (0-16.4)
Lowest oxygen saturation (%)Lowest oxygen saturation (%) 8080 9898
The distraction procedure was smooth, and good new bone formed in the distraction gap, except in 2 patients; where an unequal bone formation was seen radiologically.
Complication
Occlusion:
Post. Cross-bite.. 5 Pt. Ant. Open-bite.. 2 pt.
Long-term follow-up:
Near normal occlusion
(orthodontic treatment)
TMJ:
1. abnormal shape of the condylar process in 3 condyles.
2. a case of unilateral ankylosis was diagnosed 4 years after completion of distraction.
Relapse:
One patient
Age at primary distraction was 7months.
Pt No 1
Onset of relapse was about 3 years later, accompanied with unilateral TMJ ankylosis.
Pt No 1
Pre
Pre
Pre
Post
Re-Distraction was performed at 4.5 years of age with good results.
Pt No 1
Post 1st Dist.
Pre
Post 2nd Dist.
Pt No 1
Post
During
Pre
Pt No 3
Post-Distraction. Long-term follow-up.
Pt No 3
Post
4.5 yrs
Pre
Pt No 5
Post
4.5 yrs
Pt No 5
Post.. Long-term follow-up
Pt No 5
Post
During
Pt No 6
Post
Pt No 6
CONCLUSION
Conclusion
Distraction osteogenesis can consistently produce
a measurable cross-section airway in patients as young as 7 months.
The tongue base reliably follows the distal
segment of the mandible anteriorly.
DO caused significant improvement in obstructive sleep apnea & lowest oxygen saturation during
sleep.
Conclusion
The advantages of the modified technique used in this study showed the following:
Limited periosteal stripping. Less infection possibility. Better monitoring of the distraction procedure. Easier distractor removal.
AcknowledgementProf
Abd El-Fattah A. SadakahProf of Oral & Dental surgery & President of Tanta
All staff members of Chest & Radiology
Departments, Tanta University Hospitals, Egypt,
My wife, Dr. Ghada Atef AttiaLecturer of Chest Diseases – Tanta Faculty of
Medicine
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