942.ppt

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

Universitysadakah@tanta.edu.eg

All staff members of Chest & Radiology

Departments, Tanta University Hospitals, Egypt,

My wife, Dr. Ghada Atef AttiaLecturer of Chest Diseases – Tanta Faculty of

Medicine