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British Journal of Oral and Maxillofacial Surgery 53 (2015) 104–106
Technical note
Simple and atraumatic technique for the advancement of the genioglossus muscle for treatment of obstructive sleep apnoea T.-K. Kim, D.-W. Lee ∗ , S.-S. Jue, Y.-D. Kwon Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, Kyung Hee University, Seoul 134-727, Republic of Korea Received 20 March 2014; accepted 8 October 2014 Available online 1 November 2014 Keywords: Obstructive sleep apnea; Sleep apnea; Genioglossus muscle; Genioglossus muscle advancement; Genioglossus advancement; Upper airway; Minimal invasive technique; Facial profile; Simple technique; Atraumatic technique
Obstructive sleep apnoea is the most common type of sleep apnoea that results from obstruction of the upper airway, and genioglossal advancement is an effective way to improve the upper airway in some of these patients. Various types of osteotomy have been designed for the advancement of the genioglossus muscle and the genial tubercle complex.1 We describe a new method that uses a specially designed initial trephine drill for indentation, a final trephine drill for bicortical osteotomy, and a C-shaped plate that supports the advanced bony segment from the inside and is stepped lingually to secure the space for the lingual cortical bone without changing the facial profile (Fig. 1).2 Cone-beam computed tomography (CT) and lateral cephalometric radiographs were taken preoperatively to evaluate the distance from the incisal tip of the mandibular incisor to the genial tubercle, the length of the incisal root, and the thickness of the mandible.3 The vertical incision was made about 25 mm long on the mandibular midline, and undermined laterally to expose just enough space for placement of the trephine drill outside the incision in the mentalis muscle. The initial trephine drilling
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, #892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Republic of Korea. Tel.: +82 2 440 7500; fax: +82 2 440 7549. E-mail addresses: [email protected], [email protected] (D.-W. Lee).
was through the genial tubercle area a minimum of 5 mm below the apex of the root to prevent damage.4 The osteotomy was extended lingually using the final trephine drill to incorporate the genial tubercle as shown in the guidelines for cone-beam CT. Before the osteotomy was completed, a titanium screw was placed in the labial cortex to manipulate the bony segment. After successful bicortical osteotomies, the bony segment was advanced using this titanuim screw and forceps. We then installed the C-shape plate to support the segment from the inside, because the advanced segment
Fig. 1. Newly designed drills and plate. A = the initial trephine drill for indentation, B = the final trephine drill for bicortical osteotomy, and C = the C-shaped plate designed to fix the advanced bone flap easily.
http://dx.doi.org/10.1016/j.bjoms.2014.10.004 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
T.-K. Kim et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 104–106
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Fig. 2. The vertical incision was made on the mandibular midline, and the flap was raised minimally to place the trephine drill without a mentalis muscle incision. After initial trephine drilling for indentation, we made a bicortical osteotomy on the genial tubercle area using the final trephine drill (A). After the bicortical osteotomy, the bone segment was advanced (B). The labial bone segment was contoured, and the advanced lingual bone segment was fixed by C-shape plate and common plate (C and D).
Fig. 3. Preoperative lateral cephalometric radiograph (A) and postoperative lateral cephalometric radiograph (B) showing the enlargement of the upper airway. The lower pharyx was enlarged 8.7–20.2 mm with the advancement of genial tubercle by 12.7 mm. The yellow line indicates space in the airway. There was no appreciable change in the lower facial profile. Airway measurements were assessed by the technique described by Becker et al.5
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T.-K. Kim et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 104–106
tended to be pushed back by the genioglossus muscle. The protruding labial surface of the bony segment and the titanium screw were removed and contoured smoothly. The labial side was also fixed rigidly with a common plate and screws. The mucosal incision was closed without a drain (Fig. 2). We completed the procedure within 30 min, and confirmed the enlargement of the upper airway and lower pharynx by 8.7–20.2 mm and the advancement of the genial tubercle by 12.7 mm.5 There was no appreciable change in the lower facial profile (Fig. 3). The symptoms of two patients were improved by this technique, with no complications. The technique is more simple, atraumatic, and costeffective than traditional techniques for genioglossal advancement. It helps surgeons to do such operations efficiently and quickly, and can minimise the patient’s discomfort. We hope that it will reduce the incidence of postoperative complications such as bleeding, pain, and swelling. Conflict of interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission None required.
Acknowledgement This work was supported by a grant from Kyung Hee University Hospital at Gangdong, South Korea (KHUKHNMC-201402).
References 1. Lee NR. Genioglossus muscle advancement techniques for obstructive sleep apnea. Oral Maxillofac Surg Clin North Am 2002;14: 377–84. 2. Hennessee J, Miller FR. Anatomic analysis of the genial bone advancement trephine system’s effectiveness at capturing the genial tubercle and its muscular attachments. Otolaryngol Head Neck Surg 2005;133: 229–33. 3. Silverstein K, Costello BJ, Giannakpoulos H, et al. Genioglossus muscle attachments: an anatomic analysis and the implications for genioglossus advancement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:686–8. 4. Wang YC, Liao YF, Li HY, et al. Genial tubercle position and dimensions by cone-beam computerized tomography in a Taiwanese sample. Oral Surg Oral Med Oral Radiol Oral Pathol 2012;113: 46–50. 5. Becker OE, Avelar RL, Goelzer JG, et al. Pharyngeal airway changes in Class III patients treated with double jaw orthognathic surgery – maxillary advancement and mandibular setback. J Oral Maxillofac Surg 2012;70:639–47.
British Journal of Oral and Maxillofacial Surgery 53 (2015) 104–106
Technical note
Simple and atraumatic technique for the advancement of the genioglossus muscle for treatment of obstructive sleep apnoea T.-K. Kim, D.-W. Lee ∗ , S.-S. Jue, Y.-D. Kwon Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, Kyung Hee University, Seoul 134-727, Republic of Korea Received 20 March 2014; accepted 8 October 2014 Available online 1 November 2014 Keywords: Obstructive sleep apnea; Sleep apnea; Genioglossus muscle; Genioglossus muscle advancement; Genioglossus advancement; Upper airway; Minimal invasive technique; Facial profile; Simple technique; Atraumatic technique
Obstructive sleep apnoea is the most common type of sleep apnoea that results from obstruction of the upper airway, and genioglossal advancement is an effective way to improve the upper airway in some of these patients. Various types of osteotomy have been designed for the advancement of the genioglossus muscle and the genial tubercle complex.1 We describe a new method that uses a specially designed initial trephine drill for indentation, a final trephine drill for bicortical osteotomy, and a C-shaped plate that supports the advanced bony segment from the inside and is stepped lingually to secure the space for the lingual cortical bone without changing the facial profile (Fig. 1).2 Cone-beam computed tomography (CT) and lateral cephalometric radiographs were taken preoperatively to evaluate the distance from the incisal tip of the mandibular incisor to the genial tubercle, the length of the incisal root, and the thickness of the mandible.3 The vertical incision was made about 25 mm long on the mandibular midline, and undermined laterally to expose just enough space for placement of the trephine drill outside the incision in the mentalis muscle. The initial trephine drilling
∗ Corresponding author at: Department of Oral and Maxillofacial Surgery, Kyung Hee University Dental Hospital at Gangdong, #892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Republic of Korea. Tel.: +82 2 440 7500; fax: +82 2 440 7549. E-mail addresses: [email protected], [email protected] (D.-W. Lee).
was through the genial tubercle area a minimum of 5 mm below the apex of the root to prevent damage.4 The osteotomy was extended lingually using the final trephine drill to incorporate the genial tubercle as shown in the guidelines for cone-beam CT. Before the osteotomy was completed, a titanium screw was placed in the labial cortex to manipulate the bony segment. After successful bicortical osteotomies, the bony segment was advanced using this titanuim screw and forceps. We then installed the C-shape plate to support the segment from the inside, because the advanced segment
Fig. 1. Newly designed drills and plate. A = the initial trephine drill for indentation, B = the final trephine drill for bicortical osteotomy, and C = the C-shaped plate designed to fix the advanced bone flap easily.
http://dx.doi.org/10.1016/j.bjoms.2014.10.004 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
T.-K. Kim et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 104–106
105
Fig. 2. The vertical incision was made on the mandibular midline, and the flap was raised minimally to place the trephine drill without a mentalis muscle incision. After initial trephine drilling for indentation, we made a bicortical osteotomy on the genial tubercle area using the final trephine drill (A). After the bicortical osteotomy, the bone segment was advanced (B). The labial bone segment was contoured, and the advanced lingual bone segment was fixed by C-shape plate and common plate (C and D).
Fig. 3. Preoperative lateral cephalometric radiograph (A) and postoperative lateral cephalometric radiograph (B) showing the enlargement of the upper airway. The lower pharyx was enlarged 8.7–20.2 mm with the advancement of genial tubercle by 12.7 mm. The yellow line indicates space in the airway. There was no appreciable change in the lower facial profile. Airway measurements were assessed by the technique described by Becker et al.5
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T.-K. Kim et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 104–106
tended to be pushed back by the genioglossus muscle. The protruding labial surface of the bony segment and the titanium screw were removed and contoured smoothly. The labial side was also fixed rigidly with a common plate and screws. The mucosal incision was closed without a drain (Fig. 2). We completed the procedure within 30 min, and confirmed the enlargement of the upper airway and lower pharynx by 8.7–20.2 mm and the advancement of the genial tubercle by 12.7 mm.5 There was no appreciable change in the lower facial profile (Fig. 3). The symptoms of two patients were improved by this technique, with no complications. The technique is more simple, atraumatic, and costeffective than traditional techniques for genioglossal advancement. It helps surgeons to do such operations efficiently and quickly, and can minimise the patient’s discomfort. We hope that it will reduce the incidence of postoperative complications such as bleeding, pain, and swelling. Conflict of interest We have no conflict of interest. Ethics statement/confirmation of patients’ permission None required.
Acknowledgement This work was supported by a grant from Kyung Hee University Hospital at Gangdong, South Korea (KHUKHNMC-201402).
References 1. Lee NR. Genioglossus muscle advancement techniques for obstructive sleep apnea. Oral Maxillofac Surg Clin North Am 2002;14: 377–84. 2. Hennessee J, Miller FR. Anatomic analysis of the genial bone advancement trephine system’s effectiveness at capturing the genial tubercle and its muscular attachments. Otolaryngol Head Neck Surg 2005;133: 229–33. 3. Silverstein K, Costello BJ, Giannakpoulos H, et al. Genioglossus muscle attachments: an anatomic analysis and the implications for genioglossus advancement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:686–8. 4. Wang YC, Liao YF, Li HY, et al. Genial tubercle position and dimensions by cone-beam computerized tomography in a Taiwanese sample. Oral Surg Oral Med Oral Radiol Oral Pathol 2012;113: 46–50. 5. Becker OE, Avelar RL, Goelzer JG, et al. Pharyngeal airway changes in Class III patients treated with double jaw orthognathic surgery – maxillary advancement and mandibular setback. J Oral Maxillofac Surg 2012;70:639–47.
