YIJOM-3088; No of Pages 3
Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2015.01.019, available online at http://www.sciencedirect.com
Technical Note Orthognathic Surgery
The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea
A. A. Heggie , J. E. Portnof, R. Kumar Victorian/Tasmanian Oral and Maxillofacial Training Centre, Epworth Hospital, Richmond, Australia
A.A. Heggie J.E. Portnof, R. Kumar: The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Obstructive sleep apnoea (OSA) is a serious condition that can be the cause of a number of systemic symptoms and conditions. The diagnosis of OSA is made by clinical and radiological examination, with polysomnography as the gold standard for recording the severity of the disorder. Among the many therapies offered for OSA, maxillomandibular advancement is recognized as a powerful technique for relieving upper airway obstruction. The upper airway may be further opened by an advancement genioplasty, but this may compromise facial aesthetics by over-projecting the chin prominence. To overcome this difficulty, a modified genioplasty is presented. This is designed to enable a rotational repositioning that allows for advancement of the genioglossus attachments but also avoids an excessive projection of pogonion, which would otherwise result in an unfavourable profile.
Obstructive sleep apnoea (OSA) has been reported to affect approximately 4% of men and 2% of women worldwide.1 It is the cause of a number systemic symptoms and conditions, including excessive daytime sleepiness, fatigue, depression, hypertension, and obesity. In childhood, OSA has been associated with failure to thrive and cardiovascular and neurobehavioural abnormalities.2 The diagnosis of OSA is made by clinical and radiological examination, but polysomnography is regarded as the gold standard for the objective recording of data that defines the severity of the disorder. It also 0901-5027/000001+03
helps to identify if the obstruction is peripheral or central in nature. In most cases of upper airway obstruction, the retro-palatal (velopharynx) and retro-glossal (oropharynx) regions are the areas that are most commonly obstructed, causing repetitive apnoeic episodes, as there is narrowing of the upper airway spaces in patients with OSA.3 Craniofacial abnormalities such as midfacial hypoplasia, mandibular retrognathia, and macroglossia are known to contribute to OSA. Surgical interventions such as maxillomandibular advancement in combination with chin advancement
Key words: obstructive sleep apnoea; genioplasty; aesthetics. Accepted for publication 27 January 2015
have been proven to be effective in the relief of upper airway obstruction.4–7 Procedures that anteriorly reposition the genial tubercles pull the attachments of the genioglossus and geniohyoid forward and hence increase the airway space by advancing the tongue base. Various methods of genial advancement have been described in the literature.8–10 Advancement of the maxillomandibular complex is a powerful procedure for the relief of upper airway obstruction, and when combined with an advancement genioplasty, complete resolution or a major improvement of OSA may reasonably be
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Heggie AA, et al. The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.01.019
YIJOM-3088; No of Pages 3
2
Heggie et al.
anticipated. However, in achieving the maximum possible chin advancement, with or without a maxillary and/or mandibular advancement, it is not always possible to maintain good facial aesthetics, as further chin projection may be detrimental to good facial balance. A modification to the routine genioplasty has been developed that overcomes this problem by modifying the pattern of osteotomy and the direction of repositioning. It is the purpose of this paper to present this novel technique to demonstrate its advantages.
Fig. 2. Schematic outline of osteotomy and repositioning.
Discussion
Surgical technique
Following orthognathic procedures, an incision is made through the lower labial vestibular mucosa from canine to canine, approximately 1 cm from the mucogingival junction and continued down to bone. The anterior mandible is then degloved down to the lower border of the symphysis and just posterior to the region of the mental foramina. Three vertical bony reference marks are made with a fissure burr, and a horizontal osteotomy finishing at least 6 mm anterior to the mental foramina is performed to avoid injury to the anterior loop of the neurovascular bundle before exiting the foramina (Fig. 1). The height of the osteotomy must be planned to obtain the maximum lingual surface of muscle attachment for advancement yet avoiding potential damage to the apices of the adjacent anterior teeth. A reciprocating bone saw is then used for full thickness bilateral vertical osteotomies from the lower border and these connect to the horizontal osteotomy to mobilize the segment for repositioning. The segment is then repositioned to the planned advancement to suit the profile with a clockwise rotation, thereby increasing the advancement of the genioglossus muscles (Fig. 2). A 2-mm ‘X-shaped’ plate is adapted and four screws are used to stabilize the segment (Fig. 3). The
Fig. 1. Osteotomy pattern and reference markings.
Fig. 3. Chin segment stabilized with a miniplate.
mentalis muscles are then reattached with 4–0 resorbable sutures and the wound closed with a 3–0 resorbable continuous horizontal mattress suture.
Advancement of the chin is a valuable surgical procedure in the surgical management of OSA and may be used in isolation or as part of a maxillomandibular advancement to obtain the maximum benefit. While a number of techniques to advance the genial tubercles to draw the tongue base forward have been described, the modified ‘rotational’ genioplasty modification has two unique and important advantages. Firstly, after mobilizing the bony segment, the rotation element adds on further advancement of the muscle attachment based on the rotational arc. This arc of rotation adds close to the equivalent of a mandibular width of advancement at the symphysis. A second advantage of this modification is that, in
Fig. 4. Lateral cephalogram demonstrating genioplasty in conjunction with bimaxillary advancement.
Please cite this article in press as: Heggie AA, et al. The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.01.019
YIJOM-3088; No of Pages 3
The rotational genioplasty cases where facial aesthetics will be adversely affected by advancement of the chin in an antero-posterior direction, rotation of the segment will still enable advancement of the genial tubercles but without an undesirable projection at pogonion (Fig. 4). The modified ‘rotational’ genioplasty has been undertaken in combination with orthognathic surgery in over 20 cases and is recommended as a simple and effective tool in the treatment of OSA to gain an advancement of the tongue base and also to enable the calibration of antero-posterior repositioning to maintain facial balance. Funding
None. Competing interests
None. Ethical approval
Not required.
Patient consent
Written patient consent was obtained. References 1. Sutherland K, Lee RW, Cistulli PA. Obesity and craniofacial structure as risk factors for obstructive sleep apnoea: impact of ethnicity. Respirology 2012;17:213–22. 2. Marcus CL, Brooks LJ, Ward SD, Draper KA, Gozal D, Halbower AC, et al. Diagnosis and management of childhood obstructive sleep apnoea syndrome. Pediatrics 2012; 130:e714–55. 3. Sforza E, Bacon W, Weiss T, Thibault A, Petiau C, Krieger J. Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2000;161:347–52. 4. Meslemani D, Jones LR. Skeletal surgery in sleep apnea. Curr Opin Otolaryngol Head Neck Surg 2011;19:307–11. 5. Ephros HD, Madani M, Yalamanchilli SC. Surgical treatment of snoring and obstructive sleep apnoea. Indian J Med Res 2010;131: 267–76. 6. Li KK. Maxillomandibular advancement for obstructive sleep apnea. J Oral Maxillofac Surg 2011;69:687–94.
3
7. Prinsell JR. Maxillomandibular advancement surgery for obstructive sleep apnea. J Am Dent Assoc 2002;133:1489–97. 8. Barbick MB, Dolwick. Genial tubercle advancement for obstructive sleep apnea syndrome: a modification of design. J Oral Maxillofac Surg 2009;67:1767–70. 9. Lee NR. Genioglossus muscle advancement techniques for obstructive sleep apnea. Oral Maxillofac Surg Clin North Am 2002;14: 377–84. 10. Dattilo DJ, Aynechi M. Modification of the anterior mandibular osteotomy for genioglossus advancement with hyoid suspension for obstructive sleep apnea. J Oral Maxillofac Surg 2007;65:1876–9.
Address: Andrew Heggie Level 12 63 Exhibition Street Melbourne 3000 Australia Tel: +61 419882654 E-mail: [email protected]
Please cite this article in press as: Heggie AA, et al. The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.01.019
Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2015.01.019, available online at http://www.sciencedirect.com
Technical Note Orthognathic Surgery
The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea
A. A. Heggie , J. E. Portnof, R. Kumar Victorian/Tasmanian Oral and Maxillofacial Training Centre, Epworth Hospital, Richmond, Australia
A.A. Heggie J.E. Portnof, R. Kumar: The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. Obstructive sleep apnoea (OSA) is a serious condition that can be the cause of a number of systemic symptoms and conditions. The diagnosis of OSA is made by clinical and radiological examination, with polysomnography as the gold standard for recording the severity of the disorder. Among the many therapies offered for OSA, maxillomandibular advancement is recognized as a powerful technique for relieving upper airway obstruction. The upper airway may be further opened by an advancement genioplasty, but this may compromise facial aesthetics by over-projecting the chin prominence. To overcome this difficulty, a modified genioplasty is presented. This is designed to enable a rotational repositioning that allows for advancement of the genioglossus attachments but also avoids an excessive projection of pogonion, which would otherwise result in an unfavourable profile.
Obstructive sleep apnoea (OSA) has been reported to affect approximately 4% of men and 2% of women worldwide.1 It is the cause of a number systemic symptoms and conditions, including excessive daytime sleepiness, fatigue, depression, hypertension, and obesity. In childhood, OSA has been associated with failure to thrive and cardiovascular and neurobehavioural abnormalities.2 The diagnosis of OSA is made by clinical and radiological examination, but polysomnography is regarded as the gold standard for the objective recording of data that defines the severity of the disorder. It also 0901-5027/000001+03
helps to identify if the obstruction is peripheral or central in nature. In most cases of upper airway obstruction, the retro-palatal (velopharynx) and retro-glossal (oropharynx) regions are the areas that are most commonly obstructed, causing repetitive apnoeic episodes, as there is narrowing of the upper airway spaces in patients with OSA.3 Craniofacial abnormalities such as midfacial hypoplasia, mandibular retrognathia, and macroglossia are known to contribute to OSA. Surgical interventions such as maxillomandibular advancement in combination with chin advancement
Key words: obstructive sleep apnoea; genioplasty; aesthetics. Accepted for publication 27 January 2015
have been proven to be effective in the relief of upper airway obstruction.4–7 Procedures that anteriorly reposition the genial tubercles pull the attachments of the genioglossus and geniohyoid forward and hence increase the airway space by advancing the tongue base. Various methods of genial advancement have been described in the literature.8–10 Advancement of the maxillomandibular complex is a powerful procedure for the relief of upper airway obstruction, and when combined with an advancement genioplasty, complete resolution or a major improvement of OSA may reasonably be
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Heggie AA, et al. The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.01.019
YIJOM-3088; No of Pages 3
2
Heggie et al.
anticipated. However, in achieving the maximum possible chin advancement, with or without a maxillary and/or mandibular advancement, it is not always possible to maintain good facial aesthetics, as further chin projection may be detrimental to good facial balance. A modification to the routine genioplasty has been developed that overcomes this problem by modifying the pattern of osteotomy and the direction of repositioning. It is the purpose of this paper to present this novel technique to demonstrate its advantages.
Fig. 2. Schematic outline of osteotomy and repositioning.
Discussion
Surgical technique
Following orthognathic procedures, an incision is made through the lower labial vestibular mucosa from canine to canine, approximately 1 cm from the mucogingival junction and continued down to bone. The anterior mandible is then degloved down to the lower border of the symphysis and just posterior to the region of the mental foramina. Three vertical bony reference marks are made with a fissure burr, and a horizontal osteotomy finishing at least 6 mm anterior to the mental foramina is performed to avoid injury to the anterior loop of the neurovascular bundle before exiting the foramina (Fig. 1). The height of the osteotomy must be planned to obtain the maximum lingual surface of muscle attachment for advancement yet avoiding potential damage to the apices of the adjacent anterior teeth. A reciprocating bone saw is then used for full thickness bilateral vertical osteotomies from the lower border and these connect to the horizontal osteotomy to mobilize the segment for repositioning. The segment is then repositioned to the planned advancement to suit the profile with a clockwise rotation, thereby increasing the advancement of the genioglossus muscles (Fig. 2). A 2-mm ‘X-shaped’ plate is adapted and four screws are used to stabilize the segment (Fig. 3). The
Fig. 1. Osteotomy pattern and reference markings.
Fig. 3. Chin segment stabilized with a miniplate.
mentalis muscles are then reattached with 4–0 resorbable sutures and the wound closed with a 3–0 resorbable continuous horizontal mattress suture.
Advancement of the chin is a valuable surgical procedure in the surgical management of OSA and may be used in isolation or as part of a maxillomandibular advancement to obtain the maximum benefit. While a number of techniques to advance the genial tubercles to draw the tongue base forward have been described, the modified ‘rotational’ genioplasty modification has two unique and important advantages. Firstly, after mobilizing the bony segment, the rotation element adds on further advancement of the muscle attachment based on the rotational arc. This arc of rotation adds close to the equivalent of a mandibular width of advancement at the symphysis. A second advantage of this modification is that, in
Fig. 4. Lateral cephalogram demonstrating genioplasty in conjunction with bimaxillary advancement.
Please cite this article in press as: Heggie AA, et al. The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.01.019
YIJOM-3088; No of Pages 3
The rotational genioplasty cases where facial aesthetics will be adversely affected by advancement of the chin in an antero-posterior direction, rotation of the segment will still enable advancement of the genial tubercles but without an undesirable projection at pogonion (Fig. 4). The modified ‘rotational’ genioplasty has been undertaken in combination with orthognathic surgery in over 20 cases and is recommended as a simple and effective tool in the treatment of OSA to gain an advancement of the tongue base and also to enable the calibration of antero-posterior repositioning to maintain facial balance. Funding
None. Competing interests
None. Ethical approval
Not required.
Patient consent
Written patient consent was obtained. References 1. Sutherland K, Lee RW, Cistulli PA. Obesity and craniofacial structure as risk factors for obstructive sleep apnoea: impact of ethnicity. Respirology 2012;17:213–22. 2. Marcus CL, Brooks LJ, Ward SD, Draper KA, Gozal D, Halbower AC, et al. Diagnosis and management of childhood obstructive sleep apnoea syndrome. Pediatrics 2012; 130:e714–55. 3. Sforza E, Bacon W, Weiss T, Thibault A, Petiau C, Krieger J. Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2000;161:347–52. 4. Meslemani D, Jones LR. Skeletal surgery in sleep apnea. Curr Opin Otolaryngol Head Neck Surg 2011;19:307–11. 5. Ephros HD, Madani M, Yalamanchilli SC. Surgical treatment of snoring and obstructive sleep apnoea. Indian J Med Res 2010;131: 267–76. 6. Li KK. Maxillomandibular advancement for obstructive sleep apnea. J Oral Maxillofac Surg 2011;69:687–94.
3
7. Prinsell JR. Maxillomandibular advancement surgery for obstructive sleep apnea. J Am Dent Assoc 2002;133:1489–97. 8. Barbick MB, Dolwick. Genial tubercle advancement for obstructive sleep apnea syndrome: a modification of design. J Oral Maxillofac Surg 2009;67:1767–70. 9. Lee NR. Genioglossus muscle advancement techniques for obstructive sleep apnea. Oral Maxillofac Surg Clin North Am 2002;14: 377–84. 10. Dattilo DJ, Aynechi M. Modification of the anterior mandibular osteotomy for genioglossus advancement with hyoid suspension for obstructive sleep apnea. J Oral Maxillofac Surg 2007;65:1876–9.
Address: Andrew Heggie Level 12 63 Exhibition Street Melbourne 3000 Australia Tel: +61 419882654 E-mail: [email protected]
Please cite this article in press as: Heggie AA, et al. The rotational genioplasty: a modified technique for patients with obstructive sleep apnoea, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.01.019
