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  1. 2. BILATREAL INTRA - ORAL DISTRACTION OSTEOGENESIS FOR THE MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA IN EARLY CHILDHOOD By Amgad A. Farhat* ; Abd El-Fattah A. Sadakah** & Mohammad A. Elshal** *Chest Department, Faculty of Medicine and **Oral & Maxillofacial Department, Faculty of Dentistry; Tanta University. بسم الله الرحمن الرحيم
  2. 3. <ul><li>Sleep apnea may frequently occur in early childhood, but it is usually unnoticed. </li></ul><ul><li>The potential for airway obstruction is further increased by supine positioning, neck flexion and increased secretions during sleep. </li></ul>
  3. 4. <ul><li>Sleep apnea is one of the most frequent manifestations of respiratory obstruction. </li></ul><ul><li>Historically this clinical entity has stimulated the production of numerous valuable contributions with one purpose in mind: the improvement of airway patency. </li></ul>
  4. 5. <ul><li>In 1937 , Callister used a pediatric neurosurgical back-brace with a halo, with the infant imprisoned in this device. </li></ul>
  5. 6. <ul><li>Longmire and Sanford, 1949, used orthopedic weight hangers and pulleys attached to the patient with circum-mandibular wire. </li></ul>
  6. 7. <ul><li>Complications: </li></ul><ul><li>Frequent cutting through the symphysis & </li></ul><ul><li>TMJ ankylosis. </li></ul>
  7. 8. <ul><li>Children born with a diminutive mandible present a challenge to pediatric specialists, because of the potential for airway obstruction. </li></ul><ul><li>(Schaefer et al., 2004). </li></ul>
  8. 9. <ul><li>Pierre Robin sequence: </li></ul><ul><li>Mandibular deficiency. </li></ul><ul><li>Glossoptosis. </li></ul><ul><li>With or without cleft palate. </li></ul><ul><li>(Schaefer et al., 2004) </li></ul>
  9. 10. <ul><li>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. </li></ul><ul><li>(Burstein et al., 1995). </li></ul>Introduction
  10. 11. <ul><li>Early distraction procedures used extra oral devices that caused facial scarring with the potential for facial nerve damage. </li></ul><ul><li>(Chris et al., 1999). </li></ul>Introduction
  11. 12. <ul><li>More recently, intra oral subperiosteal appliances have been developed with the advantages of: </li></ul><ul><li>Lack of external scars. Less soft tissue trauma. </li></ul><ul><li>Near total concealment of the device. </li></ul><ul><li>Superior psychological tolerance. </li></ul>Introduction
  12. 13. <ul><li>However, in infants and young children, there is no enough room subperiosteally to accommodate the whole distractor. </li></ul>
  13. 14. In this article, we report our experience in correcting mandibular micrognethia accompanying obstructive sleep apnea syndrome (Pierre Robin sequence) by bilateral DO using a modified technique for submucosal intra-oral distractor placement. Aim of the work
  14. 15. <ul><li>Patients and Methods </li></ul>Patients and Methods
  15. 16. <ul><li> 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 ). </li></ul>Patients and Methods
  16. 17. Patients and Methods <ul><li>Sex: 3 M & 4 F </li></ul><ul><li>Age range: 7 mo – 7.5 yr </li></ul><ul><li>Follow-up: 2 – 5 yr (range) </li></ul><ul><li>Patients were: </li></ul><ul><li>Neurologically free. </li></ul><ul><li>Without associated syndromes. </li></ul>
  17. 18. <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Disturbed occlusion and difficult mastication. </li></ul>Female 7.5 yr 3 <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Difficult feeding. </li></ul><ul><li>Cleft palate. </li></ul>Female 20 mo 2 <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Difficult feeding. </li></ul>Male 7 mo 1 Pathology Sex Age Pt. No
  18. 19. <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Disturbed occlusion and difficult mastication. </li></ul><ul><li>Limitation of jaw movement. </li></ul>Female 6 yr 7 <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Disturbed occlusion and difficult mastication. </li></ul>Female 5 yr 6 <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Disturbed occlusion and difficult mastication. </li></ul>Male 4.5 yr 5 <ul><li>Severe bilateral mandibular hypoplasia. </li></ul><ul><li>Sleep apnea. </li></ul><ul><li>Cleft palate. </li></ul><ul><li>Difficult feeding </li></ul>Male 20 mo 4
  19. 20. <ul><li>Previous failed management: </li></ul><ul><li>Positioning … in all patients. </li></ul><ul><li>Tongue/lip adhesion … in 2 patients. </li></ul>
  20. 21. <ul><li>Criteria for diagnosis of obstructive sleep apnea OSA </li></ul><ul><li>Snoring . </li></ul><ul><li>Day - time somnolence and reduced activities . </li></ul><ul><li>Less than 85% oxygen saturation . </li></ul><ul><li>Apnea/hypoapnea index > 5. </li></ul>
  21. 22. <ul><li>The criteria for cure: </li></ul><ul><li>Disappearance of clinical symptoms. </li></ul><ul><li>Absence of apneic attacks during sleep hours. </li></ul><ul><li>Lowest oxygen saturation more than 85 %. </li></ul><ul><li>Apnea/hypoapnea index < 5. </li></ul>
  22. 23. <ul><li>Patient Examination: </li></ul><ul><li>Clinical. </li></ul><ul><li>Maxillo-Mandibular discrepancy </li></ul><ul><li>> 8 mm. </li></ul>
  23. 24. <ul><li>Patient Examination: </li></ul><ul><li>Radiographiclly; lateral cephalometry and panoramic views. </li></ul>Patients and Methods
  24. 25. <ul><li>Radiographic analysis : </li></ul><ul><li>Airway obstruction at the tongue-base level. </li></ul><ul><li>Required length of distraction: </li></ul><ul><li>Range, 14 -20 mm. </li></ul><ul><li>Average, 17.4 mm. </li></ul><ul><li>Over-correction by about 2-3 mm. </li></ul>
  25. 26. Airway measurements
  26. 27. <ul><li>Patient Examination: </li></ul><ul><li>All patients were subjected to diagnostic sleep study at night for at least 7 hours in sleep laboratory, Chest Department, Tanta University, Egypt </li></ul><ul><li>Polygraphic examination.. Before, at the end of activation and 3 months after consolidation. </li></ul>
  27. 28. Surgical Procedure <ul><li>The modified technique for distractor application (unburied device) </li></ul>
  28. 29. Distraction Protocol <ul><li>Latency.. 3 days . </li></ul><ul><li>Rate .. 0.5 mm twice/ day . </li></ul><ul><li>Period .. 17-24 days . </li></ul><ul><li>Consolidation.. 4 weeks . </li></ul>
  29. 30. Results Results
  30. 31. <ul><li>The subjective symptoms of all patients had disappeared completely or had been alleviated after completion of mandibular distraction osteogenesis. </li></ul>
  31. 32. <ul><li>No infection. </li></ul><ul><li>No permanent nerve injury. </li></ul><ul><li>No facial scaring </li></ul><ul><li>No psychological problems to parents </li></ul>
  32. 33. Pre -Distraction Post -Distraction Mean 70.5% , Range 31-125%
  33. 34. 98 80 Lowest oxygen saturation (%) 1.57 (0-16.4) 60 (9.8-126.5) Apnea hypoapnea index 79 68 SNB angle (degrees) 14.5 6.6 Posterior airway space (mm) Postdistraction Predistraction Mean values of
  34. 35. <ul><li>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. </li></ul>Complication
  35. 36. <ul><li>Occlusion : </li></ul>Post. Cross-bite.. 5 Pt. Ant. Open-bite.. 2 pt.
  36. 37. Long-term follow-up: Near normal occlusion (orthodontic treatment)
  37. 38. <ul><li>TMJ: </li></ul><ul><li>abnormal shape of the condylar process in 3 condyles. </li></ul><ul><li>a case of unilateral ankylosis was diagnosed 4 years after completion of distraction. </li></ul>
  38. 39. Relapse: <ul><li>One patient </li></ul><ul><li>Age at primary distraction was 7months. </li></ul>Pt No 1
  39. 40. <ul><li>Onset of relapse was about 3 years later, accompanied with unilateral TMJ ankylosis. </li></ul>Pt No 1 Pre Pre Pre Post
  40. 41. <ul><li>Re-Distraction was performed at 4.5 years of age with good results. </li></ul>Pt No 1
  41. 42. Post 1 st Dist. Pre Post 2 nd Dist. Pt No 1
  42. 43. Post During Pre Pt No 3
  43. 44. Post-Distraction. Long-term follow-up. Pt No 3
  44. 45. Post 4.5 yrs Pre Pt No 5
  45. 46. Post During Pt No 5
  46. 47. Post 4.5 yrs Pt No 5
  47. 48. Post.. Long-term follow-up Pt No 5
  48. 49. Post During Pt No 6
  49. 50. Post Pt No 6
  50. 51. CONCLUSION Conclusion
  51. 52. <ul><li>Distraction osteogenesis can consistently produce a measurable cross-section airway in patients as young as 7 months. </li></ul><ul><li>The tongue base reliably follows the distal segment of the mandible anteriorly. </li></ul><ul><li>DO caused significant improvement in obstructive sleep apnea & lowest oxygen saturation during sleep. </li></ul>Conclusion
  52. 53. <ul><li>The advantages of the modified technique used in this study showed the following: </li></ul><ul><li>Limited periosteal stripping. </li></ul><ul><li>Less infection possibility. </li></ul><ul><li>Better monitoring of the distraction procedure. </li></ul><ul><li>Easier distractor removal. </li></ul>
  53. 54. Acknowledgement <ul><li>Prof </li></ul><ul><li>Abd El-Fattah A. Sadakah </li></ul><ul><li>Prof of Oral & Dental surgery & President of Tanta University </li></ul><ul><li>[email_address] </li></ul><ul><li>All staff members of Chest & Radiology Departments, Tanta University Hospitals, Egypt, </li></ul><ul><li>My wife, Dr. Ghada Atef Attia </li></ul><ul><li>Lecturer of Chest Diseases – Tanta Faculty of Medicine </li></ul>
  54. 55. THANK YOU