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168 Surgical treatment of a Pattern I Obstructive Sleep Apnea Syndrome individual - clinical case report

CASE REPORTS

Surgical treatment of a Pattern I Obstructive
Sleep Apnea Syndrome individual - clinical case
report

Christiane Cavalcante Feitoza1 ABSTRACT
Matheus Corrêa da-Silva2 Obstructive Sleep Apnea Syndrome (OSA) is a multifactorial disease that highly alters a persons
Yasmim Lima Nascimento2 quality of life. It is characterized by the repeated interruption of breathing during sleep, due to an
Elaine Sobral Leite3 obstruction or the collapse of the upper airways. Since it is a multifactorial etiological disorder, it
Corintho Viana Pereira4 requires a thorough diagnosis and treatment with an interdisciplinary team, which comprises seve-
ral professionals such as a surgical dentist, phonoaudiologist, otorhinolaryngologist, sleep doctor,
Lucas Gomes Patrocínio5 neurologist and physiotherapist. The diagnosis and the degree of severity of the syndrome is deter-
mined through a polysomnography examination. After that, the best form of treatment is devised
1
Universidade Fede'al de Alagoas, Cam- depending on the gravity of the case. In cases of moderate to severe apnea, invasive treatment
pus Arapiraca - Arapiraca - AL - Brazil. through surgical procedures such as maxillomandibular advancement remains the preferred option
2
Universidade Federal de Alagoas, as it increases the posterior air space, reducing and/or eliminating the obstruction. Thus, improving
Curso de Odontologia - Maceió - AL the patients respiratory function and, consequently, his quality of life as it is shown in the clinical
- Brazil case at hand. In which the male patient, facial pattern type I, 41 years of age, diagnosed with mo-
3
Faculdades Unidas do Norte de Minas derate OSA (Apnea-Hypopnea Index - AHI of 23.19), decided to have a surgical treatment instead
- FUNORTE - Maceió - AL - Brazil of a conservative one, resulting in the cure of apnea (AHI of 0.3).
4
Clínica OTOFACE, Recife - PE -
Brazil Keywords: Orthognathic Surgery. Sleep Apnea Syndromes. Esthetics.
5
Clínica OTOFACE, Uberlândia - MG
- Brazil

Corresponding author: Christiane
Cavalcante Feitoza. E-mail: christiane.
feitoza@iqb.ufal.br
Received: June 26, 2017; Accepted:
September 13, 2017.

DOI: 10.5935/1984-0063.20170029

Sleep Sci. 2017;10(4):168-173

age Jordan et al. all the muscles involved are moved forward. The index used to define the severity of first choice for patients with moderate to severe forms of the the syndrome is the Apnea-Hypopnea Index (AHI). which may be partial or complete. until he is awoken1. patients may describe difficulties in concentration. the airway is also small and may. of the Pharyngeal lumen. we have the small lumen of the upper airways. by episodes of obstruction in the upper airways during sleep. during the in the study. Nevertheless. is the best way and risk factors. Because of that. Patients with OSA have the pharyngeal space. enlarging the lumen after a precise detection of the place where improving quality of life and reducing the clinical developments the obstruction occurs. Besides. medium and long term monitoring.10(4):168-173 . problems in the anatomy of the upper airways. this sleep According to Libman et al. therefore easily and mood swings. forms of treatment have failed1. memory loss when small. In these Patients with OSA must be treated in a multidisciplinary cases. which results selected patients with craniofacial malformations or when other in a volumetric increase of the airway6. it must be reserved for that. Therefore. The apnea greater respiratory effort and an increase in the levels of carbon or hypopnea. some patients are intolerant to this treatment. respiratory function with little to no compromise in facial harmony. which can generate traffic accidents. where OSA brings grave consequences such as excessive the craniofacial structure or body fat has reduced the size daytime sleepiness. efforts. especially the genioglossus and connected with metabolic syndromes. Feitoza CC et al. Calculated disease. ability of the respiratory volume. nighttime cardiac and respiratory parameters during sleep. Liquid retention and fluid of clinical history. Obstructive Sleep Apnea Syndrome (OSA) is a disorder This syndrome results in oxygen desaturation. many are also studied. determined by the degree of the obstruction. Sensorial pharyngeal compromise may also contribute Medicine. the diagnosis of OSA is given through the analysis to the collapsing of the upper airway. OSA. 169 INTRODUCTION excessive daytime sleepiness. obesity. a question arises: What is the repercussion Pattern I individual with the clinical case report. The resulting hypoxia is linked to a wide causes progressive asphyxia so that the desaturation of oxygen range of problems deriving from the oxidative stress as well as makes the individual require increasingly higher respiratory to mortality concerning the coronary arteries3. increasing approaches of the upper airways. moderate or severe cases1. of sleep apnea. its varies according to the sample and the type of diagnosis used prevention through early diagnosis and treatment. The dilator muscles. physical. Obesity frequently reduces the residual functioning impact on quality of life4. although the data the options for treatment become limited.3. leading to a higher probability of it may be associated with a significant cardiovascular morbidity collapsing. as the number of obstructive events by hour of sleep. fluid retention. the removal of the cause of obstruction of the upper airways. It can claiming discomfort when using the mask. dioxide in the blood. OSA is multifactorial and. impaired memory and fatigue. synergist breathing muscles not structures and systems of the craniocervical/oral region7. unstable respiratory control. which in turn characterized by repeated nighttime episodes of collapsing of provokes an increase in blood pressure due to the need of a the upper airways.2 point out. This is a highly efficient treatment. which below-average dimensions of the upper airways and the requires short. a straight and its surgical treatment of Bimaxillary Advancement in a profile. among the predisposing growing and developing phase of children. radiographic and polysomnographic displacement from the legs into the neck during the night can examinations. performing their function. the prevalence of this disorder can bring about important medical consequences and syndrome in the adult population is high. this alternative has become possible for such individuals. particularly when in supine According to the American Academy of Sleep position. of a Bimaxillary Advancement in facial aesthetics? With the improvements in surgical techniques and in the modification REVISION OF THE LITERATURE of the occlusal plane with counter-clockwise rotation during The Obstructive Sleep Apnea Syndrome is characterized fixation. which was observed in this clinical case report. It favoring clearance of the airway for the improvement of the may be associated to clinical signs and symptoms like snoring. surgical treatment must be considered. forward for it can cause important alterations in many organs. 5.2. accept sleeping while connected to a mechanic device8. smoking. Alternative options include weight control. to detect obstructive events and alterations in the saturation of the Continuous Positive Air Pressure (CPAP) device is the oxygen in the blood. while others do not characterize minimal. orthognathic surgery allows maxillomandibular repositioning so by being a very invasive procedure. Lung volume may be a casual factor since. This last one consists of the evaluation of affect the mechanics of the airways as well. aiming Among the available options for the treatment of OSA. In addition. If not diagnosed and treated promptly.6. Sleep Sci. mild. This article aims at performing a revision of the literature It is important to point out that OSA also attacks about the aspects of the Obstructive Sleep Apnea Syndrome patients with facial morphology type Pattern I. that is. Continuous Positive Air Pressure (CPAP) is very effective. whose objective is way and several options for treatment are available nowadays. as predisposing factors of and adenotonsillar hypertrophy2. 2017. irritability and depression causing a great collapse. However. Maxillomandibular advancement induces an anterior mandibular protrusion devices and a number of surgical displacement of the soft palate and of the tongue.

1-NA 7mm 2mm 4mm The treatment of choice was Bimaxillary Advancement 1. frequent headaches) and with the ANB 2° 12° 2°(+ -2) cephalometric and facial analysis (table 2). male.025” with individual spurs and ligatures (figure 2). This 23.1 0.S.5 years post Initial surgical surgical that is. confirm the diagnosis 1. a Morelli fixed metallic orthodontic appliance was installed. Initial and cephalometric control values.P. SNB 75° 82° 80°(+ -2) concentration difficulties. facial features pattern I. the patient returned to the office for occlusion examination and guidance in the use of intermaxillary elastics (figure 3). passive form.19 and average basal oxyhemoglobin desaturation of 95% and a minimum of Table 2.19 4. during which the first four premolar teeth were Average O2 saturation 95% 97% 98% extracted (figure 1).clinical case report CLINICAL CASE REPORT Table 1. 2017. 6 months post 2. dolichofacial and class I Angle. 42. Thirty days after surgery.A. Sleep Sci. Intra-oral photographs of the preoperative orthodontic preparation. Edgewise prescription. which was carried out together with the surgeon. Patient H.170 Surgical treatment of a Pattern I Obstructive Sleep Apnea Syndrome individual . considering that the patient had not accepted a 1-NB 9mm 4mm 4mm conservative. Initial and polysomnographic control values. SNA 77° 95° 82°(+ -2) clinical history of signs and symptoms (daytime sleepiness.NB 22° 32° 25° Surgery. rectangular steel archwires 0. 84%. As orthodontic AFAI 95mm 88mm 67mm CoA 97mm 107mm 91mm CoGN 139mm 140mm 112mm FMA 24° 25° 25°(+ -5) FMIA 90° 86° 68° IMPA 62° 59° 87° Upphw-PP1 18mm 25mm 26mm PP2-PP2’ 15mm 18mm 12mm PNS-P 43mm 37mm Mpphw-MaphW 13mm 22mm 22mm PAS 8mm 13mm LAS 10mm 14mm presurgical planning. These data associated with the physical examination. The models were mounted in semi-adjustable articulator for model surgery and confection of surgical models based on the measurements of the predictive surgical tracing (10 mm maxillary advancement with a 2 mm impaction of the anterior nasal spine.L. palliative treatment with CPAP.. Figure 2. During this postoperative Figure 1.019”x0. straight profile. with obstructive events of up to 4 minutes in duration Cephalometric measurements Preoperative Postoperative Standard (table 1). Minimal O2 saturation 84% 93% 95% Polysomnography revealed an IAH of 23.NA 26° 5° 22° and the moderate severity of this OSA.3 same subject had already undergone conventional orthodontic AIH/hour treatment for the correction of the masticatory function and Moderate Normal Normal for aesthetics.10(4):168-173 . 3 mm lowering of the posterior nasal spine and 15 mm mandibular advancement with counter-clockwise rotation of the occlusal plane). Initial photographs and radiographs.

13 indicated that the prevalence of OSA is higher in elderly individuals than it is in middle-aged ones. six months later. Pattern I and quite harmonious. breathing and sleep (figure 4). intraoral devices. therefore.6. that is. the patient was already reporting an improvement in the quality of his sleep and. with minimal oxygen saturation of 95% and average of 98% (table 1). In this case report. a tube and a flow Sleep Sci. There are some options for the medical treatment of OSA. as well as weight loss. when there is a 50% reduction in the breathing volume for longer than 10 seconds5. In conformity with reports from many authors and their experiences with orthognathic surgery. considering that the subject’s profile remained straight. In a mid-term control. 171 period. He seemed very pleased with his face. as OSA affects.9. common symptomatology. two and a half years after the orthognathic surgery. However. clinic and radiographic characteristics such as: snoring. nasal obstruction.10(4):168-173 . a considerable gain in his general well-being. AHI was even better than before at 0. Orthodontic treatment extended for another year after surgery. minimal oxyhemoglobin saturation of 93% and an average of 97% (table 1). we can observe. sleepiness.12.3 events/hour. in the vast majority of patients.10. 2017. The CPAP nasal device is used for the pneumatic support of the upper airway. this same subject underwent a new polysomnography test and the data turned up promising about the improvement of OSA. Control photographs after two and a half years of orthognathic surgery non-surgical alternative which uses a mask. the male patient. The improvement in the flow of air through the posterior superior air column was observed in postsurgical lateral teleradiography (table 2). a study which evaluates oral health in ill patients who make use of CPAP. Photographs and radiographs after 30 days of orthognathic surgery. occlusion. oropharyngeal abnormalities like tonsil hyperplasia. Contentions were installed and the balance between masticatory function. through control polysomnography which showed an AHI of 4. adenoidal enlargement and macroglossia among others3. Bilevel Positive Airway Pressure (BIPAP) devices. Feitoza CC et al. corroborates the prevalence registered in literature. in order to refine occlusion.1 events/hour of sleep. arrhythmia. A Figure 4. a young adult. Tsuda et al. periods of apnea in which breathing through the nose or the mouth ceases for longer than 10 seconds and hypopneas. DISCUSSION Obstructive Sleep Apnea Syndrome (OSA) consists of Figure 3. (figure 3) and the cure of OSA was confirmed. in the majority of cases. respiratory function and facial aesthetics was reached. men between 40 and 60 years of age11. including Continuous Positive Air Pressure (CPAP) appliances.

a Computed Tomography scan 1. obtained through its use disappear14. Is Counterclockwise Rotation of the Man- an AHI below 10/hour or a higher-than-50% reduction after dibular Complex Stable Compared to Clockwise Rotation in the Dentof- acial Deformities? A Systematic Review and Meta-Analysis.6(23):410-4. et It is clear that the pattern of expansion of superior air al. levator veli palatini. Fernandes EG. Libman E. Pereira CV. also in its medial-lateral diameter. 2015. palatoglossus and obstrutiva do sono em crianças. Cardoso MA. Gharibeh T. 2010.3/h.383(9918):736-47. Grandi D.74(10):2066. Present in 100% of cases with an 85% 15. Kobayashi S.2:233- imbalance and also. 2017. Ribeiro AA.15. to make the patient free from the use of any mechanical Mainly. Aust Fam Physician. Feitoza CC. Rossi RR. Jordan AS. Tsukamoto Y. Tratamento ortodôntico cirúrgico da birretrusão associado 23. Spicuzza L. Capelloza Filho L. Phan NT. Coromina J. Long-term adherence to CPAP treatment in patients with ob- Most authors firmly state that maxillomandibular structive sleep apnea: importance of educational program. J Clin Sleep Med. These changes were observed in plex. et al. maxillary advancement of 10mm and mandibular advancement 13. Clinical guideline for the evaluation. There are no reports of 14.16 and Raffaini and Pisani17 Disord.5(19):311-24. Wallwork B.172 Surgical treatment of a Pattern I Obstructive Sleep Apnea Syndrome individual . Countless studies report the benefits of orthognathic It is the dental surgeon’s responsibility to know the surgery for mandibular advancement in the upper airway and diagnostic parameters.2017:2760650.17:26-30. Obstructive sleep apnea syndrome: natural history. 2015.22(3):233-9. This result was obtained thanks to a surgical à SAOS: relato de caso. 2012. J Oral Maxil- surgery. 2001.6(5):273-85. Friedman N. in spite of being widely used. Vargas Jr CS. Raimond P. Caruso D. A Ortodontia no diagnóstico e tratamento da apneia the tensor veli palatini. Bailes S. 2011. while for the cure of the disease the AHI should be lofac Surg. Scartabellati A. Okushi T. maxillomandibular advancement results not only in the 4. 2010.10(4):168-173 . Guimarães TM. Prinsell JR. J Oral Maxillofac Surg. the most definite and effective straight facial profile1. OSA. the clinical case report presented. Pizzol KED. Echarri P. Creti L. Al-Moraissi and Wolford18. Sleep Sci. and emerging treatment options. Gavranich Junior J. La Piana GE. Arisaka T. Sleep 2010. Likewise. 8. For the authors.6 and Mehra 2016. Kristo D. Ferraz et al. lower than 5/h. Rowley JA. Al-Moraissi EA.clinical case report generator but. Lancet. Carro improvement rate in up to 1 year after surgery. Surgery for adult patients with obstruc- tive sleep apnoea: A review for general practitioners.19/h to 0.33(10):1396- the mandible is moved forward due to the force vectors form 407. Prado BN. Strollo PJ Jr. cardiovascular ones. devices. Mehra R. Baltzan M. strutiva do Sono: Diagnóstico e Tratamento. Fichten CS. Effectiveness of Maxillomandibular advancement (MMA) surgery in space is different between maxilla and mandible. mental paresthesia. Fabbro CD. Such success depends on a maxillomandibular 11. combined maxillary and mandibular CONCLUSION advancement orthognathic surgery has been the chosen OSA has arisen as the most frequent and important procedure in the treatment of respiratory disorders in order sleep disorder while connecting to several systemic alterations. Treatment Adherence in Women with Obstructive Sleep Apnea. 2017. genioglossus muscles9. Sleep In accordance with Lye et al. Cunali PA. Nature Sci Sleep. Wolford LM. et al.45(8):574-8.10(38):98-105. Nary Filho H. offers the potential for 3D reconstructions of such structures 2. 2016. Papel do médico dental occlusion (as long as there is orthodontic treatment prior dentista no tratamento da roncopatia e do síndrome de apneia/hipoap- neia obstrutiva do sono (SAHOS). Pharyngeal airway space changes after counterclockwise rotation of the maxillomandibular com- advancement beyond 9. Azevedo WRS.9 mm. such surgeries are safe procedures. Cirurgia ortognática no tratamento da síndrome da apneia obstru- augmentation of the anteroposterior diameter of the airway but tiva do sono . Feres R. Ferraz O. Chaves CM. Downie M.5:555-62. where AHI was reduced from 12. is a teams that monitor and treat respiratory sleep disorders. McSharry DG. 6. Pita MC. the established definitions and the limits the association of this procedure with the counter-clockwise of his field of work when working as part of the multidisciplinary rotation of the occlusal plane. 9. Pallanch JF. it maintains a balanced facial profile for 55. Emery JMT.21.16. Moreira TCA.9(3):134-9. Wolford LM.relato de caso. Guedes FP. advancement surgery not only treats OSA but also re-establishes 16. 3. and Wolford19 concluded that surgical success is attained with 10. In addition. 2017. Pérez-Campoy MA. Ronchi L. CPAP its price makes it inaccessible for the population in general14. 2013. in the anteroposterior direction is bigger with the advancement Surgical modifications of the upper airway for obstruc¬tive sleep apnea of the maxilla and the medial-lateral diameter grows more when in adults: a systematic review and meta-analysis. Elamin MB. Effect of maxillomandibular advancement on morphology of velopharyngeal space. Apneia Ob- of 15 mm with rotation of the occlusal plane. Rev Odontol Univ Cid São Paulo. Tonogi M. Rizzo D. Epstein LJ. 2011.14. stable procedure in the long term and maximizes the aesthetic Several therapeutics have been proposed depending on function after surgery even in patients who already have a the gravity of the diagnosis. 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