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Accelerated Orthognathic Surgery and Increased Orthodontic Efficiency: A Paradigm Shift3rd William H. Bell LectureshipJoseph A. Broujerdi, MD, DMDRichard L. Jacobson, DMD, MSStephen A. Schendel, MD, DDS, FACSVolumetric Three-Dimensional Upper Airway Analysis in Patients with Obstructive Sleep Apnea Following Maxillomandibular AdvancementPrepared by Jenny R. ArmstrongReferencesMaxillomandibular advancement is an effective treatment option for patients with sleep apneaHolty JE, Guilleminnault C. Maxillomandibular Advancement for the Treatment of OSA: A Systematic Review and Meta-Analysis, Sleep Medical Review. 2010 Oct.; 14(5):287-97 Schendel S., Powell N., Jacobson R. Maxillary, Mandibular, and Chin Advancement: Treatment Planning Based on Airway Anatomy in Obstructive Sleep Apnea. Journal of Oral and Maxillofacial Surgery. 2011 March; 69(3):663-76

3-Dimensional volumetric analysis is reproducible and accurateSchendel S. Automated 3-D Airway Analysis by Cone Beam CT. Journal of Oral and Maxillofacial Surgery. 2010 March; 68(3):696-701Kaban LB et al. Three-Dimensional Computed Tomographic Airway Analysis of Patients with Obstructive Sleep Apnea Treated by Maxillomandibular Advancement. Journal of Oral and Maxillofacial Surgery. 2011 March; 69(3):677-86

Our Analytical ApproachSmart Art Graphics4Clinical Experience3dMD Photo Overlayed over Skull and Airway OR change colors of bone5Clinical ExperienceSurgical TechniqueLeFort I Maxillary Osteotomy AdvancementBone grafting+/- Septoplasty and/or turbinectomyBilateral Sagittal Split Osteotomy of the Mandible Advancement+/- Genioglossal Advancement

Photo is placeholder for video of spinning head7Post-Operative CarePre- and Post- Op Data: AHIPTSEXAGEBMIPRE-AHIPOST-AHINBM5127423.8CDM3630.5310KGM5129480RJM352854.61.5SDM4723184VEF4919.853.528.4TMM5629.2215Ortho, mm movement9Pre- and Post- Op Data: Movement (mm)PTSKELETALPATTERNMAND MOVEMENT (MM)MAX MOVEMENT (MM)GENIO MOVEMENT (MM)NBII998CDI990KGII990RJII8126SDII1180VEII10114TMI11110Average Mandibular Movement: 9.57 mmAverage Maxillary Movement: 9.86 mmAverage Genio Movement: 6 mmInsert Averages below chart10Pre- & Post- Operative Volumetric AnalysisAverage % Change UAS236.99%Average % Change RP361.97%Average % Change RG164.56%PTPRE-UAS

VOL

cm3POST- UAS

VOL

cm3

% CHNGE

UASPRE-RP

VOL

cm3

POST- RP

VOL

cm3

% CHNGE

RPPRE-RG

VOL

cm3

POST-RG

VOL

cm3

% CHNGE

RG

NB3.3521.46540.60%1.338.46536.09%1.8913.00587.83%CD7.5610.2235.19%3.974.4913.10%3.595.7359.61%KG11.616.4441.72%3.915.7747.57%7.1610.6749.02%RJ3.4630.9793.06%1.2020.561613.33%2.269.34313.27%SD10.2714.1737.97%4.928.8980.69%5.415.532.22%VE12.3929.48137.93%7.4416.04115.59%4.828.0266.39%TM11.8820.4972.47%4.7010.69127.45%7.0012.1573.57%

Pre- & Post- Operative Surface Area AnalysisPTPre-Choke PointRetro-palatal mm2Post-Choke Point Retro-palatal mm2% ChngePre-Choke Point Retro-glossal mm2Post-Choke Point Retro-glossal mm2% ChngePre- Loc-ation of Chke PtPost-Location of Chke PtNB19.71191.87873.47%49.68155.34212.68%PGCD74.5261.83-17.03%88.65116.0130.86%PPKG103.80158.8553.03%109.89152.0138.33%PGRJ8.37273.53167.62%44.28156.60253.66%PGSD104.84187.8379.16%107.46161.1049.92%PGVE139.70400.58186.74%133.65268.46100.87%GGTM95.36387.69306.55%60.0072.3220.53%GGAverage Choke Point RP Pre78.04 mm2Average Choke Point RP Post237.45 mm2Average % Change RP664.22%

Average Choke Point RG Pre84.80 mm2Average Choke Point RG Post154.55 mm2Average % Change RG100.98%Location of Choke Pt Pre-Operatively5 Patients Retropalatal, 2 Patients RetroglossalLocation of Choke Pt Post-Operatively6 Patients Retroglossal, 1 Patient retropalatal

12Pre- & Post- Operative Transverse AnalysisPTPre-Choke Pt RPTrans-verse (mm)Post-Choke Pt RPTrans-verse (mm)Mm differ-encePre-Choke Pt RGTrans-verse (mm)Post-Choke Pt RG Trans-verse (mm)Mm differ-enceNB8.130.622.510.223.413.2CD16.516.80.319.819.2-0.6KG24.029.75.721.927.35.4RJ1.828.226.4123018SD28.534.86.323.732.48.7VE26.437.511.126.128.82.7TM22.031.29.212.414.82.4Average change in the transverse dimension Retropalatal: 11.64 mmRetroglossal: 7.11 mm

Slice CutsThe RP Transverse dimension increases greater than the RG transverse dimension13Pre- & Post- Operative A-P AnalysisPTPre-Choke Pt RPA-P (mm)Post-ChokePt RPA-P (mm)Mm differ-encePre-Choke Pt RGA-P (mm)Post-Choke Pt RG A-P (mm)Mm differ-enceNB25.73.75.46.91.5CD5.76.60.9693KG34.51.56.98.71.8RJ625.219.24.26.62.4SD2.16.94.85.160.9VE4.89.64.83.912.68.7TM411.27.26.46.40Average change in the A-P dimension Retropalatal: 6.40 mmRetroglossal: 2.61 mm

Generally, A-P increases more in RP than in RG, and greater increases millimetrically in transverse than in A-P14Average Change in UAS height2.86 mmAverage Change in RP height3.14 mmAverage Change in RG height4.29 mmPTPre-UAS (mm)Post-UAS (mm)Pre-RP (mm)Post-RP (mm)Pre-RG (mm)Post-RG (mm)NB807446443230CD707040383032KG748038323648RJ686638323032SD747234344038VE646232343228TM767826225056Pre- & Post- Operative Height Analysis

Pouseilles LawAs radius increases and height decreases, the resistance of flow decreases

ResultsVolumeThe UAS enlarged significantlyThe shape of the UAS changed from a funnel to a tube like shapeThe retropalatal space increases in volume more than the retroglossal spaceSurface AreaThe surface area at the choke point in the retropalatal space increases by a greater percent change than the retroglossal spaceThe location of the choke point is generally pre-operatively in the retropalatal space and post-operatively in the retroglossal spaceIndication of normalizing the airway and eliminating any bottlenecking/funnelingThe airway enlarges in a rectangular fashionLengthThe transverse dimension increases more than the A-P dimension in millimeter changeThe A-P dimension increases more than the transverse dimension in percent changeThe retropalatal space increases more in the transverse and A-P dimensions than the retroglossal space doesHeightThe height of the airway measured from the posterior of the post nasal spine to the superior tip of the hyoid bone generally decreases post-operativelyThe height of the airway was pre-operatively shorter in the retropalatal space than the height of the retroglossal spaceThe height of the airway was post-operatively shorter in the retroglossal space than the retropalatal space

Case IPre-SurgicalPost-Surgical

Case I

Case I

Case IPre-SurgicalPost-Surgical

Case ICase IICase II

Case II

Conclusions3-Dimensional airway analysis indicates that maxillomandibular advancement is an effective treatment option for patients with obstructive sleep apnea by increasing tension and changing the position of the palatal and pharyngeal muscles. As a result:Airway volume increasesShape of airway changesChange from a funnel to cylindrical shapeHeight of airway decreasesResistance decreasesRadius of the airway increasesHeight of the airway decreases

height decreases, resistance decreases, radius increases26ReferencesMaxillomandibular advancement is an effective treatment option for patients with sleep apneaHolty JE, Guilleminnault C. Maxillomandibular Advancement for the Treatment of OSA: A Systematic Review and Meta-Analysis, Sleep Medical Review. 2010 Oct.; 14(5):287-97 Schendel S., Powell N., Jacobson R. Maxillary, Mandibular, and Chin Advancement: Treatment Planning Based on Airway Anatomy in Obstructive Sleep Apnea. Journal of Oral and Maxillofacial Surgery. 2011 March; 69(3):663-76

3-Dimensional volumetric analysis is reproducible and accurateSchendel S. Automated 3-D Airway Analysis by Cone Beam CT. Journal of Oral and Maxillofacial Surgery. 2010 March; 68(3):696-701Kaban LB et al. Three-Dimensional Computed Tomographic Airway Analysis of Patients with Obstructive Sleep Apnea Treated by Maxillomandibular Advancement. Journal of Oral and Maxillofacial Surgery. 2011 March; 69(3):677-86