Influence of Surgeon Experience on Surgical Outcome of Maxillomandibular Advancement for Obstructive Sleep Apnea

The primary aim of this study was to assess the association between clinical efficacy outcomes (i.e., polysomnography (PSG) results) of maxillomandibular advancement (MMA) and surgeons' experience. The second aim was to assess the association between the occurrence of postoperative complications of MMA and surgeons' experiences. Patients treated with MMA for moderate to severe obstructive sleep apnea (OSA) were enrolled in this retrospective study. The patient population was divided into two groups based on two different surgeons performing MMA. The associations between surgeons' experience on the one hand and PSG results and postoperative complications on the other hand were investigated. A total of 75 patients were included. There was no significant difference in baseline characteristics between the two groups. The reductions in apnea-hypopnea index and oxygen desaturation index were both significantly greater in group-B than group-A (p = 0.015 and 0.002, respectively). The overall success rate after MMA was 64.0%. There was a negative correlation between surgeon experience and surgical success (odds ratio: 0.963 [0.93, 1.00], p = 0.031). No significant association was found between surgeon experience and surgical cure. Additionally, there was no significant association between surgeon experience and the occurrence of postoperative complications. Within the limitations of this study, it is concluded that surgeon experience may have little to no influence on the clinical efficacy and safety of MMA surgery in OSA patients.

Facial esthetics and subjective impairment assessed after maxillomandibular advancement surgery for patients with obstructive sleep apnea

OBJECTIVE

To assess facial esthetics and quality of life (QoL) as measure of success or failure after maxillomandibular advancement (MMA) surgery for obstructive sleep apnea (OSA).

METHODS

Visual analog scales (VAS) on facial esthetics and QoL survey, including EQ-5D3L, Epworth Sleepiness Scale (ESS), and Functional Outcome of Sleep Questionnaire (FOSQ) were collected. Outcomes were analyzed for surgical-success/failure after MMA.

RESULTS

Forty-one patients returned completed surveys (response: 66%). Mean VAS on facial esthetics was 57 ± 22 mm preoperative and 51 ± 24 mm postoperative (p = 0.217). When MMA was considered a surgical-failure, VAS was significantly more negative (40 ± 22 mm; p = 0.026). EQ-5D-3L showed an overall mean score of 73.2 ± 15.7, ESS was 6.3 ± 5.4, and FOSQ was 16.0 ± 3.3.

CONCLUSION

No significant alteration of facial esthetics were reported after MMA; however, lower QoL was associated with surgical-failure; whereas, in surgical-success, QoL were higher.

Lactoferrin and the development of salivary stones: a pilot study

Salivary stones (sialoliths) are calcified structures located in the ductal system of the major salivary glands. Their exact cause is not clear but in general they are characterized by concentric inorganic (hydroxyapatite) layers. The formation is a slow intermittent process which may result in enlargement of the sialolith causing obstruction of saliva secretion resulting in mealtime related pain and swelling of the affected salivary gland. Various studies reported the presence of organic material such as proteins and lipids in the core of sialoliths. In the present study the protein composition of twenty submandibular sialoliths was analyzed. It was found that proteins contributed on average 5% to the dry weight of submandibular stones whereby small salivary stones contained more extractable proteins than large salivary stones. Using a combination of SDS-PAGE gel electrophoresis and Western blotting, we identified α-amylase (in all stones; 100%), lysozyme (95%), lactoferrin (85%), secretory-IgA (75%), MUC7 (60%), complement C4 (60%) and C-reactive protein (35%). The presence, and the combinations, of lactoferrin, lysozyme, s-IgA and α-amylase in sialoliths was confirmed by ELISA. The gradually increasing size of a sialolith might provoke a local inflammatory response in the duct of the submandibular gland whereby the relatively low concentrations of lactoferrin and lysozyme may originate from neutrophils. The interaction of lactoferrin with s-IgA could contribute to the accumulation of lactoferrin in sialoliths. In summary, these results suggest a new pathophysiological role for lactoferrin, in the formation of sialoliths.

Long-Term Outcome of Surgical Treatments for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis in Children

PURPOSE

Information on long-term treatment outcome for nontuberculous mycobacterial (NTM) cervicofacial lymphadenitis in children is scarce. The purpose of this study is to evaluate long-term outcome for surgical treatment, which is the mainstay treatment modality.

METHODS

This case series describes recurrence rates of surgically treated NTM cervicofacial lymphadenitis patients with a follow-up of at least 10 years. The current study data were partially collected from a randomized, prospective, multicenter, multidisciplinary trial (CHIMED study), which was conducted between 2000 and 2006 to determine the optimal treatment for NTM cervicofacial lymphadenitis in children. After the CHIMED trial inclusion ended, our institute continued to serve as a referral center. This enabled us to enlarge the surgical CHIMED cohort by adding patients who were treated during 2007 to 2010 in our center and collect the rest of the current study data.

RESULTS

About 427 children with chronic cervicofacial lymphadenopathy were analyzed. Among these, 290 had microbiologically confirmed cervicofacial mycobacterial infections (n = 3 Mycobacterium tuberculosis, n = 1 Mycobacterium bovis, n = 286 NTM). Of these 286 children with NTM cervicofacial lymphadenitis, 189 were treated surgically (median age: 41 months, range: 9-144, 46.0% males). The affected lymph nodes were excised in 151 children (79.9%), and curettage was performed in 38 children (20.1%). One patient (0.07%) experienced a reactivation/recurrence 2 years after surgical excision and required another surgical excision. Three children (7.9%) experienced infection reactivation/recurrences after curettage, confirmed by redness or a draining fistula, within the first year after healing. Two of these 3 patients were treated with additional surgical excisions.

CONCLUSION

The long-term outcome of surgical excision for NTM cervicofacial lymphadenitis is favorable with a low recurrence rate. Curettage or a conservative wait-and-see approach can be considered an alternative in advanced and surgically challenging cases. However, healing will take longer, and late recurrences are possible.

Combined orthodontic and surgical treatment for a patient with Hallermann-Streiff-Francois syndrome, severe obstructive sleep apnea, and history of antiresorptive medication

Micrognathia and retrognathia, as observed in patients with the Hallermann-Streiff-Francois syndrome, might result in obstructive sleep apnea syndrome. When it becomes severe (apnea-hypopnea index [AHI], ≥30), noninvasive treatment options might be insufficient. An orthognathic treatment with mandibular advancement will increase the upper airway volume, which results in a decrease of apneas. A 53-year-old woman with Hallermann-Streiff-Francois syndrome and a history of antiresorptive medication suffered from severe obstructive sleep apnea (AHI, 77.7). She was treated with a combined orthodontic and surgical approach. The AHI decreased to 1, and the patient felt fitter after treatment. No medication-induced osteonecrosis nor inhibition of tooth movement was seen. A combined orthodontic and surgical treatment of a patient with severe obstructive sleep apnea was a good treatment choice. With a history of antiresorptive medication, the risks related to these medications have to be weighed up against the consequences of not treating obstructive sleep apnea syndrome. With a drug holiday, successful surgical treatment can be achieved.

[Maxillomandibular advancement surgery as an optional therapy for patiens with severe obstructive sleep apnoea]

Obstructive sleep apnoea (OSA) is a common chronic disorder which often requires lifelong treatment. Its prevalence in the Netherlands is estimated to be around 300.000 people. In this study 12 patients with severe OSA were treated with maxillomandibular advancement surgery between 2011 and 2012. The mean advancement during surgery was 8.7 mm and the mean postoperative admission was 4 days. All patients underwent polysomnography at 3 months. Three months after surgical treatment, the apnoea-hypopnea index had decreased with 74.9% (57.3 to 14.4). The subjective sleepiness of the patients had also decreased with a mean of 57.5%. The literature indicates comparable results in patients with severe OSAS, specifically a reduction of the apnoea-hypopnea index of 80-90%. Considering the successful results following maxillomandibular advancement surgery, this therapy is an appropriate alternative for patients who cannot cope with 'continuous positive airway pressure' or patients who want a permanent therapeutic solution. Further research is recommended to achieve higher levels ofevidence for maxillomandibular advancement surgery in patients with OSA.

[A second generation of premolars in the mandible]

Two developing supernumerary bicuspids were noticed accidentally in the mandible of a 12 years old girl when evaluating an impacted 35 on a radiograph. The development of these teeth was followed, but at a later stage they were removed. In a 17 years old man multiple complete developed bicuspids were seen on a radiograph. The backgrounds and treatment concerning supernumerary bicuspids in the mandible are discussed.