Mechanism and Causes for Obstructive Sleep Apnea

Obstructive sleep apnea is the condition where breathing is interrupted during sleep. This is caused by insufficient space for the tongue in a retruded lower jaw. The tongue falls back into the throat during sleep and obstructs the airway. This results in a pause in breathing followed by a brief awakening with a popping sound.

The resultant hypoxemia causes frequent arousals throughout the night. These episodes of periodic wakefulness stimulate the sympathetic nervous system. This results in vasoconstriction and reduced peripheral blood flow. There is an associated increase in heart rate and blood pressure due to this.

This is an extremely disruptive condition that leads to snoring and interrupted sleep. The person feels sleep deprived even after a full eight hours of sleep. It is usually the person’s sleeping partner who first notices this condition. There is also excessive daytime somnolence due to the poor quality of sleep caused by sleep apnea.

Restless legs syndrome can also be a result of obstructive sleep apnea. Wearing oral appliances during sleep can help with obstructive sleep apnea. This helps maintain constant positive airway pressure. Risk factors for complications are minimal through these appliances can be cumbersome.

Sleep labs conduct studies to diagnose sleep disorders. There is often blockage of the upper airway in sleep disorders. Management of obstructive sleep apnea can both be done through medical and surgical means. Both are equally effective at correcting sleep-disordered breathing. These disorders can also cause loud snoring.

Prolonged sleep disorders can lead to high blood pressure and heart disease. This increases your risk for life-threatening events. Oxygen level drops drastically in obstructive sleep apnea. Tongue and soft palate fall back obstructing the throat and breathing. The patient needs to stay overnight during a sleep study.

Need to Undergo Sleep Study for Confirmation of Obstructive Sleep Apnea

A sleep study, which is known as polysomnography in medical parlance, is a test to diagnose sleep apnea. This is conducted in a sleep lab. The patient is hooked up to several monitors during sleep. These record the brain waves, level of blood oxygen, eye movements, heart rate, breathing and movement of extremities.

Patient Referred to our Hospital Following Sleep Study

The patient is a 21-year-old male from Secunderabad in Telangana, India. He stated that he has been plagued with disturbed sleep since he can remember. There were frequent episodes of interrupted sleep throughout the night. These episodes were accompanied by an audible popping sound.

He was also a heavy snorer. There was excessive daytime somnolence despite a full night’s sleep. He also complained of always feeling tired.

His parents had consulted a doctor in their hometown who had referred them for a sleep study. The results of the study came back indicative of obstructive sleep apnea. They were referred to our hospital for management since they requested the best surgical care.

Specialty Center for Jaw Correction Surgery

We have been performing jaw correction surgery for over 30 years now. Mandibular advancement with a bilateral sagittal split osteotomy (BSSO) is a specialty surgery performed at our center. Patients regularly undergo BSSO for asymmetry correction of the mandible. We use advanced digital facial biometric studies to ensure the best cosmetic and functional results.

Initial Consultation at our Hospital for Management of Sleep Apnea

Dr. SM Balaji, a Sleep Apnea specialist, examined the patient and ordered imaging studies. He analyzed the results of the sleep study in detail. The patient had a retruded mandible.

A treatment plan was formulated and presented to the patient and his parents. They were in full agreement with the treatment plan and consented to surgery.

Genial Tubercle Advancement and BSSO Advancement of Lower Jaw

Genial tubercles are bony protuberances that are situated on the lingual side of the anterior mandible. They are located bilaterally in the region of the lingual foramen. Two muscles are attached to the genial tubercle. These muscles play a very important role in the mechanism of sleep apnea.

They are the geniohyoid and genioglossus with the former pulling the hyoid bone forwards and upward. The genioglossus helps protrude the tongue and pull it to the opposite side.

In a retruded mandible, the pull from these muscles is not sufficient to keep the tongue from falling backward during sleep. Surgical forward positioning of the genial tubercle will help address this issue. The tongue also does not have sufficient space in a retruded mandible.

Successful Completion of BSSO and Genial Tubercle Advancement

The genial tubercle was advanced and stabilized anteriorly using plates and screws. This was followed by BSSO with the advancement of the mandible by 12 mm. The inferior alveolar nerve was mobilized with the proximal segment. Care was taken to ensure that there was no injury to the nerve throughout the surgery.

A Le Fort I maxillary osteotomy was next performed to ensure correction occlusion with the mandible. Occlusion was checked before stabilization with plates and screws. This also resulted in a dramatic improvement of the patient’s facial esthetics.

Resolution of Sleep Apnea with Normal Postsurgical Sleep Study

The patient subsequently underwent a sleep study in his hometown. All parameters were normal in this sleep study.

His obstructive sleep apnea symptoms had completely resolved. He had also stopped snoring during sleep. Oxygen saturation levels were normal.

His parents reported that he slept fitfully throughout the night. The patient also reported that he felt refreshed upon waking up. Daytime somnolence had also completely resolved.

Complete Patient Satisfaction with Treatment at our Hospital

The patient and his parents were delighted with the results of the surgery. His parents stated that he seemed like a new person with a lot of energy and focus. He too stated that there was a greatly improved overall quality of life.

They expressed their gratitude to the hospital staff for the care and attention rendered during their hospital stay.

Surgery Video

Patient born with bilateral cleft lip and palate deformity

The patient is a 7-1/2-year-old girl from Sadurangapattinam in Tamil Nadu, India. She was born with a bilateral cleft lip and palate defect. It was very severe. Her parents were extremely distressed upon seeing the degree of her facial deformity. They were reassured at the hospital that this could be surgically managed.

The incidence of cleft deformities among newborns is higher in the Sadras region than the national average. Many infants born with this deformity have been successfully rehabilitated in our hospital. Some of the patients who were operated on over 20 years ago are now happily married with children of their own.

The patient and her parents were referred to our hospital for surgical management of her cleft defects. It was explained to them that the road to total cleft rehabilitation was a long one. They stated a complete understanding of this. Plastic surgeons also perform this procedure in western countries.

She first underwent bilateral cleft lip repair at the age of 3 months. This was followed by cleft palate repair at 11 months of age. The premaxillary setback with bone grafts to the region of the cleft alveolus was also performed for the patient.

Continuation of the rehabilitation process at our hospital for the patient

Orthodontic consultation was also initiated for the patient. Our hospital is a super-specialty center for cleft orthodontics in India. She will need extensive orthodontic intervention in later years.

Her teeth are malaligned due to her cleft deformity. She also has a few congenitally missing teeth. The remaining teeth will need to be brought into perfect alignment. Dental implant surgery would ensure the replacement of her missing teeth. This final step would complete her rehabilitation. Soft tissue molding would also be perfect following this step.

She still had nasal deformities that needed to be corrected. There was a collapsed columella. This caused extreme flattening of her nose. She also had a very blunt nasal tip. Some patients also have asymmetry of the alar bases.

There was also stunting of the prolabium with a resultant short upper lip. The patient was instructed to present for correction of these deformities.

Surgical planning for correction of her collapsed columella and stunted prolabium

Dr. SM Balaji, cleft nose correction surgeon, examined the patient and obtained pertinent studies. The patient would require an open rhinoplasty with the reconstruction of philtrum. It was decided to reconstruct her collapsed columella with a flap dissected from the prolabium. The resultant prolabium defect would be reconstructed using a lower lip Abbe flap.

It was explained to the patient that she would not be able to open her mouth for two weeks following surgery. This period would enable revascularization of the Abbe flap from the upper lip tissue. They were in agreement with the treatment plan and consented to surgery.

Cosmetic and functional rehabilitation of her cleft related deformities

Under general anesthesia, markings were made on the prolabium. This was followed by a dissection of the prolabium and the columella. The lower lateral cartilages were identified, dissected and separated.

Medial crura were sutured together as well as to the nasal septum. This would ensure a sharp alar dome. Prolabium was then utilized to reconstruct and lengthen the columella.

A full-thickness Abbe flap was then raised from the lower lip to reconstruct the prolabium. Extreme care was taken to ensure patency of the inferior labial artery in the flap tissue. The flap was then sutured to the region of the upper lip defect.

Blood supply would be from the inferior labial artery until the establishment of supply from the upper lip. The inferior labial artery is a branch of the facial artery. This arises near the angle of the mouth, at the region of the edge of the lower lip

Separation of the lower lip flap from the upper lip with good flap vascularity

Abbe flap was separated after a period of two weeks. There was good perfusion of blood within the upper lip flap. She now had a sharp nose with a long columella. Her nose now had a straight profile.

The upper lip also had adequate length due to the lengthened prolabium. This provided increased lip tissue for her to appose her lips together. Visible scar tissue was also negligible following the surgery. She expressed her satisfaction with the cosmetic results from the surgery. Her parents too were very happy with the results of the surgery.

Surgery Video

Patient with a Hereditary Tendency for a Large Lower Jaw Running Through his Family

The patient is a 24-year-old male from Ludhiana in Punjab, India. He has always had a large lower jaw. This caused an unattractive facial structure. The scientific term for this is mandibular prognathism. Many members of his family also have a large lower jaw.

Functional and Esthetic Difficulties Caused by Mandibular Prognathism

This has caused him to have problems with eating and speech. He has also felt very self-conscious because of the cosmetic compromise from the large jaw. Desiring to get this corrected, he and his parents made inquiries with many surgeons including dentists and oral surgeons. They had been referred to our hospital for surgical correction.

Certain syndromes have been associated with a large lower jaw. Acromegaly, which is a condition caused by excess growth hormone in adults results in mandibular prognathism. A percentage of these patients also have gum disease due to chronic mouth breathing.

Specialty Procedures performed in our hospital

A common term for a very large lower jaw is lantern jaw. The chin is extremely prominent and forwardly positioned. Mastication and speech are rendered very difficult in these cases. Patients undergoing facial feminization also undergo jaw reduction procedures.

Our hospital is a specialty center for jaw reconstruction surgery. Le Fort I surgery is performed for retrusion or advancement of the upper jaw. Distraction osteogenesis is also used for the advancement of the retruded maxillaLower Jaw Protrusion – Bilateral Sagittal Split Osteotomy Reduction and retrognathic mandible.

Jaw reduction surgery is routinely performed in our hospital. All these surgeries are performed under general anesthesia in our state of art operating theatres.

Initial Consultation and Examination at our Hospital

Dr. SM Balaji, Specialist in Jaw Surgery, examined the patient. A detailed history was also obtained. He then ordered imaging studies including a 3D CT scan. These are mandatory for patients undergoing jaw surgery.

This showed that the patient had a skeletal overbite of 12 mm. There was also a horizontally impacted right third molar. He had bilateral impacted wisdom teeth. These were also indicated for removal.

Treatment Planning Explained in Detail to Patient and his Parents

Treatment planning was modified as the patient wanted to undergo both procedures at the same time. The mandibular setback is usually performed six months after wisdom tooth extraction, but an exception was allowed in this patient.

The patient will first undergo presurgical fixed orthodontics to decompensate the arch. This would be followed by surgery and postsurgical orthodontics. The last stage of orthodontics would be fine-tuning his dental occlusion. They then consented to surgery.

Wisdom Tooth Surgery Followed by Mandibular Setback

Under general anesthesia, both impacted third molars were extracted. Sectioning of the left third molar was performed to enable easy wisdom tooth extraction. Attention was turned to the bilateral sagittal split osteotomy (BSSO) following wisdom teeth extraction. The bilateral sagittal split osteotomy would enable backward positioning of the lower jaw to achieve good alignment with the upper jaw.

Preservation of Inferior Alveolar Nerve throughout Surgery

Bilateral sagittal split osteotomies were made. The inferior alveolar nerve was mobilized with the proximal segment. This allowed for mobilization of the distal segment. A slice of bone 14 mm was removed from the site of the osteotomy.

The mandible was then set back and occlusion was checked. Stabilization of the mandibular segments was performed with plates and screws. Care was taken to ensure that the inferior alveolar nerve remained safe throughout the procedure.

Complete Patient Satisfaction with Results of Surgery

There was a tremendous immediate improvement in facial esthetics. The patient and his family were very happy with the results of the surgery. They expressed their satisfaction before their final discharge from the hospital.

Surgery Video