Stability of Modified Maxillomandibular Advancement Surgery in a Patient With Preadolescent Refractory Obstructive Sleep Apnea  Hyo-Won Ahn, PhD, Baek-Soo Lee, PhD, Sung-Wan Kim, PhD, Su-Jung Kim, PhD  Journal of Oral and Maxillofacial Surgery  Volume 73, Issue 9, Pages 1827-1841 (September 2015) DOI: 10.1016/j.joms.2015.02.028 Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 1 A flowchart of the clinical pathway for orthodontic approaches in treating children with obstructive sleep apnea (OSA). First, the enlarged adenoid or tonsils are surgically removed. If residual symptoms of OSA exist, the origin should be evaluated further as either skeletal or soft tissue. When the degree of skeletal deformity is severe or residual growth will be negligible, orthognathic surgery can be performed. If the skeletal discrepancy is moderate and the growth potential is sufficient, growth modification can be performed, depending on the target area using orthopedic or functional appliances. Soft tissue problems underlying functional habits can be controlled by myofunctional therapy. It will reinforce the perioral and masticatory musculature and improve the tongue posture. If the patient is obese, weight loss should be encouraged. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 2 A-D, Initial photographs of the face and E-J, occlusion. The patient had a convex profile with a retruded chin, an open mouth, and constricted upper and lower dental arches, with moderate crowding, and a large overjet. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 2 A-D, Initial photographs of the face and E-J, occlusion. The patient had a convex profile with a retruded chin, an open mouth, and constricted upper and lower dental arches, with moderate crowding, and a large overjet. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 3 Initial lateral cephalogram. Skeletal Class II, with a retrognathic mandible and a hyperdivergent pattern, was seen in relation to the backward and downward position of the tongue and hyoid and a constricted oropharyngeal and hypopharyngeal airway width. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 4 A-D, Final photographs of the face and E-J, occlusion. Functional occlusion was obtained with a pleasing facial profile. The patient's lips were closed, with enhanced breathing. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 4 A-D, Final photographs of the face and E-J, occlusion. Functional occlusion was obtained with a pleasing facial profile. The patient's lips were closed, with enhanced breathing. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 5 A-D, Postretention photographs of the face and E-J, occlusion at 4 years postoperatively. Improved occlusion, facial proportion, and breathing function were stably maintained. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 5 A-D, Postretention photographs of the face and E-J, occlusion at 4 years postoperatively. Improved occlusion, facial proportion, and breathing function were stably maintained. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 6 Superimposition was performed to identify the A, postoperative changes and B, postretention changes, including residual facial growth. Although 1 mm of additional mandibular forward growth occurred without any remarkable maxillary changes after maxillomandibular advancement surgery, a slight rebound of an increased airway width was observed in the retroglossal area with backward relapse of the hyoid position, supposedly resulting from the increased body mass index. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 7 Cone-beam computed tomography images showing volumetric changes in the airway A-C, initially, D-F, 6 months after surgery, and G-I, 4 years after retention, in which the cross-sectional areas were measured at the retropalatal (Rp) and retroglossal (Rg) level. Even with a relapse rate of 12.3% at the retropalatal level and 23.1% at the retroglossal level, an overall 2.54-fold (postoperative) and 2.23-fold (postretentive) volumetric enlargement of the oropharyngeal airway was achieved. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions

Figure 7 Cone-beam computed tomography images showing volumetric changes in the airway A-C, initially, D-F, 6 months after surgery, and G-I, 4 years after retention, in which the cross-sectional areas were measured at the retropalatal (Rp) and retroglossal (Rg) level. Even with a relapse rate of 12.3% at the retropalatal level and 23.1% at the retroglossal level, an overall 2.54-fold (postoperative) and 2.23-fold (postretentive) volumetric enlargement of the oropharyngeal airway was achieved. Journal of Oral and Maxillofacial Surgery 2015 73, 1827-1841DOI: (10.1016/j.joms.2015.02.028) Copyright © 2015 American Association of Oral and Maxillofacial Surgeons Terms and Conditions