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Standard treatment of obstructive sleep apnea (OSA) is nightly application of positive airway pressure therapy (CPAP). However, adherence to CPAP is limited due to side effects and complications, and patients are frequently untreated or undertreated. In this scenario, patients with OSA are at risk of developing comorbidities such as arterial hypertension, coronary artery disease, or diabetes, and are exposed to an increased risk of experiencing traffic or occupational accidents due to daytime sleepiness. Alternative treatments include mandibular advancement devices or positional devices to prevent patients sleeping on their back, as well as anatomy-altering surgical procedures. For several years now, an additional surgical treatment-hypoglossal nerve stimulation-has been available for selected OSA patients. Hypoglossal nerve stimulation is a dynamic surgical approach that uses electrical stimulation to activate key muscles of the upper airway to achieve airway patency.

ackground Early studies report on different calibers of the mesopharynx opening in the states of wakefulness and sedation. Objectives Is it possible to manipulate the widening of the mesopharyngeal isthmus by particular maneuvers in the states of wakefulness and sedation? Methods The mesopharyngeal isthmus of 50 healthy subjects was examined endoscopically in wakefulness and under sedation. The intraoral negative pressure was controlled by a vacuum activator. The following maneuvers were performed and widening of the isthmus was documented pictorially: spontaneous breathing with closed lips (SB), mandibular advancement (MA), tongue repositioning maneuver (TRM), and mandibular advancement combined with TRM (MA, TRM). While performing the tongue repositioning maneuver with closed lips, the tongue is adapted closely to the row of teeth and also to the hard and soft palate. Results In wakefulness, 123 endoscopic pictures were analyzed, 35 with SB, 34 with MA, 35 with TRM, 19 with TRM and MA. In sedation there were 125 pictures, 35 with SB, 32 with MA, 34 with TRM, 24 with TRM and MA. The results represent that in sedation the TRM has a significant widening effect on the opening of the mesopharyngeal isthmus compared to SB without TRM (p < 0.05). Compared to SB in sedation, the combined maneuver of TRM and MA had an additional effect on the widening of the mesopharyngeal isthmus (p < 0.05). Conclusions In sedation, the mesopharyngeal isthmus is stabilized by the TRM and the combined maneuver with MA and TRM because of the forward displacement of the tongue out of the pharynx with closed contact to the hard palate and apposition of the velum to dorsum of the tongue. Hintergrund. Frühere Studien berichten über unterschiedlicheWeitstellungen des Mesopharynx im Wachzustand und in Sedierung. Fragestellung. Lässt sich der mesopharyngeale Isthmus imWachzustand und in Sedierung durch bestimmteManöver beeinflussen? Material und Methoden. Bei 50 gesunden Probanden (18 m, 32 w) wurde der mesopharyngeale Isthmus imWachzustand und in Sedierung endoskopisch untersucht und der intraorale Unterdruckmit einemVakuumaktivator kontrolliert. Folgende Manöver wurden durchgeführt und dabei der Isthmus bildlich dokumentiert: Spontanatmungmit anteriorem Lippenschluss (SA), Unterkieferprotrusion (UP), Zungenrepositionsmanöver (ZRM), Unterkieferprotrusion mit ZRM (UP, ZRM). Während des ZRM ist – bei geschlossenen Lippen – die Zunge an den Zahnreihen, den Hartgaumen und an das Velum angelagert. Ergebnisse. Im Wachzustand wurden 123 Bilder analysiert, davon 35 mit SA, 34 mit UP, 35 mit ZRM, 19 mit ZRM und UP. In Sedierung waren es 125, davon 35 mit SA, 32 mit UP, 34 mit ZRM, 24 mit ZRM und UP. Die Resultate zeigen, dass in Sedierung das ZRM einen signifikant erweiternden Effekt auf die Weite des mesopharyngealen Isthmus imVergleich zur sedierten SA ohne ZRM (p < 0,05) hatte. Das kombinierteManöver mit ZRM und UP hatte im Vergleich zur sedierten SA einen additiven Effekt auf die Weitstellung des mesopharyngealen Isthmus (p < 0,05). Schlussfolgerung. In Sedierung wird mittels ZRM und kombiniertemManöver mit UP und ZRM der mesopharyngeale Isthmus durch Vorverlagerung der Zunge aus dem Pharynxraum mit enger Zungengaumenkontaktposition sowie durch Anlagerung des Velums am Zungenrücken stabilisiert. peerReviewed

Mandibular advancement devices are used for the therapy of obstructive sleep apnea. We investigated whether the therapeutically necessary CPAP value is a useful predictor of the efficacy of oral devices.We retrospectively compared polysomnography data from 67 patients, 8 women and 59 men, (age mean/standard deviation: 54.2 ± 12.3 years; BMI: 28.6 ± 4.3 kg/m²; apnea-hypopnea index: 21.9 ± 12.3/h). All patients were initially treated with CPAP. Due to problems with the CPAP mask, they switched to a mandibular advancement device.Under the use of CPAP, the apnea-hypopnea index decreased from 21.9 ± 12.3 to 3.4 ± 4.6/h, with the mandibular advancement device to 9.7 ± 11.6/h. The apnea-hypopnea index while using an oral device was remarkably different when the therapeutically necessary CPAP value was taken into consideration: in the patient group with a pressure of 4 mbar, it was 6.1 ± 8.7 and in the group with values 8 mbar, it was 23 ± 9.6/h. Thus, the efficacy was signficantly different for CPAP values above 8 mbar.The therapeutically necessary CPAP value is a valuable predictor for the efficacy of mandibular advancement devices.

Optimal treatment of the obstructive sleep apnoea syndrome (OSAS) requires an individually designed and interdisciplinary approach. Continuous positive airway pressure (CPAP) is accepted as the first line therapy for patients with OSAS. However, non-CPAP therapies may be indicated as supportive therapeutical approach in CPAP failure or as an alternative approach in CPAP intolerance. Overall, the level of evidence for the majority of non-CPAP therapies is low. Mandibular advancement devices as a medical non-CPAP treatment have proven to reduce respiratory disturbances to a level which may be sufficient in mild to moderate sleep apnoea. Apnoea triggered neurostimulation of upper airway muscles is an innovative approach that has shown promising results in preclinical studies. Surgical treatment has previously been performed as single level surgery of the nasal, the oropharyngeal or hypopharyngeal level. However, only tonsillectomy in the presence of tonsillar hypertrophy and maxillomandibular advancement are recommended in carefully selected cases. Due to low success rates for single level surgery, multilevel surgery has been proposed as the surgical approach for the future.

In terms of pathophysiology, an anatomically narrow airway is a predisposing factor for obstruction of the upper respiratory tract. The correlation between the nasopharyngeal airway and the craniofacial structures is discussed in this context. Thus a mutual interaction between the pharynx and the mandibular position was demonstrated, whereby the transverse dimension of the nasopharynx was significantly larger in patients with prognathism than in patients with retrognathism. The influence of chronic obstruction of the nasal airway on craniofacial development was also discussed. The form-and-function interaction, which ought to explain the causal relationship between nasal obstruction and craniofacial growth, appears to be of a multifactorial rather than a one-dimensional, linear nature. It is not disputed, however, that expanding the maxilla improves not only nasal volume and nasal flow, but also the subjective sensation of patients, although it is not possible to make a prognostic statement about the extent of this improvement because of the differing reactions of individuals. Orthodontic appliances for advancing the mandible can also be successfully used in the treatment of mild obstructive sleep apnea syndrome. This treatment method should be considered particularly for patients who are unwilling to undergo or cannot tolerate CPAP treatment.

The question of the study was to obtain the relapse after long distance mandibular advancement while immobilization of the suprahyoidal mussels by using the 1996 developed method of H. E Umstadt. Instead of cutting the suprahyoidal mussels, which involves the adverse effects of a usual mandibular advancement, the risk of distinct haematoma in the submundibular area and scar contraction, 23 patients were treated with Botulinumtoxin to immobilize the suprahyoidal mussels. The combinated orthognatic surgery and orthodontic treatment of the mandibular retrognathism has been established during the last decades. The method of choice is the retromolar sagittal split of the lower jaw with advancement of the dental segment. A lot of studies showed that the osteosynthesis with screws or the combination of plates and screws obtained the most reliable results. The examined patients were treated with the semi-rigid osteosynthesis using set screws. The applied method with set screws is the best compromise between stability and the functional adjustment of the temporo-mandibular joints. The bone treatment is pretty well developed. Although this innovative development long distance mandibular advancements showed distinct relapse of 10 % to 50 % during the postoperative period depending on the method of surgery and osteosynthesis. The main problem is still the soft tissue management. The main reason of developing a relapse is the retral traction of the suprahyoidal mussels. Lateral X-rays of the scull were produced and analyzed before surgery and up to two years after surgery. On the basis of the X-rays two distances concerning the mandibular bone, the SNB-angle and the posterior airway space were analyzed. Conclusion of the study: 1. The relapse concerning the mandibular bone is with 5 % considerable lower than the results of comparable studies. 2. The t-Test showed no differences concerning the analyzed ranges of the mandibular after surgery compared to the ranges one and two years after surgery. 3. In the ratio to the base of the skull the mandibular showed a relapse of 3 % after one year and 5 % after two years after surgery. 4. A high correlation has been found between the SNB-angel and the posterior airway space. 5. Despite of the immobilisation of the suprahyoidal mussels with botulinumtoxin in combination with mandibular advancement the posterior airway space showed no constriction. 6. No patient showed side effects, which had not been seen even after conventional surgery. The results show an amazing advantage in the soft tissue management with reduced postoperative risks of complications and a reduced relapse., Die Fragestellung, die es in der vorliegenden Studie zu klären galt, war die Beobachtung des Rezidivs nach langstreckigen Unterkiefervorverlagerungen unter temporärer Ruhigstellung der suprahyoidalen Muskulatur mit Botulinumtoxin nach der von Umstadt 1996 entwickelten Methode. Als Alternative zur Myotomie, die neben den Nebenwirkungen einer normalen Unterkiefervorverlagerung das Risiko ausgeprägter Hämatome im Mundboden und Narbenkontrakturen bietet, erfolgte bei 23 Patienten die temporäre Ruhigstellung der suprahyoidalen Muskulatur mit Botulinumtoxin. Die kombinierte kieferchirurgische, kieferorthopädische Therapie der mandibulären Retrognathie hat sich in den letzten Jahrzehnten zu einer anerkannten und etablierten Therapiemethode entwickelt. Hierbei hat sich die beidseitige, retromolare, sagittale Spaltung des Unterkiefers mit anschließender Vorverlagerung des zahntragenden Segmentes als Methode der Wahl erwiesen. Als Ostesynthesemethode stellte sich in vielen Studien die Schraubenosteosynthese oder die Kombination aus Platten mit Schrauben als das Verfahren mit den stabilsten Ergebnissen heraus. Die Schraubenosteosynthese, die in dem untersuchten Patientenklientel als semirigide Stellschraubenosteosynthese durchgeführt wurde, stellt hier den besten Kompromiss zwischen Stabilität und funktioneller Kiefergelenkseinstellung dar. Das Hartgewebsmanagement ist damit relativ weit entwickelt. Trotz dieser innovativen Weiterentwicklungen in den letzten Jahren kommt es speziell bei weitstreckigen Vorverlagerungen des Unterkiefers im postoperativen Verlauf zu ausgeprägten Rezidiven, die in der Literatur mit Werten zwischen 10 % und 50 % angegeben werden, abhängig von Operationsmethode und Vorverlagerungsstrecke. Probleme bereitet immer noch das Weichteilmanagement. Als größter, das Rezidiv begünstigender Faktor wird hier der retral gerichtete Muskelzug der suprahyoidalen Muskulatur mit dem Muskulus geniohyoideus und den vorderen Bäuchen der Muskuli digastrici gesehen. Es wurde eine Auswertung von prä- und postoperativ erstellten, seitlichen Fernröntgenbildern des Schädels vorgenommen. Die Bilder wurden vor Operation, nach Operation und im Verlauf nach sechs Wochen, einem halben Jahr, einem und zwei Jahren aufgenommen. Anhand der Bilder wurden zwei Strecken im Bereich des Unterkieferknochens, der SNB-Winkel, der das Verhältnis des Unterkiefers zur Schädelbasis beschreibt, sowie der posterior airway space vermessen. Als Ergebnis der Studie bleibt festzuhalten: 1. Das Rezidiv im Bereich der Messstrecken der Mandibula liegt mit etwa 5 % deutlich unter den in der Literatur beschriebenen Rezidivquoten. 2. Der t-Test zeigt postoperativ keine Veränderung in der erzielten Vorverlagerungsstrecke, sowohl ein als auch zwei Jahre postoperativ verglichen mit dem unmittelbar postoperativ erzielten Wert. 3. Auch im Verhältnis des Unterkiefers zur Schädelbasis zeigt sich ein Rezidiv von nur 3 % nach einem Jahr und 5 % bereinigt nach zwei Jahren. 4. Ein großer SNB-Winkel korreliert mit einem weiten posterior airway space. Dies zeigt, dass die Lage des Unterkiefers zur Schädelbasis eine entscheidende Auswirkung auf die Architektur der oberen Atemwege hat. 5. Trotz teilweiser Ruhigstellung der suprahyoidalen Muskulatur mit Botulinumtoxin kommt es bei gleichzeitiger Vorverlagerung des Unterkiefers postoperativ nicht zu einer Einengung des posterior airway space und damit verbunden zu einer Einengung der oberen Atemwege. 6. Keiner der Patienten berichtete postoperativ über unangenehme Nebenwirkungen, die auch nicht bei einer konventionellen Unterkiefervorverlagerung zu beobachten sind. Die Ergebnisse zeigen einen erheblichen Fortschritt im Bereich des Weichteilmanagements mit sowohl reduziertem perioperativem Risiko als auch reduziertem Ausmaß des Rezidivs.

Mandibular advancement appliances are employed in treating snoring and various forms of obstructive sleep apnea syndrome (OSAS). The splints facilitate the displacement of the mandible anteriorly and widens the pharyngeal lumen during sleep. Two-splint systems are anchored on the dental arches in the maxilla and mandible. The resulting reciprocal forces are transferred onto the teeth, leading to dental side effects when used long-term. We retrospectively examined the dental changes that occurred after patients had worn the Thornton Adjustable Positioner (TAP®) for over two years. We enrolled all patients consecutively in whom the diagnosis of OSAS was made following polysomnography in a sleep laboratory between January 2004 and December 2005 and who had been treated primarily with a TAP®. We compared the patients’ baseline findings with follow-up findings after more than 24 months of continuous appliance wear. 24/47 of the patients were still wearing the splints regularly after an average of 33 ± 9.1 months. Overbite was highly significantly reduced (p = 0.006). We noted a reduction in the frontal overbite of more than 1 mm in ten patients (47.6%), and the overbite of one patient decreased by 4 mm. The maxillary front teeth showed significant palatal tipping and those in the mandible significant labial tipping. Clinically small but statistically significant dental side effects predominantly affecting the incisors’ inclination occur after long-term wear of a TAP® appliance. The clinical relevance of these dental changes to the patient can only be judged individually within the scope of an entire assessment.

The objective of this study was to verify the effects of treatment to correct Class II malocclusion with the Functional Mandibular Advancer (FMA) on the relative positions of the articular disc and mandibular condyle. In particular, we aimed to find out whether the disc-condyle relationship changed between baseline and post-treatment, in temporomandibular joints initially exhibiting a physiological relationship and alternatively, in temporomandibular joints initially presenting anterior displacement of the articular disc. Treatment progress in 15 patients was monitored at defined points in time by manual structural analysis (MSA) and magnetic resonance (MR) imaging. The disc-condyle relationship was assessed by examining the parasagittal MR images made up of three slices each (lateral, central, medial) taken in habitual intercuspation and maximum-open mouth position. The MR images were metrically analyzed to determine the sagittal positional relationship of the articular disc and mandibular condyle using two methods on the central slices of the images taken in closed-mouth position. MSA was used in particular to determine the disc-condyle relationships and to metrically record the extent of active movement of the mandible during mouth opening, protrusion, laterotrusion, and retrusion. Comparison of baseline and post-treatment findings revealed that none of the joints exhibited a treatment-induced deterioration in the disc-condyle relationship, while the relationship improved in five joints. After categorization of the joints according to groups according to disc position, metric analysis of the MR images showed significantly-improved post-treatment disc positions in the joints that had initially exhibited anterior disc displacement. Post-treatment findings for maximum-open mouth position, protrusion, and laterotrusion corresponded to the baseline values recorded before bite-jumping, and the extent of maximum active retrusion increased significantly. Functional jaw orthopedics for correction of skeletal Class II with the rigid fixed FMA leads to side-effects reflected in the disc-condyle relationship in the temporomandibular joints: no adverse effects were observed in joints presenting an initial physiological disc-condyle relationship, whereas the disc position may improve in joints with initial partial or total anterior disc displacement. In comparison with the baseline findings, we observed no post-treatment restriction in the extent of maximum mouth opening, protrusion, and left and right laterotrusion. Maximum active retrusion increased due to the treatment. MR imaging and MSA only partly cover the same aspects of temporomandibular joint diagnostics.

The aim of this clinical study was to reveal skeletal effects during the treatment of Class II malocclusions in adolescents and young adults using a protrusive-acting fixed, rigid functional orthodontic appliance, and to quantify them in comparison with an untreated control group. We aimed to determine whether, and if so, to what extent skeletal effects diminish with increasing age, and whether inter-individual differences can be observed.To correct their intermaxillary jaw relationship, the functional mandibular advancer (FMA) was inserted in 16 adolescents and young adults (eight males, eight females, aged from 12 years, 3 months to 18 years, 7 months) presenting with a skeletal Class II malocclusion. The course of treatment was documented cephalometrically.In all patients, the FMA treatment led to neutroclusion or overcorrected neutroclusion and a marked reduction in overjet. The occlusion's improvement in the sagittal dimension (overjet reduction by 4.43 +/- 2.10 mm, molar relationship improvement by 3.88 +/- 1.12 mm) was achieved by a combination of dental effects (distalization of upper teeth, mesialization of lower teeth) and skeletal effects (mandibular growth stimulation). Excepting the position and morphology of the maxillary base and the condyle's dorsal position in the fossa, all sagittal skeletal and dental changes induced by the FMA treatment were statistically significant. There was a mean increase of 1.71 +/- 1.11 mm in sagittal length of the mandible, in the sagittal-diagonal dimension of 1.42 +/- 1.51 mm and 1.53 +/- 2.15 mm, as well as a slight, significant increase in the gonial angle area. Whereas the condylar position remained stable, a forward positioning of the chin and thus significant increase in distance length was recorded from the posterior condylar margin to the anterior mandibular margin.Treatment with a fixed functional appliance in Class II patients effected significant changes in mandibular growth and correction of the distal intermaxillary relationship even after the pubertal growth spurt in adolescents and young adults. While the proportion of the orthopedically-induced skeletal share is subject to substantial inter-individual variability in adolescents, the overall conclusion can be drawn that skeletal effects (= stimulation of mandibular growth) in general clearly lessen with increasing patient age. In young adult patients, the correction of a distal intermaxillary jaw relationship is manifested primarily as a dento-alveolar compensation for the skeletal malocclusion.

Psycho-esthetic aspects play an important role in motivating patients to undergo combined orthodontic-surgical treatment as well as in the subjective appraisal of treatment outcome. The facial soft tissues are the crucial interlink between the underlying skeletal and dental structures and their perception by the patient and his social environment. TREATMENT OF SHORT FACE SYNDROME: In the therapy of Class II malocclusions with skeletal deep bite and short lower face (short face syndrome), the soft tissues and the psycho-esthetic treatment expectations of the patient are taken systematically and appropriately into account during treatment planning and evaluation.The respective elements of the treatment concept are outlined and explained in this article. Based on the empirical evaluation of 15 patients treated according to this concept, the soft tissue changes in patients with short face syndrome and the changes in esthetic and psychosocial self-perception are reported.The results demonstrate the efficiency of the treatment concept in improving facial soft tissues, especially in the vertical dimension, and the resulting psycho-esthetic benefit to the patient.

In the treatment of snoring (SN) and sleep-related breathing disorders (SRBD), mandibular advancement devices (MAD) are of increasing importance. Their mode of action is based on the advancement of the mandible, thereby increasing various upper airway dimensions and thus airway patency and airflow during sleep. The aim of the present study was to investigate efficacy and tolerability of an individually fitted MAD on 11 patients (10 males, 1 female), mean age 57 years, using sleep laboratory methods in 3 subsequent nights (adaptation-, baseline-, treatment night). The MAD consists of 2 separate parts that attach to both dental arches. On occlusion the upper maxillary part with a protruding cone meets an inclined plane of the lower mandibulary part, thereby forcing the mandible to advance. 10 patients (6 with obstructive sleep apnea, 3 with obstructive hypopnea and 1 primary snorer) tolerated the MAD well; one patient (primary snorer) removed the MAD after 1 hour. Regarding the target variable, the snoring index (SI), confirmatory statistics demonstrated a significant improvement from 108 to 53/h sleep, though normalisation could not be achieved. Descriptive data analysis showed significant improvement of the apnea-hypopnea index (AHI) from 15 to 5.5/h and of the oxygen desaturation index (O2-DI) from 21 to 13/h sleep. Arousal variables and periodic leg movement index (PLMI) improved as well. Objective sleep efficiency and subjective sleep- and awakening quality remained unchanged. Thus, besides the good therapeutic efficacy (the medians of improvement of the SI, AI, AHI, O2-DI and PLMI were 37, 48, 53, 51 and 29%, respectively), acute acceptance of the MAD was also satisfactory. Last but not least our present study showed once more the necessity of an adaptation night, as from the first to the second sleep laboratory night respiratory indices deteriorated significantly.

The treatment effect of patients suffering from obstructive sleep apnoea/hypopnea (OSAHS) with an oral appliance is considerably varied, and its clinical outcome is unpredictable. The aim of our investigation was to examine the changes in pharyngeal airway size at different degrees of mandibular protrusion in order to assess the therapeutic efficacy in relation to the amount of protrusion.Fifteen patients with the polysomnographic diagnosis of mild to moderate OSAHS were included in this prospective study. Nasal video endoscopy of the pharynx was done with the patients in supine position at four different degrees of mandibular protrusion do assess the changes of airway size. After 3 - 4 weeks a control polysomnography was carried out, with the mandible in optimal protrusion.The pharyngeal diameter did not increase linearly to the amount of mandibular protrusion. In the polysomnographic examination the respiratory variables were significantly increased. None of the patients in this group was classified as a non-responder to the oral appliance therapy.The endoscopically-assisted adjustment of the mandibular protrusion appliance is an additional tool to optimise treatment effectiveness. The increase in pharyngeal diameter is not proportional to the amount of mandibular protrusion.

Developed under interdisciplinary cooperation, the Functional Mandibular Advancer (FMA) is a new, rigid and fixed appliance for sagittal correction of the intermaxillary jaw relationship in adolescents and young adults. The appliance is non-dependent on patient compliance and is aimed at providing an alternative to the Herbst and MARA appliances. A number of designs, all based on the mechanical principle of the inclined plane combined with guide pins and allowing reactivation, were developed. The version of the appliance providing the best technical advantages was developed to the stage of practical application in patients.

The mandibular advancement device (MAD) is accepted as an additional treatment option for snoring and mild obstructive sleep disorders. Its therapeutic efficacy can only be verified through nocturnal polysomnography with the appliance in situ. The relevance of the craniofacial skeletal and soft-tissue structures as an etiological cofactor is controversial. While the lateral cephalogram of the facial skeleton is of no direct diagnostic relevance, it remains unclear to what extent cephalometric assessment can provide prognostic information to better ensure treatment success with an MAD.This study is based on the evaluation of 57 patients diagnosed polysomnographically with obstructive sleep apnea (OSA). The patients were treated primarily with a modified activator; after 6-12 weeks, control polysomnography was carried out in the sleep laboratory. The cephalometric variables were analyzed using a multivariate regression procedure with the response variable of treatment outcome. In addition to a horizontal craniofacial morphology, the downward and forward posture of the hyoid is a prognostic variable for effective therapy with an MAD.

The aim of this study was to investigate the stability achieved with high sagittal supraforaminal osteotomy (HSSO) for setback and advancement procedures of the mandibular ramus.Computerized cephalometric X-rays of 102 patients, taken at four different times during treatment, were evaluated.The mean postoperative relapse was 20%, depending on the extent of the surgical correction (correlation coefficient: -0.68). Mandibular setback gave more stability than mandibular advancement. The type of osteosynthesis (positional screw combined with miniplate osteosynthesis or intermaxillary fixation) did not influence the stability. Unimaxillary osteotomies were more stable than bimaxillary procedures (p0.001).

The aim of the study was the prospective cephalometric analysis of 58 patients who underwent sagittal split ramus osteotomy (SSRO). Stabilisation of the fragments was achieved with an adjustable monocortical bone fixation system. Lateral cephalograms were taken preoperatively, postoperatively, 6 months postoperatively, and 12 months postoperatively. The radiographs were digitised, and a computerised analysis was performed. The mean mandibular advancement was 8.5 mm with a mean relapse of 0.8 mm after 12 months (P0.05). The mean mandibular setback was 7.8 mm with a mean relapse of 1.2 mm after 12 months (P0.05). The results of the present study show a minimal relapse after mandibular advancement and setback for the SSRO and the new adjustable fixation system. Postoperative analysis reveals a safe intraoperative positioning of the condyles with subsequent prevention of an immediate relapse. The results after 12 months indicate sufficient long-term stability, although additional evaluations with results after 5 and 10 years are necessary for a final report.

The main aesthetic concern of patients with Angle class II deformities with skeletal deep bite--short face syndrome--is the short lower face. It is the orthodontist's task to correct this deformity insofar as possible. Depending on the extent, even orthodontists at the beginning of their training will recognize this. Since presurgical orthodontic treatment determines the kind and extent of the surgical procedure, the orthodontist has to plan the treatment in for individual case. It is the purpose of this article to demonstrate a concept of treatment for patients with class II deformities, skeletal deep bite, and a short lower face. Presurgical orthodontic treatment and the surgical procedure to correct the deformity are discussed. The treatment results show that it is necessary to leave or to create a certain curve of Speed, depending on the extent of the deformity, to achieve a satisfactory result in terms of to function, aesthetics, and stability. It can be concluded that it is only possible to reach the preset treatment goals with an exact diagnosis and the knowledge of the necessary preparation in combination with the surgical procedure.

Oral appliances are used to treat snoring and sleep apnea. Yet, their success cannot be predicted without a therapeutical trial. This uncertainty and the high prices of the appliances are the reasons for their limited use. We tested a cheap, custom fit mandibular advancement device (SnorBan) for the treatment of sleep disordered breathing in order to assess its efficacy. 39 consecutive patients (51.1 +/- 9.2 years, BMI = 27.4 +/- 4.5 kg/m2) with different degrees of sleep disordered breathing (AHI = 16.6/h +/- 15.6/h) received the device after a thorough clinical examination. After getting used to the device a second polysomnography was performed. The AHI improved significantly from 16.6/h to 8.2/h (P0.01) in the whole group. The only patient who became worse could not get used to the device. Time with snoring dropped significantly from 16.3% to 6.6%, 59.1% of the sleep apnea patients were successfully treated as their RDI dropped below 10/h. The sleep efficiency remained unchanged. Slow wave sleep and REM-sleep increased significantly from 12% to 16% (P0.05). The overall compliance was 75%. The custom fit mandibular advancement device Snorban is a cheap and effective treatment for a number of patients with snoring and sleep apnea. The oral appliance is proven to be a useful and simple, non-surgical treatment option. Polysomnographic follow-up is mandatory as breathing may worsen with the device while asleep.

Children with craniofacial malformations are at special risk for the development of peripheral airway obstruction. The problems are magnified in patients with retroposition or hypoplasia of the mandible. In these cases, the base of the tongue is posteriorly displaced, hereby decreasing the airway diameter. By application of distraction osteogenesis the mandible can be lengthened to move the base of the tongue forward and open the airway. Three female patients aged between 7, 11, and 15 months suffering from peripheral airway obstruction caused by mandibular hypoplasia were treated by gradual distraction. All of them had a gastrostomy or a nasogastral tube in place, respectively, due to severe nutrition problems. In the youngest patient tracheostomy was performed shortly after birth and was already planned in the 15-month-old child, who had received a permanent nasopharyngeal tube. The 11-month-old child suffered from severe refractory sleep apnea. Exercises in oral feeding were possible in the youngest patient after 10 days of distraction. In the oldest one, the airway tube was removed on the six day of distraction and, thus, tracheotomy was successfully avoided. In the 11-month-old child apneic events a rapidly decreased. Our experience suggests that distraction osteogenesis after careful preoperative evaluation can be successfully performed for the treatment of peripheral airway obstruction in patients with selected craniofacial anomalies.

Diagnosis and therapy of obstructive sleep-related breathing disturbances SRBD in adults may not be applied without hesitation to children. SRBD in newborn and infants are often due to craniofacial disturbances (Pierre Robin syndrome, Goldenhars syndrome etc.), obesity is of minor importance. More than 30 infants with SRBD and craniofacial changes have been diagnosed and successfully treated over a 2-year period. Conservative therapy starts immediately after birth. The first step in newborn with Pierre Robin syndrome, for instance, is prone position for protrusion of tongue and mandible and mandibular growth stimulation. Intermediate nightly nasopharyngeal tubes are an alternative to nCPAP-/BiPAP treatment. Conventional orthopaedic/orthodontic treatment should not be neglected, even if it takes years to become effective. Surgical therapies are able to support, sometimes to replace or at least to shorten conservative methods. In rare cases when prone position in combination with palatal plates in cases of Robin syndrome, for instance, are not fully effective, mandibular extension is indicated. Aplasia or defects demand adequate surgical reconstruction, even if this does not necessarily mean abolishment of SRBD. In contrast to adults adenotonsillectomy is highly effective in infants and does not only reduce SRBD, but also improves nasal breathing and thus positively influences facial growth. A relatively new method is gradual mandibular distraction osteogenesis according to Ilizarov, which also enhances soft tissue growth. Maxillary and mandibular advancement osteotomies should not be considered before the termination of facial growth. Thanks to this refined treatment concept we were able to avoid tracheotomies in children during the past few years.

Genioplasty with rigid fixation using miniplates, preservation of vascular supply and accurate refixation of the soft tissue results in accurately predictable and stable bone and soft tissue contours. The Krefeld study of 36 patients who underwent genioplasty showed a consistent ratio of 85:100 of soft tissue to bone by advancement genioplasty and a 81:100 ratio by set back genioplasty.

Chin correction is an important procedure in orthognathic and facial plastic surgery. Whereas simple genioplasty can be easily performed by sliding or jumping osteotomies, extreme chin advancement, i.e., an advancement greater than 10 mm, requires the use of the double-step sliding technique. Independent of the fixation technique chosen these bony segments tend towards instability when being pedicled on the periosteum and the posterior muscle attachments. The traction force of the geniohyoid, genioglossus and digastric muscles is responsible for the instability of the advanced segments. To compensate for this muscle force a special double-step osteotomy was developed that combines the sliding and jumping osteotomy and allows the positioning of the pedicled basal chin segment in front of the mandible. Using this new tandem genioplasty, six cases of retrogenia with an advancement of 16 to 20 mm were corrected. The only complications in one case was mild wound dehiscence of the mucous membrane of the mandible's frontal vestibulum.

Pharyngeal Effects: The protrusion of the mandible by prosthetic appliances ("Esmarch-prosthesis") may be a simple therapy for obstructive sleep apnea, but is effective only in rare cases. Aim of this study was the cephalometric investigation of pharyngeal changes by mechanic-/prosthetic mandibular protrusion in respect of the amount of protrusion. Cephalometric investigation was performed in 46 patients before and after mandibular protrusion, subdivided into 3 groups with protrusion of less than 7 mm, 7 to 10 mm, and more than 10 mm. A significant pharyngeal enlargement was found in all patients, but there was no correlation between the amount of protrusion and the amount of pharyngeal enlargement. Mandibular protrusion of more than 10 mm did not necessarily lead to more pharyngeal enlargement. A reliable prognosis of pharyngeal enlargement in respect of the amount of mandibular protrusion is not possible by cephalometric evaluation, even less a reliable prognosis of treatment success in respect of obstructive sleep apnea.