Anatomic and examination considerations of the oral cavity.

Patients often present to their physician with complaints of dental and/or oral pain. It is important for physicians to understand the complexities of oral anatomy and how to perform a basic clinical examination of this area to evaluate and potentially manage patients with these complaints. This article discusses anatomic structures of the oral cavity and systematic clinical examination of this area.

Reoperative treatment of obstructive sleep apnea.

Over the last several decades, various surgical treatments have been advocated and used to treat obstructive sleep apnea. Treatments ranging from aggressive procedures, such as tracheostomy, to the least-invasive procedures, such as radioablation, have not yielded satisfactory results. One of the major causes for surgical failures and lower success rates lies in the inadequate understanding and appreciation of the anatomic and pathophysiologic factors that contribute to upper airway obstruction. In some cases, combinations of various surgical techniques may help improve the conditions. This article reviews several major types of surgical procedures, their complications, and the recommended approaches for retreatments.

Psychological issues in sleep apnea.

The overlap of sleep disorders with various psychiatric problems is so great that one would suspect that both types of problems may have common biologic roots. An estimated 65% to 90% of adults with major depression experience some kind of sleep problem. Sleep problems also increase the risk for developing depression. Since the early days of research on disturbed sleep, clinical studies have suggested the existence of a relationship between depression and obstructive sleep apnea.

Pseudoaneurysm of the facial artery as a late complication of bilateral sagittal split osteotomy and facial trauma.

Pseudoaneurysms, or arteriovenous fistulas, of the extracranial arterial system, particularly the facial artery, are rare. Its occurrence after reconstructive facial surgery has been reported rarely in the literature. In this article we describe a rare case of pseudoaneurysm developing over 4 weeks after an uneventful Le Fort I maxillary osteotomy, sagittal split osteotomy, and advancement genioplasty. A 22-year-old man presented with a severe class III skeletal deformity, mandibular hyperplasia, and maxillary hypoplasia. The patient's immediate postoperative course was uneventful for a 2-week period after surgery. Then the patient, while at home, experienced an accidental injury to his jaw and started to bleed from his left retromandibular side. He was taken to a local hospital where his bleeding was controlled by topical coagulant and pressure. During this short hospital visit he was given 3 units of blood and was subsequently discharged. He had no further bleeding and was monitored on a regular basis. One month after his double jaw surgery and 2 weeks after his bleeding episode, the left facial swelling diminished in size but was still visible. This mass was soft and pulsatile with a palpable thrill and auditory machinery murmur on auscultation. Although the patient was totally asymptomatic at this time, he was sent to the emergency room for a computerized tomography scan with 3-dimensional reconstruction. A Doppler ultrasound was also ordered. The ultrasound revealed the mass to be a pseudoaneurysm. Angiography revealed a pseudoaneurysm of the left facial artery. Coil embolization of the left facial artery was performed with a Cordis Trufill complex coil. The patient tolerated the procedure well and a repeat angiogram demonstrated no further evidence of aneurysm, arteriovenous malformation, vasospasm, or feeding branches to the fistula. The patient made an uneventful recovery and was discharged the day after the procedure. In this article, we review the anatomy of the extracranial arterial system of the head and neck, discuss the pathogenesis and clinical presentation of pseudoaneurysm, and present diagnostic imaging and treatment options for pseudoaneurysms of the face.

Surgical treatment of snoring & obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) syndrome is a potentially serious disorder affecting millions of people around the world. Many of these individuals are undiagnosed while those who are diagnosed, often exhibit poor compliance with nightly use of continuous positive airway pressure (CPAP), a very effective nonsurgical treatment. Various surgical procedures have been proposed to manage and, in some cases, treat OSA. In this article we review methods used to assess the sites of obstruction and a number of surgical procedures designed to address OSA. Effective surgical management of OSA depends upon developing a complete database and determining different levels of obstruction, which may include nasal, nasopharyngeal, oropharyngeal, and hypopharyngeal/retrolingual, or a combination of these sites. A systematic approach to clinical evaluation, treatment planning and surgical management is recommended and is likely to result in more predictable outcomes. Surgical treatment may involve various procedures that are performed in different stages depending on the patient's sites of obstruction. The most commonly performed procedures include nasal reconstruction, uvulopalatopharyngoplasty (UPPP), advancement genioplasty, mandibular osteotomy with genioglossus advancement, and hyoid myotomy and suspension. In more severe cases, maxillomandibular advancement (MMA) with advancement genioplasty may be indicated. Even after appropriate surgical treatment, some patients may demonstrate continued obstruction with associated symptoms. Published indications for surgical treatment include an elevated respiratory disturbance index (RDI) with excessive daytime somnolence (EDS), oxygen desaturations below 90 per cent, medical co-morbidities including hypertension and arrhythmias, anatomic abnormalities of the upper airway and failure of medical treatment. The success of surgery in OSA is generally measured by achieving a (RDI) of less than 5, improvement of oxygen nadir to 90 per cent or more with no desaturations below 90 per cent and quality of life improvements with elimination or significant reduction of OSA symptoms. From a practical point of view, achieving these goals may be extremely difficult without patients' cooperation, most notably in the realm of weight loss and maintenance of a healthy lifestyle.

Epidemiology, pathophysiology, and clinical features of obstructive sleep apnea.

The normal cycle of respiration includes a unique balancing force between many upper airway structures that control its dilation and closure. Alteration of this delicate equilibrium, possibly by an increased airflow resistance, can cause various degrees of obstructive sleep apnea (OSA). OSA is now recognized as a major illness, an important cause of medical morbidity and mortality affecting millions of people worldwide, and a major predisposing factor for several systemic conditions, such as hypertension, cardiovascular disease, stroke, diabetes, and even sexual dysfunction. Initial evaluation for possible OSA may be done by dental professionals who can provide guidance for its comprehensive evaluation and management. Because of the complexity of the disease, factors contributing to its development must be identified. Some factors caused by the patient's anatomic structures are slightly easier to rectify, whereas others may relate to the patient's age, sex, habits, or associated illnesses, including obesity. In this article, various epidemiologic, pathophysiologic, and clinical features of OSA are discussed.

Gardner's syndrome presenting with dental complaints.

Dental professionals play an important role in discovering the early signs of many illnesses. Gardner's syndrome, which affects one in 7500 births in the United States, is an inherited autosomal dominant disorder. There are three distinctive features associated with this syndrome: familial intestinal polyposis or adenomatosis, surface tumors of hard tissues particularly osteoma in the skull, maxillae, and mandible, and finally surface tumors of the soft tissue. The intestinal polyps have a 100% risk of undergoing malignant transformation if not treated. Consequently, early identification of the disease is critical. In this article an 18-year-old male patient with previously undiagnosed Gardner's syndrome who presented for removal of multiple impacted and unerupted teeth is reported to illustrate the importance of early detection and proper referral. This report describes an unusual presentation of a patient seeking extraction of teeth only, while he was totally unaware of potentially deadly situation.

Snoring and obstructive sleep apnea.

The number of patients who suffer from snoring and sleep apnea in Iran has been increasing in proportionate to the rest of the world as the prevalence of obesity has soared within the last two decades. This pandemic obesity is blamed on consumption of more energy-dense, nutrient-poor foods with high levels of sugar and saturated fats. Obesity is one of the major contributing factors of obstructive sleep apnea. The number of people snoring in Iran is not well established, but since many years ago this bizarre behaviour was looked upon as an annoying sound that some people have and it was thought that they have to live with it. It was not until early twentieth century that scientists began to relate an association between snoring, obesity, and sleep-related disorders. At present time, it is well documented and universally agreed that snoring as well as sleep apnea are far more prevalent in societies and can lead to other serious illnesses including heart attack, stroke, and even nocturnal death. Obstructive sleep apnea is a term used to describe cession of breathing while sleep for a period of 10 seconds or more and repeated over five times per hour of sleep. In this article, we review various methods of surgical treatments and the long-term relapse potential for each.

Complications of laser-assisted uvulopalatopharyngoplasty (LA-UPPP) and radiofrequency treatments of snoring and chronic nasal congestion: a 10-year review of 5,600 patients.

PURPOSE: Recent laser and radiofrequency techniques for the treatment of snoring have provided improvements, but intraoperative and postoperative risks, complications, and long-term results have not been explored in a statistically large enough sample of patients. The goal of this article is to provide practitioners with important data and guidelines to help them in decision-making and prepare them to anticipate problems and recommend a systematic approach to avoid or treat complications. PATIENTS AND METHODS: This investigation was a retrospective review of 5,600 cases, performed over a 10-year period by a single investigator, in a private practice setting. The data on complications were gathered from chart review as well as questionnaires filled out on each patient and by patient reports. The inclusion criteria for this review were: 1) patients with a history of chronic snoring or nasal congestion; 2) patients with an American Society of Anesthesiologists physical status classification (ASA) Classes I or II medical history; 3) patients provide a detailed preoperative snoring questionnaires; 4) patients provide informed consent; 5) patients were followed for a minimum of 2 years following surgery; 6) patients completed a comprehensive postoperative survey; 7) operative report stating the exact nature of any complications; 8) surgeons provided a clinical assessment; 9) sleep apnea reports if available; and 10) patient body mass index of less than 30 kg/m2. RESULTS: Laser-assisted uvulopalatopharyngoplasty (LA-UPPP) was used for the treatment of snoring and mild obstructive sleep apnea in all cases; 40% of patients also had simultaneous nasal radioablation. No fatalities were recorded and fewer than 3% of patients had long-term complications. The most common intraoperative complication was bleeding, which occurred in 9.5% of patients. CONCLUSION: Reducing the amount of tissue resected from the soft palate helped reduce or eliminate the common complications of traditional uvulopalatopharyngoplasty procedures. LA-UPPP and radioablation procedures are effective, safe, and can be carried out in an office setting equipped with anesthesia monitors and services. The complications associated with the procedure were rare and usually manageable.