Distraction Osteogenesis Maxillary Expansion (DOME) is a technique that helps widen the narrow nasal floor, improving nasal breathing and giving room for the tongue to fit in the concavity of the palate. It can be done separately or in conjunction with other procedures. Dr. Stanley YC Liu introduced adult maxillary expansion (DOME) for OSA with Professor Christian Guilleminault in 2015, and has continued to update the comprehensive sleep surgery protocol at Stanford.
Genioglossus Advancement (GGA) is a surgical procedure where the tongue muscle that is attached to the lower jaw is pulled forward, making the tongue firmer and less collapsible during sleep. In this procedure, a small window of bone is made in the lower jaw, and the piece of bone along with the attachment for the tongue is pulled forward and fixed by a small screw or a plate in the external bone surface.
In this course you will learn how to perform both DOME and GGA to manage patients with sleep apnea. You will practice both procedures in a hands-on cadaver lab.
Registration Cost: Physicians: $500
· Includes lectures, course-related materials, and course-related meals.
Sleep Apnea Surgeons, Fellows and Residents
Liu, Stanley & Guilleminault, Christian & Huon, Leh Kiong & Yoon, Audrey. (2017). Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients with High Arched Palate. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 157. 194599817707168. 10.1177/0194599817707168. A narrow maxilla with high arched palate characterizes a phenotype of obstructive sleep apnea (OSA) patients that is associated with increased nasal resistance and posterior tongue displacement. Current maxillary expansion techniques for adults are designed to correct dentofacial deformity. We describe distraction osteogenesis maxillary expansion (DOME) tailored to adult patients with OSA with narrow nasal floor and high arched palate without soft tissue redundancy. DOME is performed with placement of maxillary expanders secured by mini-implants along the midpalatal suture. This minimizes the maxillary osteotomies necessary to re-create sutural separation for reliable expansion at the nasal floor and palatal vault. We report the safety and efficacy profile of the first 20 patients at Stanford who underwent DOME.
Iwasaki, Tomonori & Yoon, Audrey & Guilleminault, Christian & Yamasaki, Youichi & Liu, Stanley. (2020). How does distraction osteogenesis maxillary expansion (DOME) reduce severity of obstructive sleep apnea?. Sleep and Breathing. 24. 10.1007/s11325-019-01948-7. Objective
Distraction osteogenesis maxillary expansion (DOME) is a reliable method to expand the nasal floor and hard palatal vault in adults with obstructive sleep apnea (OSA). DOME results in a reduction in the apnea-hypopnea index (AHI) and subjective report of improved nasal breathing. Using rhinomanometry augmented computational fluid dynamic (CFD) modeling, we propose a mechanism of how DOME reduces upper airway pharyngeal collapse in adults with OSA.
Material and method
A retrospective cohort with 20 subjects and mean age of 29.6 ± 8 years who completed DOME at Stanford University from September 2014 to April 2016. Subjects were included if polysomnography, airway morphology, and rhinomanometry were available for use. From the CBCT data, 3D nasal and pharyngeal airway model were generated. Numeric CFD simulation of the airway models were analyzed under the following conditions: (1) the volume of air was flowing at a velocity of 300 cm³/s, (2) the wall surface was not slippery, and (3) the simulations were repeated 1000 times to calculate mean values. Statistical analyses using SPSS v24 software included paired t tests, nonparametric Wilcoxon rank test, Friedman test with Bonferroni correction, and Spearman’s correlation coefficients (p < 0.05).
Mean AHI improved from 17.8 ± 17.6 to 7.8 ± 7.1 events per hour (p < 0.001). Mean lowest oxygen saturation improved from 88.2 ± 7.2 to 90.9 ± 4.2% (p < 0.05). Mean airflow velocity within the nasal airway decreased from 15.6 ± 7.3 to 7.4 ± 2.1 m/s (p < 0.001) after DOME. Mean negative pressure of the nasal airway, retropalatal airway, oropharyngeal airway, and hypopharyngeal airway is reduced from − 158.4 ± 115.3 to − 48.6 ± 28.7 Pa, from − 174.8 ± 119.9 to − 52.5 ± 31.3 Pa, from − 177.0 ± 118.4 to − 54.9 ± 31.8 Pa and from − 177.9 ± 117.9 to − 56.9 ± 32.1 Pa (p < 0.001), respectively. AHI positively correlated with nasal flow velocity (p < 0.05) and negatively correlated with pharyngeal airway pressure (p < 0.05). ODI was positively correlated with nasal velocity (p < 0.05) and negatively correlated with nasal airway pressure (p < 0.05), retropalatal airway pressure (p < 0.001), oropharyngeal airway pressure (p < 0.001), and hypopharyngeal airway pressure (p < 0.05).
Anatomic expansion of the nasal floor with widening of the hard palatal vault from DOME is associated with reduction of nasal airflow velocity and downstream reduction of negative pressure in the pharyngeal airway. This dynamic interaction correlates with a reduction in the apnea-hypopnea index (AHI) and Oxygen Desaturation Index (ODI).
Liu, Stanley & Guilleminault, Christian & Yoon, Audrey. (2020). Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients. 10.1016/B978-0-323-44339-5.00059-6.
Chang, Edward & Kwon, Yong-Dae & Jung, Junho & Capasso, Robson & Riley, Robert & Liu, Stanley & Camacho, Macario. (2019). Genial tubercle position and genioglossus advancement in obstructive sleep apnea (OSA) treatment: a systematic review. Maxillofacial Plastic and Reconstructive Surgery. 41. 10.1186/s40902-019-0217-1. Background:
To systematically review the literature for methods to localize the genial tubercle as a means for performing an advancement of the genioglossus muscle.
PubMed, Google Scholar, CRISP, EMBASE, CINAHL, and Scopus were searched from inception through June 16, 2015.
One hundred fifty-two articles were screened, and the full text versions of 12 articles were reviewed in their entirety and 7 publications reporting their methodology for localizing the genial tubercle. Based upon these measurements and the results published from radiographic imaging and cadaveric dissections of all the papers included in this study, we identified the genial tubercle as being positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandibular border.
Based upon the results of this review, the genial tubercles were positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandible border. It may serve as an additional reference for localizing the genial tubercle and the attachment of the genioglossus muscle to the mandible, although the preoperative radiological evaluation and the palpation of the GT are recommended to accurately isolate.
Yoon, Audrey & Guilleminault, Christian & Zaghi, Soroush & Liu, Stanley. (2019). Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients with Narrow Maxilla and Nasal Floor. Sleep Medicine. 65. 10.1016/j.sleep.2019.06.002.
Abdelwahab Md, Mohamed & Yoon, Audrey & Okland, Tyler & Poomkonsarn, Sasikarn & gouveia, chris & Liu, Stanley. (2019). Impact of Distraction Osteogenesis Maxillary Expansion (DOME) on the Internal Nasal Valve in Patients with Obstructive Sleep Apnea (OSA). Otolaryngology Head and Neck Surgery. 161. 10.1177/0194599819842808. Objective: to assess the effect of Distraction Osteogenesis Maxillary Expansion (DOME) on objective parameters of the internal nasal valve and correlate findings with subjective outcomes.
Study Design: Retrospective cohort study
Setting: Tertiary referral center
Subjects and Methods:
After IRB approval, subjects with OSA undergoing DOME from September 2014 to April 2018, with available before and after expansion cone beam CT were included. Measurement of the internal nasal valve parameters was performed using Invivo6 ™ Software (version 6.0.3). Inter-rater reliability of all pre- and post-expansion parameters was measured. Patient-reported outcome measures used were the NOSE and ESS scores, and correlation between objective and subjective outcomes were evaluated for correlation by Spearman correlation analysis.
32-subjects met inclusion criteria. All subjects showed significant improvement in their NOSE and ESS scores as well as an increase in their internal valve parameters. Significant correlation was observed between increased angles and improvement in post-expansion NOSE score ((P=0.024, P=0.029).
DOME widens the internal nasal valve objective measures which correlates significantly with improvement of NOSE score.
Liu, Stanley & Huon, Leh Kiong & Zaghi, Soroush & Riley, Robert & Torre, Carlos. (2016). An Accurate Method of Designing and Performing Individual-Specific Genioglossus Advancement. Otolaryngology -- Head and Neck Surgery. 156. 10.1177/0194599816670366. There is too much individual patient variation in mandibular anatomy for any single described genioglossus advancement technique to be used consistently. Virtual surgical planning allows surgeons to design genioglossus osteotomy that captures the structures of interest. Intraoperative osteotomy and positioning guides mitigate known risks of the procedure while maximizing the reproducibility and efficacy of the procedure. In this report, we demonstrate the protocol step by step as it had been used on 10 patients, and we highlight 3 clinical scenarios that exemplify its utility.
Vinha PP, Eckeli AL, Faria AC, Xavier SP, de Mello-Filho FV. Effects of surgically assisted rapid maxillary expansion on obstructive sleep apnea and daytime sleepiness. Sleep Breath. 2016 May;20(2):501-8. doi: 10.1007/s11325-015-1214-y. Epub 2015 Jun 20. PMID: 26092279.
Thuler, Eric & Rabelo, Fabio & Yui, Mariane & Tominaga, Quedayr & Júnior, Vanier & Arap, Sergio. (2021). Correlation between the transverse dimension of the maxilla, upper airway obstructive site and OSA severity. Journal of Clinical Sleep Medicine. 17. 10.5664/jcsm.9226. Study objectives:
Acquiring a better comprehension of obstructive sleep apnea (OSA) physiopathology can contribute to improve patient selection for surgical treatments. We hypothesize that maxillary transverse deficiency restricts the space available for the tongue, leading to upper airway obstruction during sleep. Our primary hypothesis is that maxillary transverse deficiency increases the prevalence of tongue collapse during drug induced sleep endoscopy. The secondary hypothesis is that it will also increase the prevalence of circumferential collapse at the velopharynx. The exploratory hypothesis is its association with an increased OSA severity. The objectives of this study were to correlate maxillary morphometric measurements with (1) the anatomic level of obstruction during drug induced sleep endoscopy (DISE) and (2) apnea-hypopnea index on polysomnography.
Cross-sectional analysis of OSA patients undergoing DISE in search of PAP alternative treatment. Maxillary measurements were collected from CT scan (interpremolar distance - IPMD, intermolar distance - IMD and Sella Nasion A point angle - SNA), findings from DISE and sleep study variables from polysomnography (PSG). Correlation between CT, DISE and PSG data was assessed using Pearson's correlation, ROC curves were determined for each facial measurement.
Sixty-nine patients were included in the study. The group with velopharyngeal circumferential collapse had mean IMD = 26.30 (25.5-31.45) mm and the group with anteroposterior collapse had mean IMD = 29.20 (26.8-33.10) mm (p = 0.040). The group with complete tongue base obstruction had mean IPMD = 26.40 (25.1-28) mm and IMD = 26.30 (25.6-28.4) mm and without obstruction mean IPMD = 28.7 (27.2-30) mm (p = 0.003) and IMD = 34.06 (32.1-37) mm (p <0.001). The Roc curve determined an IMD cutoff of 29.8mm for predicting the tongue base obstruction.
The maxillary transverse deficiency, identified by reduction in IPMD and IMD, predicted the occurrence of complete tongue base obstruction, complete concentric collapse at the velopharynx, and multilevel obstruction during DISE. We did not find an association between the maxillary measurements and OSA severity. These associations hold some promise in ultimately supplanting insights previously only available through DISE.
Stanley Yung Liu, MD, DDS, FACS
Director, Sleep Surgery Fellowship
Assistant Professor of Otolaryngology
Stanford University Medical Center
Eric Thuler, MD, MBA, PhD
Postdoctoral Researcher, Penn Otorhinolaryngology – Head & Neck Surgery
Associate Researcher, Hospital Sirio-Libanes, Sao Paulo, Brazil