Maxillomandibular Advancement Surgery for Patients Who Are Refractory to Continuous Positive Airway Pressure: Are There Predictors of Success?

Comparison of phenotypic characteristics between responders and non-responders to treatment for obstructive sleep apnea with maxillomandibular advancement in adults

BACKGROUND AND OBJECTIVE

3D cone-beam computed tomography (CBCT) images obtained presurgery and postsurgery can expand our knowledge of predictors of successful maxillomandibular advancement (MMA) for treatment of adult patients with obstructive sleep apnea (OSA). This prospective cohort study aimed to identify predictors of successful MMA surgery for adults with OSA using anatomical CBCT measurements.

METHODS

Analysis of anatomical outcomes was conducted by comparing postoperative with preoperative measures from 3D CBCT images. Preoperative and postoperative variables of responders were compared with non-responders. A postoperative AHI <10 and a reduction of >50 % identified responders.

RESULTS

A total of 50 patients met the inclusion criteria. The mean (SD) AHI was 32.3 (21.0). The mean (SD) age was 32.4 (9.2) years; 72 % were male; mean (SD) body mass index was 22.4 (3.2) kg/m2. Mean (SD) time of follow-up was 2.0 (1.5) years. Thirty participants were identified as responders. Compared with preoperative characteristics of non-responders, AHI was significantly lower, the maxilla was shorter, the hyoid position was higher and more forward, tongue and soft palate were shorter, and oropharyngeal airway space was wider and larger (all p < .05). Multivariate logistic regression revealed preoperative variables of maxillary and mandibular width, tongue length, airway length, oropharyngeal anteroposterior dimension, and the surgical variable for degree of mandibular advancement were predictors of successful treatment of OSA with MMA.

CONCLUSIONS AND RELEVANCE

Our findings suggest preoperative anatomical characteristics, as well as required surgical advancement should be evaluated when considering MMA for treatment of adults with OSA. The application of 3D CBCT provided detailed information on anatomical characteristics that should be an essential tool when evaluating adult patients with OSA who will benefit from treatment with MMA.

Maxillomandibular Advancement Safety and Effectiveness in Obstructive Sleep Apnea: Systematic Review and Meta-Analysis

OBJECTIVE

To provide an updated evaluation of clinical effectiveness and sequelae of maxillomandibular advancement surgery in obstructive sleep apnea.

DATA SOURCES

PubMed, Scopus, CINAHL.

REVIEW METHODS

Included studies described patients with obstructive sleep apnea that completed maxillomandibular advancement with any reported sequelae. Meta-analysis of proportions, regressions, and single means with 95% confidence interval were calculated using random and fixed effects models.

RESULTS

Of 380 unique abstracts reviewed, a total of 31 studies (n = 1597) were included in meta-analysis. Maxillomandibular advancement patients showed significant improvements in apnea-hypopnea index (AHI), respiratory disturbance index (RDI), SpO2 Nadir, Epworth sleepiness scale (ESS), and body-mass index (BMI) by -41.87/h [-49.86 to -33.89], -46.24/h [-62.18 to -30.29], 6.29% [3.42 to 12.08], -8.69 [-11.54 to -5.83], and -0.74 kg/m2 [-1.35 to -0.12], respectively. Sequelae with the greatest incidence were early lower facial numbness (83.40%), late lower facial numbness at less and greater than 1 year follow-up (66.51%, 32.73% respectively), and hardware removal (21.99%). There was a positive correlation between both preoperative BMI and length of hospital stay (r = 0.81, P = .052) and age and lower facial numbness (r = 0.42, P = .196). A negative correlation was found between Change in AHI and time to follow up (r = 0.75, P = .087). No major complications nor mortality were reported.

CONCLUSION

Maxillomandibular advancement has the highest success rate for obstructive sleep apnea among current surgical treatments, with most sequelae being transient. Early lower facial numbness should be highlighted preoperatively to ensure informed decision-making. Further research should be geared towards reducing this risk.

Maxillomandibular advancement for obstructive sleep apnea: a retrospective prognostic factor study for surgical response

PURPOSE

To identify potential predictors of surgical response to maxillomandibular advancement (MMA) in patients with obstructive sleep apnea (OSA) from the most common clinically available data (patient-related, polysomnographic, cephalometric, and surgical variables).

METHODS

This was a retrospective study comprised of consecutive patients who underwent MMA for moderate to severe OSA. Relevant clinical, polysomnographic, cephalometric, and surgical variables were collected as independent variables (predictors). The association of the independent variables with a favorable surgical response to MMA was assessed in univariate and multivariate analyses.

RESULTS

In 100 patients (82% male; mean age 50.5 years), the mean apnea hypopnea index [AHI] was 53.1 events/h. The rate of favorable surgical response was 67%. Based on multivariate analysis, patients with cardiovascular disease (CVD) had 0.140 times lower odds of a favorable response to MMA (OR: 0.140 [0.038, 0.513], P = 0.003). For each 1-unit increase in central apnea index (CAI) and superior posterior airway space (SPAS), there were 0.828 and 0.724 times lower odds to respond favorably to MMA (OR: 0.828 [0.687, 0.997], P = 0.047; and 0.724 [0.576, 0.910], P = 0.006), respectively.

CONCLUSION

The findings of this study suggest that the surgical outcome of MMA may be less favorable when patients with OSA have certain phenotypic characteristics: the presence of CVD, higher CAI and larger SPAS. If confirmed in future studies, these variables may guide patient selection for MMA.

Development and Internal Validation of a Prediction Model for Surgical Success of Maxillomandibular Advancement for the Treatment of Moderate to Severe Obstructive Sleep Apnea

Background: Maxillomandibular advancement (MMA) has been shown to be the most effective surgical therapy for obstructive sleep apnea (OSA). Despite high success rates, there are patients who are considered as non-responders to MMA. In order to triage and inform these patients on their expected prognosis of MMA before the surgery, this study aimed to develop, internally validate, and calibrate a prediction model for the presence of surgical success for MMA in patients with OSA. Methods: A retrospective cohort study was conducted that included patients that had undergone MMA for moderate to severe OSA. Baseline clinical, polysomnographic, cephalometric, and drug-induced sleep endoscopy findings were recorded as potential predictors. Presence or absence of surgical success was recorded as outcome. Binary logistic regression analyses were conducted to develop the model. Performance and clinical values of the model were analyzed. Results: One hundred patients were included, of which sixty-seven (67%) patients reached surgical success. Anterior lower face height (ALFH) (OR: 0.93 [0.87−1.00], p = 0.05), superior posterior airway space (SPAS) (OR: 0.76 [0.62−0.92], p < 0.05), age (OR: 0.96 [0.91−1.01], p = 0.13), and a central apnea index (CAI) <5 events/hour sleep (OR: 0.16 [0.03−0.91], p < 0.05) were significant independent predictors in the model (significance level set at p = 0.20). The model showed acceptable discrimination with a shrunken area under the curve of 0.74, and acceptable calibration. The added predictive values for ruling in and out of surgical success were 0.21 and 0.32, respectively. Conclusions: Lower age at surgery, CAI < 5 events/hour, lower ALFH, and smaller SPAS were significant predictors for the surgical success of MMA. The discrimination, calibration, and clinical added values of the model were acceptable.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Evaluation of Facial Profile Esthetics After Maxillomandibular Advancement Surgery for the Treatment of Obstructive Sleep Apnea

PURPOSE

Maxillomandibuar advancement (MMA) surgery has been shown to be a successful treatment for obstructive sleep apnea (OSA), but concerns still exist regarding esthetic outcomes due to the large advancements involved. The objective of this study was to evaluate facial profile changes in patients who underwent MMA surgery for OSA by utilizing panels of external evaluators.

METHODS

Pre- and posttreatment silhouettes of 21 patients (10 females, 11 males; mean age 43.2 [±11.5] years), who underwent MMA surgery for OSA, were generated from profile photographs. Utilizing survey software, the individual silhouettes were shown in random order to surgeons, orthodontists and laypeople, who assessed the esthetics of each via a sliding visual analogue scale (0 to 10).

RESULTS

For all evaluators combined, postsurgical esthetic scores were significantly improved in 19 of 21 patients (P < .001). Ninety-five percent of evaluators judged the changes after surgery as positive or neutral. There was a mean increase in postsurgical esthetic scores of 1.9 [±1.9], which was moderately correlated with AHI changes (r = 0.48, P < .05). Mean esthetic score changes were significantly different between evaluator groups for 12 of 21 patients (P < .05), with surgeons and orthodontists reporting more positive change than laypeople.

CONCLUSIONS

Overall, MMA surgery for the treatment of OSA does not have a negative impact on facial profile esthetics, with external evaluators judging the changes as favorable in the majority of patients assessed.

Maxillomandibular advancement effectively treats obstructive sleep apnea in adolescents at short-term follow-up

OBJECTIVE

To evaluate the efficacy of maxillomandibular advancement (MMA) surgery for the treatment of malocclusion and obstructive sleep apnea (OSA) in an adolescent population.

STUDY DESIGN

A retrospective cohort study was designed using electronic medical record chart review.

RESULTS

Fifteen patients aged 20 years or younger (range, 14-20) were included. All patients underwent MMA surgery for the primary correction of malocclusion and secondary treatment of OSA. Mean preoperative apnea-hypopnea index (AHI) was 28.9 ± 16.0 events/h (range, 7.1-54.7), and mean postoperative AHI was 5.7 ± 4.6 events/h (range, 1.5-18.4), reflecting a reduction of 23.2 events/h, an 80.6% reduction (P < .001). Fourteen patients (93.3%) experienced improvement in AHI. Mean minimal posterior airway space increased from 4.6 mm to 8.6 mm (P < .001). Mean posterior airway space at the level of the uvular tip increased from 6.7 mm to 11.5 mm (P < .001). Patients who underwent adjunct genioglossus advancement (GGA) had a mean decrease in AHI of 35.3 events/h (P = .004), which was not significantly different from the decrease in those who did not receive GGA.

CONCLUSIONS

MMA surgery with or without GGA is an effective treatment option for adolescents with a malocclusion and an AHI >5.0 events/h. In this population, it is shown to decrease AHI and increase posterior airway space. More research is required to determine the ideal adolescent candidate for MMA surgery.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion

BACKGROUND

Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies.

METHODS

A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20.

RESULTS

A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups.

CONCLUSIONS

While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.