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Yang J, Tan ML, Ho JPTF, Rosenmöller BRAM, Jamaludin FS, van Riet TCT, de Lange J. Non-sleep related outcomes of maxillomandibular advancement, a systematic review. Sleep Med Rev 2024; 75:101917. [PMID: 38503113 DOI: 10.1016/j.smrv.2024.101917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/21/2024]
Abstract
Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.
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Affiliation(s)
- Joshua Yang
- Harvard School of Dental Medicine, Boston, MA, USA
| | - Misha L Tan
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands.
| | - Jean-Pierre T F Ho
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Boudewijn R A M Rosenmöller
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands; Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands
| | - Faridi S Jamaludin
- Information Specialist Medical Library, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), Amsterdam, the Netherlands
| | - Tom C T van Riet
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Amsterdam University Medical Centre, Location Academic Medical Center (AMC), and Academic Centre for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands
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Ebker M, Goedecke M, Wollersheim T, Heiland M, Ebker T. Maxillomandibular advancement is a safe procedure in patients with obstructive sleep apnoea. Results of a retrospective study. Br J Oral Maxillofac Surg 2023; 61:491-496. [PMID: 37517940 DOI: 10.1016/j.bjoms.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 06/18/2023] [Accepted: 07/06/2023] [Indexed: 08/01/2023]
Abstract
Obstructive sleep apnoea (OSA) is a syndrome with a high burden on public health. Maxillomandibular advancement (MMA) has proven to be a highly effective treatment option. This retrospective analysis evaluated the safety of maxillomandibular advancement with rotation in patients with OSA. A total of 63 patients with OSA were included in this study. Surgical treatment by maxillomandibular advancement was virtually planned based on preoperative cone beam computed tomography (CBCT). A 3D printed guide and a customised implant were used for surgical transfer. The safety of MMA was evaluated based on the necessity of postoperative intermediate care unit (IMCU) stay, duration of stay in hospital, and recording of medical complications. A total of 63.5% of the OSA patients treated by MMA (n = 40/63) were postoperatively transferred from the recovery room directly to the regular ward, while 36.5% of the patients (n = 23/63) stayed on IMCU for at least one night. On average, the length of hospitalisation was four days after surgery. One patient from the ward group and one patient from the IMCU group developed a major complication according to Clavian-Dindo classification grade IV. MMA is a safe surgical procedure. The necessity for postoperative monitoring in an IMCU setting should be based on an individual risk evaluation. However, since major complications can occur, MMA should be performed as an inpatient procedure in a hospital with available intensive medicine care. This study underlines the safety of MMA in OSA patients.
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Affiliation(s)
- Maria Ebker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universit ät zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Maximilian Goedecke
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universit ät zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Tobias Wollersheim
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universit ät zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353 Berlin, Germany; Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universit ät zu Berlin, and Berlin Institute of Health, Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Max Heiland
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universit ät zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Tobias Ebker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universit ät zu Berlin, and Berlin Institute of Health, Department of Oral and Maxillofacial Surgery, Augustenburger Platz 1, 13353 Berlin, Germany.
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Zhou N, Ho JPTF, Visscher WP, Su N, Lobbezoo F, de Lange J. Maxillomandibular advancement for obstructive sleep apnea: a retrospective prognostic factor study for surgical response. Sleep Breath 2023; 27:1567-1576. [PMID: 36271189 PMCID: PMC10427554 DOI: 10.1007/s11325-022-02731-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/21/2022] [Accepted: 10/13/2022] [Indexed: 12/25/2022]
Abstract
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.
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Affiliation(s)
- Ning Zhou
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Jean-Pierre T F Ho
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Wouter P Visscher
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Naichuan Su
- Department of Oral Public Health, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jan de Lange
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
- Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Gurgel M, Cevidanes L, Costa F, Pereira R, Cunali P, Bittencourt L, Ruellas A, Gonçalves J, Bianchi J, Chaves C. Three-dimensional comparison between the effects of mandibular advancement device and maxillomandibular advancement surgery on upper airway. BMC Oral Health 2023; 23:436. [PMID: 37391785 PMCID: PMC10314553 DOI: 10.1186/s12903-023-03125-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/10/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND The efficacy of mandibular advancement devices (MAD) and maxillomandibular advancement (MMA) in improving upper airway (UA) patency has been described as being comparable to continuous positive airway pressure (CPAP) outcomes. However, no previous study has compared MAD and MMA treatment outcomes for the upper airway enlargement. This study aimed to evaluate three-dimensionally the UA changes and mandibular rotation in patients after MAD compared to MMA. METHODS The sample consisted of 17 patients with treated with MAD and 17 patients treated with MMA matched by weight, height, body mass index. Cone-beam computed tomography from before and after both treatments were used to measure total UA, superior/inferior oropharynx volume and surface area; and mandibular rotation. RESULTS Both groups showed a significant increase in the superior oropharynx volume after the treatments (p = 0.003) and the MMA group showed greater increase (p = 0.010). No statistical difference was identified in the MAD group considering the inferior volume, while the MMA group showed a significantly gain (p = 0.010) and greater volume (p = 0.024). Both groups showed anterior mandibular displacement. However, the mandibular rotation were statistically different between the groups (p < 0.001). While the MAD group showed a clockwise rotation pattern (-3.97 ± 1.07 and - 4.08 ± 1.30), the MMA group demonstrated a counterclockwise (2.40 ± 3.43 and 3.41 ± 2.79). In the MAD group, the mandibular linear anterior displacement was correlated with superior [p = 0.002 (r=-0.697)] and inferior [p = 0.004 (r = 0.658)] oropharynx volume, suggesting that greater amounts of mandibular advancement are correlated to a decrease in the superior oropharynx and an increase in the inferior oropharynx. In the MMA group, the superior oropharynx volume was correlated to mandibular anteroposterior [p = 0.029 (r=-0.530)] and vertical displacement [p = 0.047 (r = 0.488)], indicating greater amounts of mandibular advancement may lead to a lowest gain in the superior oropharynx volume, while a great mandibular superior displacement is correlated with improvements in this region. CONCLUSIONS The MAD therapy led to a clockwise mandibular rotation, increasing the dimensions of the superior oropharynx; while a counterclockwise rotation with greater increases in all UA regions were showed in the MMA treatment.
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Affiliation(s)
- Marcela Gurgel
- Department of Dental Clinic, School of Dentistry, Federal University of Ceará, Fortaleza, 1273 Monsenhor Furtado St, CE, Brazil
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, United States of America
| | - Lucia Cevidanes
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, United States of America
| | - Fabio Costa
- Department of Dental Clinic, School of Dentistry, Federal University of Ceará, Fortaleza, 1273 Monsenhor Furtado St, CE, Brazil.
| | - Rowdley Pereira
- Department of Pneumology, Division of Sleep Medicine and Biology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Paulo Cunali
- Department of Pneumology, Division of Sleep Medicine and Biology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Lia Bittencourt
- Department of Pneumology, Division of Sleep Medicine and Biology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Antonio Ruellas
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, United States of America
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joao Gonçalves
- Department of Pediatric Dentistry, School of Dentistry, Sao Paulo State University (Unesp), Araraquara, Brazil
| | - Jonas Bianchi
- Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, United States of America
- Department of Pediatric Dentistry, School of Dentistry, Sao Paulo State University (Unesp), Araraquara, Brazil
- Department of Orthodontics, University of the Pacific, Arthur A. Dugoni School of Dentistry, San Francisco, CA, United States of America
| | - Cauby Chaves
- Department of Dental Clinic, School of Dentistry, Federal University of Ceará, Fortaleza, 1273 Monsenhor Furtado St, CE, Brazil
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Li K, Holey JE, Guilleminault C, Amat P. Maxillomandibular Advancement for OSA: A 25-year perspective. Orthod Fr 2023; 94:187-201. [PMID: 37114810 DOI: 10.1684/orthodfr.2023.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Objective The aim of this study was to evaluate the result of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) by a single surgeon. Materials and Methods Patients that underwent MMA for the treatment of OSA over a 25-year period were included in the study. Patients who initially presented for revision MMA surgery were excluded. Demographics (e.g., age, gender, pre- and post-MMA body mass index [BMI]), pre- and post-MMA cephalometrics (e.g., sella-nasion-point A angle [SNA], sella-nasion-point B angle [SNB], posterior airway space base of tongue [PAS]) and pre- and post-MMA sleep study metrics (e.g., respiratory disturbance index [RDI], lowest desaturation [SpO2-nadir], oxygen desaturation index [ODI], total sleep time [TST], % TST Stage N3 sleep, % TST rapid eye movement [REM] sleep) were abstracted. MMA surgical success was defined as a ≥ 50% reduction in RDI (or ODI) and post-MMA RDI (or ODI) < 20 events/hour. MMA surgical cure was defined as a post-MMA RDI (or ODI) < 5 events/hour. Results A total of 1010 patients underwent MMA for the treatment of OSA. The mean age was 39.6 ± 14.3 years, and the majority were male (77%). Nine hundred forty-one patients with complete pre- and postoperative PSG data were analyzed. The mean ODI and RDI improved from 32.6 ± 27.4 to 7.7 ± 15.5 and 39.1 ± 24.2 to 13.6 ± 14.6 events per hour, respectively. The overall surgical success and surgical cure based on ODI was 79.4% and 71.9%, respectively. The overall surgical success and surgical cure based on RDI was 73.1% and 20.7%, respectively. Stratified by preoperative RDI showed older age, greater BMI were associated with greater preoperative RDI. Bivariate predictors of greater RDI reduction include younger age, female gender, lower preoperative BMI, higher preoperative RDI, greater BMI reduction postoperatively and greater change in SNA and PAS. Bivariate predictors of surgical cure based on RDI (RDI < 5) include younger age, female gender, lower preoperative RDI, and greater change in SNA and PAS. Bivariate predictor of RDI success (RDI < 20) include younger age, female gender, lower preoperative BMI, lower preoperative RDI, greater BMI reduction, greater increase in SNA, SNB and PAS postoperatively. Comparison of the first 500 patients and the later 510 patients demonstrate patients undergoing MMA have become younger, having lower RDI while achieving a better surgical outcome. Linear multivariate associations of greater percentage RDI reduction include younger age, greater percent change of SNA, greater preoperative SNA, lower preoperative BMI and higher preoperative RDI. Conclusions MMA is an effective treatment to improve OSA, but the result can vary. Patient selection based on favorable prognostic factors and maximizing the advancement distance can improve outcomes.
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Affiliation(s)
- Kasey Li
- Sleep Apnea Surgery Center, 1900 University Avenue, Suite 105, East Palo Alto, CA, États-Unis
| | - Jon-Erik Holey
- Pulmonary and Critical Care, Stanford University School Medicine, Stanford, 3165 Porter Dr, Palo Alto, CA 94304, États-Unis
| | - Christian Guilleminault
- Deceased. Sleep Medicine Division, Stanford University School of Medicine, Stanford, 3165 Porter Dr, Palo Alto, CA 94304, États-Unis
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Ogisawa S, Nishikubo S, Nakajima J, Azaki H, Mayahara K, Shinozuka K, Tonogi M. The changes in oral volume and hyoid bone position after maxillomandibular advancement and genioglossus advancement for patients with obstructive sleep apnea. Sleep Breath 2023; 27:239-244. [PMID: 35380343 DOI: 10.1007/s11325-022-02600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/16/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Maxillomandibular advancement (MMA) and genioglossus advancement (GA) are surgeries for patients with obstructive sleep apnea (OSA). Postoperative evaluation is primarily based on the apnea-hypopnea index (AHI) measured by polysomnography. The purpose of this study was to identify the timing of hyoid bone relocation after MMA and GA surgery and to investigate whether or not hyoid bone relocation can be an indicator of postoperative evaluation of OSA. METHODS Patients with OSA underwent MMA and GA surgery. Changes in hyoid bone position and tongue-to-oral volume ratio were analyzed on lateral radiographs before, immediately after, and 1 year after surgery. Then, a correlation was verified between these changes and postoperative AHI. RESULTS In 18 patients studied, the position of the hyoid bone did not show a constant tendency immediately after surgery. One year after surgery, the bone had moved anteriorly and toward the oral cavity in all patients compared to its preoperative position. And AHI correlated with the movement of the hyoid bone to the oral side. DISCUSSION One year after surgery, the tongue was adapted to the newly enlarged oral space, and as a result, the low position of the hyoid bone before the operation was improved. The findings suggest that the degree of lowering of the hyoid bone may be an indicator of the improvement of AHI.
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Affiliation(s)
- Shouhei Ogisawa
- First Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan
| | - Shuichi Nishikubo
- First Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan.
| | - Junya Nakajima
- First Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan
| | - Hiroaki Azaki
- First Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan
| | - Kotoe Mayahara
- Department of Orthodontics, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan
| | - Keiji Shinozuka
- First Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan
| | - Morio Tonogi
- First Department of Oral and Maxillofacial Surgery, Nihon University School of Dentistry, 1-8-13, Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-8310, Japan
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Li K, Guilleminault C. Maxillomandibular Advancement for OSA: Serious Complications and Failures. Orthod Fr 2022; 93:61-73. [PMID: 36704949 DOI: 10.1684/orthodfr.2022.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA) performed elsewhere. Materials and Methods During a five-year period, 16 patients presented with complications and/ or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. Results Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patients), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). Conclusions Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.
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Li K, Holey JE, Guilleminault C. Maxillomandibular Advancement for OSA: A 25-year perspective. Orthod Fr 2022; 93:97-108. [PMID: 36704953 DOI: 10.1684/orthodfr.2022.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective The aim of this study was to evaluate the result of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) by a single surgeon. Materials and Methods Patients that underwent MMA for the treatment of OSA over a 25-year period were included in the study. Patients who initially presented for revision MMA surgery were excluded. Demographics (e.g., age, gender, pre- and post-MMA body mass index [BMI]), pre- and post-MMA cephalometrics (e.g., sella-nasion-point A angle [SNA], sella-nasion-point B angle [SNB], posterior airway space base of tongue [PAS]) and pre- and post-MMA sleep study metrics (e.g., respiratory disturbance index [RDI], lowest desaturation [SpO2-nadir], oxygen desaturation index [ODI], total sleep time [TST], % TST Stage N3 sleep, % TST rapid eye movement [REM] sleep) were abstracted. MMA surgical success was defined as a ≥ 50% reduction in RDI (or ODI) and post-MMA RDI (or ODI) < 20 events/hour. MMA surgical cure was defined as a post-MMA RDI (or ODI) < 5 events/hour. Results A total of 1010 patients underwent MMA for the treatment of OSA. The mean age was 39.6 ± 14.3 years, and the majority were male (77%). Nine hundred forty-one patients with complete pre- and postoperative PSG data were analyzed. The mean ODI and RDI improved from 32.6 ± 27.4 to 7.7 ± 15.5 and 39.1 ± 24.2 to 13.6 ± 14.6 events per hour, respectively. The overall surgical success and surgical cure based on ODI was 79.4% and 71.9%, respectively. The overall surgical success and surgical cure based on RDI was 73.1% and 20.7%, respectively. Stratified by preoperative RDI showed older age, greater BMI were associated with greater preoperative RDI. Bivariate predictors of greater RDI reduction include younger age, female gender, lower preoperative BMI, higher preoperative RDI, greater BMI reduction postoperatively and greater change in SNA and PAS. Bivariate predictors of surgical cure based on RDI (RDI < 5) include younger age, female gender, lower preoperative RDI, and greater change in SNA and PAS. Bivariate predictor of RDI success (RDI < 20) include younger age, female gender, lower preoperative BMI, lower preoperative RDI, greater BMI reduction, greater increase in SNA, SNB and PAS postoperatively. Comparison of the first 500 patients and the later 510 patients demonstrate patients undergoing MMA have become younger, having lower RDI while achieving a better surgical outcome. Linear multivariate associations of greater percentage RDI reduction include younger age, greater percent change of SNA, greater preoperative SNA, lower preoperative BMI and higher preoperative RDI. Conclusions MMA is an effective treatment to improve OSA, but the result can vary. Patient selection based on favorable prognostic factors and maximizing the advancement distance can improve outcomes.
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Ho JPTF, Zhou N, Verbraecken J, Vries ND, Lange JD. Central and mixed sleep apnea related to patients treated with maxillomandibular advancement for obstructive sleep apnea: A retrospective cohort study. J Craniomaxillofac Surg 2022; 50:537-542. [PMID: 35778235 DOI: 10.1016/j.jcms.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 06/03/2022] [Accepted: 06/14/2022] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to evaluate the clinical efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) patients with a percentage of central and mixed apnea index in the total apnea-hypopnea index (CMAI%) ≧25%. Patients treated with MMA for OSA were retrospectively evaluated for baseline and postoperative patient data and polysomnographic results. The pre- and postoperative obstructive, central and mixed apnea parameters were compared. Of the included 78 patients, 21 patients (27%) presented with CMAI% ≧25% (median CMAI%, 49.1%; 35.9-63.8) prior to MMA. In 67% of these cases, MMA resulted in CMAI% <25 (median CMAI%, 6.1%; 2.1-8.9) and significantly improved the apnea-hypopnea index (AHI) (p < 0.001), the lowest oxyhemoglobin saturation (p < 0.001), central and mixed apnea index (p < 0.001), percentage of central and mixed apneas of total AHI (p = 0.004), central apnea index (p < 0.001), and mixed apnea index (p < 0.001). CMAI% ≧25% emerged in 25% of patients after MMA (median CMAI%, 49.1%; 35.9-63.8). Within the undeniable limitations of the study, it seems that the presence of CMAI% ≧25% should not be regarded as a contraindication for MMA in OSA patients.
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Affiliation(s)
- Jean-Pierre T F Ho
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Oral and Maxillofacial Surgery, Northwest Clinics, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands.
| | - Ning Zhou
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium.
| | - Nico de Vries
- Department of Orofacial Pain and Dysfunction, Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, University of Antwerp, Antwerp, Belgium; Department of Otorhinolaryngology - Head and Neck Surgery, OLVG, Amsterdam, the Netherlands.
| | - Jan de Lange
- Amsterdam UMC Location University of Amsterdam, Department of Oral and Maxillofacial Surgery, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands; Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
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10
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Li K, Guilleminault C, Amat P. [Treatment of OSA by maxillomandibular advancement: Serious Complications and Failures]. Orthod Fr 2022; 93:155-168. [PMID: 35818285 DOI: 10.1684/orthodfr.2022.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIM The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA)performed elsewhere. METHODS During a five-year period, 16 patients presented with complications and/or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. RESULTS Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patient), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). CONCLUSIONS Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.
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11
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Rocha NS, de França AJB, Niño-Sandoval TC, do Egito Vasconcelos BC, Filho JRL. Efficiency of maxillomandibular advancement for the treatment of obstructive apnea syndrome: a comprehensive overview of systematic reviews. Clin Oral Investig 2022; 26:4291-4305. [PMID: 35488905 DOI: 10.1007/s00784-022-04489-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 04/10/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the efficiency of maxillomandibular advancement using aggregated individual patient data from multiple studies. MATERIALS AND METHODS This overview was structured according to the PICO strategy. It adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist and was recorded on the international prospective register of systematic reviews (PROSPERO-CRD42020206135). Searches were conducted in the PubMed/MEDLINE, Scopus, Embase, Web of Science, LILACS, and Cochrane databases for studies published until January 1, 2021. Data from the included studies were collected by one author, while another reviewed the compilation. RESULTS Twelve systematic reviews were included. The outcome measures studied were the apnea-hypopnea index, respiratory disturbance index, mean oxygen saturation, lowest oxygen saturation, sleepiness data, posterior air space, sella-nasion point A angle, sella-nasion point B angle, surgical success, and surgical cure in patients who underwent surgery. The AMSTAR scale presented moderate evaluations, with grades varying between 6 and 10 points. The Glenny scale revealed that the study selection did not include all languages. Only three reviews identified quality assessments conducted by at least two reviewers and only five related possible searches for unpublished data. CONCLUSIONS Bimaxillary advancement surgery improved respiratory indicators, sleepiness data, and increased upper airway size. However, it is necessary to standardize the surgical criteria to establish measurable efficiency of the procedure. CLINICAL RELEVANCE This overview makes a critical analysis of the results of the selected systematic reviews with the aim of presenting the most clinically relevant data on the maxillomandibular advancement for treating obstructive apnea syndrome, with a focus on improving respiratory, anatomical, and quality of life indices. There are no overviews that approach this theme from a well-structured perspective.
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Affiliation(s)
- Nelson Studart Rocha
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Oswaldo Cruz Hospital, University of Pernambuco, Arnóbio Marques S., 310 - Santo Amaro, Recife, PE, 50.100-130, Brazil
| | - Arthur José Barbosa de França
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Oswaldo Cruz Hospital, University of Pernambuco, Arnóbio Marques S., 310 - Santo Amaro, Recife, PE, 50.100-130, Brazil
| | - Tania Camila Niño-Sandoval
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Oswaldo Cruz Hospital, University of Pernambuco, Arnóbio Marques S., 310 - Santo Amaro, Recife, PE, 50.100-130, Brazil
| | - Belmiro Cavalcanti do Egito Vasconcelos
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Oswaldo Cruz Hospital, University of Pernambuco, Arnóbio Marques S., 310 - Santo Amaro, Recife, PE, 50.100-130, Brazil
| | - José Rodrigues Laureano Filho
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Oswaldo Cruz Hospital, University of Pernambuco, Arnóbio Marques S., 310 - Santo Amaro, Recife, PE, 50.100-130, Brazil.
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12
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Navasumrit S, Chen YA, Hsieh YJ, Yao CF, Chang CS, Chen NH, Liao YF, Chen YR. Skeletal and upper airway stability following modified maxillomandibular advancement for treatment of obstructive sleep apnea in skeletal class I or II deformity. Clin Oral Investig 2022; 26:3239-3250. [PMID: 35088225 DOI: 10.1007/s00784-021-04306-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Maxillomandibular advancement (MMA) is an effective short-term treatment for obstructive sleep apnea (OSA). This study aimed to evaluate the long-term stability of the facial skeleton, upper airway, and its surrounding structures, as well as improvement in OSA following MMA. MATERIALS AND METHODS Thirty-one adults with moderate-to-severe OSA underwent surgery-first modified MMA as primary surgery. Polysomnography and cone-beam computed tomography were obtained pre-surgery, early post-surgery, and at follow-up (i.e., ≥ 2 years post-surgery). Image analysis software assessed the facial skeleton, upper airway, and its surrounding structures. RESULTS Early post-surgery, apnea-hypopnea index (AHI) had decreased significantly (p < 0.001) and the minimum oxygen saturation (MSAT) increased (p = 0.001), indicating significant improvement in OSA. At follow-up, the AHI and MSAT remained stable. However, the anterior maxilla, soft palate, and tongue moved backward while the hyoid moved downward. There was also a significant decrease in the minimal cross-sectional area of the oropharynx. The reduction in AHI was significantly related to the anterior movement of the anterior maxilla and tongue, inferior movement of the posterior maxilla, and superior movement of the soft palate tip. CONCLUSIONS The improvement of OSA after modified MMA remained stable for at least 2 years following treatment, despite the relapse of the facial skeleton, upper airway, and its surrounding structures. The reduction of AHI was not related to changes in the caliber of the upper airway but to the movement of the maxilla, soft palate, and tongue. Clinical relevance Modified MMA is clinically effective for long-term treatment of patients with moderate-to-severe OSA.
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Affiliation(s)
| | - Ying-An Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yuh-Jia Hsieh
- Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Craniofacial Orthodontics, Guishan District, Chang Gung Memorial Hospital, No. 123, Dinghu Road, Taoyuan City 333, Taiwan
| | - Chuan-Fong Yao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ning-Hung Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Fang Liao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan. .,Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Department of Craniofacial Orthodontics, Guishan District, Chang Gung Memorial Hospital, No. 123, Dinghu Road, Taoyuan City 333, Taiwan.
| | - Yu-Ray Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan.,Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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13
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Zhou N, Ho JPTF, Huang Z, Spijker R, de Vries N, Aarab G, Lobbezoo F, Ravesloot MJL, de Lange J. Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis. Sleep Med Rev 2021; 57:101471. [PMID: 33831676 DOI: 10.1016/j.smrv.2021.101471] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/03/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022]
Abstract
Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which target different levels of airway obstruction. The objective of this review was to comparatively evaluate the clinical efficacy and safety of MMA and MLS in the treatment of OSA. MEDLINE and Embase databases were searched for studies on MMA and/or MLS in OSA patients. Twenty MMA studies and 39 MLS studies were identified. OSA patients who underwent MMA showed significant improvements in AHI, LSAT, ODI, and ESS by -46.2/h, 13.5%, -30.3/h, and -8.5, respectively. The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%, respectively. Patients who underwent MLS showed significant improvements in AHI, LSAT, ODI, and ESS by -24.7/h, 8.7%, -19.1/h, and -5.8, respectively. The pooled surgical success and cure rates for MLS were 65.1% and 28.1%, respectively. The rates of major complication of MMA and MLS were 3.2% and 1.1%, respectively, and the rate of minor complication of MMA was higher than that of MLS. We conclude that both MMA and MLS are effective treatment options for OSA. Compared to MLS, MMA may be more effective in improving OSA. However, the complication rate of MMA is higher.
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Affiliation(s)
- Ning Zhou
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC Location AMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands; Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Jean-Pierre T F Ho
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC Location AMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands
| | - Zhengfei Huang
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Clinical Neurophysiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - René Spijker
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nico de Vries
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Ghizlane Aarab
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Madeline J L Ravesloot
- Department of Otorhinolaryngology - Head and Neck Surgery, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC Location AMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands
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14
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Rubio-Bueno P, Hernando G, Capote-Moreno A, Landete P, Wix R, Peñaloza A, Rocío E, Zamora E, Soriano JB, Naval-Gías L. A one-arm surgical trial of obstructive sleep apnea (OSA) patients before and 12 months after Bilateral Internal Ramus Distraction of the mandible (BIRD). Sleep Med 2021; 80:57-65. [PMID: 33567348 DOI: 10.1016/j.sleep.2021.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/01/2021] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND An innovative approach for the primary and definitive treatment of obstructive sleep apnea (OSA) in adult patients is presented: Bilateral Internal Ramus Distraction of the mandible (BIRD), which is a slow, progressive and more stable procedure to advance the mandibular bone. This study investigated whether this surgical approach is useful to cure OSA. METHODS Study design was of an interventional (surgical) one-arm trial of OSA patients assessed before and 12 months after BIRD. All patients were evaluated by pre- and post-operative polysomnography and three-dimensional scans. The amount of skeletal advancement, percentage of upper airway volume increase and postoperative value of mandibular occlusal plane were the predictor variables. Changes in the apnoea-hypopnoea index (AHI), oxygen desaturation index (ODI), and percentage of time with saturation under 90% (TC90) were the main outcome variables. FINDINGS Thirty-two subjects with a mean ± SD age of 41.9 ± 13.3 years and 87.5% male were included, and they were followed-up 32 ± 14.2 months. AHI was 47.9 ± 23.1 per hour before surgery and the Epworth Sleepiness Scale (ESS) was 13.4 ± 4.4. Postoperative AHI was 4.8 ± 5.6 per hour 12 months after surgery (P < 0.001), with 81.2% of the patients considered cured (AHI<5) and 18.8% suffering from a mild-to-moderate residual OSA. ESS decreased to 1.9 ± 1.8 at the end of the surgical treatment (P < 0.001). 3D changes revealed an upper airway volume increase of 188.4% ± 73.5% (P < 0.001). INTERPRETATION Lengthening the mandibular ramus by distraction osteogenesis to cure OSA appears to be more effective and safer when compared to other surgical protocols, especially in very severe cases with initial AHI>50/h. Titration of the mandibular advancement weekly using respiratory polygraphy allows better healing control and customization of the skeletal advancement, enhancing the aesthetic result.
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Affiliation(s)
- P Rubio-Bueno
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain.
| | - G Hernando
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - A Capote-Moreno
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - P Landete
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - R Wix
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - A Peñaloza
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - E Rocío
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - E Zamora
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - J B Soriano
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - L Naval-Gías
- Oral and Maxillofacial Department, Pneumology Department, Neurophysiology Department, Instituto de Investigación Hospital Universitario de La Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
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15
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Zhou A, Li H, Wang X, Zhang J, Zhang Y, He J, Liu S. Preliminary comparison of the efficacy of several surgical treatments based on maxillomandibular advancement procedures in adult patients with obstructive sleep apnoea: a systematic review and network meta-analysis. Eur Arch Otorhinolaryngol 2021; 278:543-55. [PMID: 32809057 DOI: 10.1007/s00405-020-06287-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the efficacy of eight different surgical treatments based on maxillomandibular advancement (MMA), which has emerged in recent years, for adult obstructive sleep apnoea (OSA) patients. METHODS The literature was searched from January 2010 to May 2020 for studies of adult OSA patients with different types of MMA procedures to perform a network meta-analysis. The outcomes were changes in the apnoea-hypopnoea index (AHI), the lowest pulse oxygen saturation (SpO2 min) and the Epworth Sleepiness Scale (ESS). Treatment hierarchy was summarized according to the rank charts. RESULTS Eight studies were included and encompassed a total of 227 adult patients diagnosed with OSA. Among them, 225 patients underwent combined surgery or simple MMA surgery, including modified maxillomandibular advancement (MMMA),counterclockwise maxillomandibular advancement (CMMA), drug-induced sleep endoscopy and maxillomandibular advancement (MMA + DISE), transoral robotic surgery and maxillomandibular advancement (MMA + TORS), uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement and uvulopalatopharyngoplasty (MMA + UPPP), uvulopalatopharyngoplasty with uvula preservation and maxillomandibular advancement (MMA + HUPPP); MMA consisting of Le Fort I osteotomy and bilateral inverted-L osteotomy (ILOs), genioplasty and iliac bone grafting; and MMA consisting of Le Fort I osteotomy, bilateral sagittal split ramus osteotomies and genioplasty. The results showed that the most effective surgical treatment is MMA + HUPPP [- 56.79 (WMD); 95% confidence interval (CI): - 113.02 to - 3.33] (P < 0.00001), which was far superior to other approaches. CONCLUSION MMA combined with HUPPP had the highest efficacy. The MMA consisted of Le Fort I osteotomy, bilateral sagittal split ramus osteotomies and genioplasty; CMMA and MMA + TORS are likely also great choices.
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16
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Houppermans P, Verweij J, Gooris P, Asin J, Bergsma E, van Merkesteyn R, Mensink G. Maxillomandibular advancement in edentulous patients as a treatment option for obstructive sleep apnea: report of two cases and a proposed treatment protocol. Heliyon 2020; 6:e03873. [PMID: 32373751 PMCID: PMC7193315 DOI: 10.1016/j.heliyon.2020.e03873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/05/2019] [Accepted: 04/23/2020] [Indexed: 10/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common disease that often causes debilitating symptoms. In its most severe form, OSA increases the risk of cardiovascular disease and mortality. OSA is characterized by repeated episodes of pharyngeal collapse leading to airway obstruction. The treatment options available in severe cases are limited to continuous positive airway pressure ventilation and maxillomandibular advancement (MMA). OSA is particularly difficult to treat successfully in edentulous patients. Two cases are presented here to illustrate use of MMA in edentulous patients with OSA. Our learning points based on these cases are shared, and a treatment and follow-up protocol is proposed for this specific patient group.
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Affiliation(s)
- Pascal Houppermans
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Department of Oral and Maxillofacial Surgery, Haga Hospital, The Hague, the Netherlands
| | - Jop Verweij
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Peter Gooris
- Department of Oral and Maxillofacial Surgery, Amphia Hospital, Breda, the Netherlands
| | - Jerryll Asin
- Department of Pulmonology, Center for Sleep Medicine, Amphia Hospital, Breda, the Netherlands
| | - Eelco Bergsma
- Department of Oral and Maxillofacial Surgery, Amphia Hospital, Breda, the Netherlands
| | - Richard van Merkesteyn
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Gertjan Mensink
- Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Department of Oral and Maxillofacial Surgery, Amphia Hospital, Breda, the Netherlands
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17
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Abstract
This article focuses on the role of skeletal surgery within the modified Stanford protocol with particular attention focused on the evolved role of MMA. First, surgery in patients presenting with congenital dentofacial deformity or characteristic drug-induced sleep endoscopy findings, then the growing role of maxillary expansion in a newly identified patient phenotype, and finally genioglossus advancement, are discussed. Less commonly used and validated techniques, such as isolated mandibular advancement and maxillomandibular expansion are not discussed in this article.
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Affiliation(s)
- Michael Awad
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Northwestern University, 675 N, St Clair Street, 15th Floor, Suite 200, Chicago, IL 60611, USA
| | - Robson Capasso
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA 94305, USA.
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18
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Petelle B. [Surgical treatment for obstructive sleep disordered breathing]. Orthod Fr 2019; 90:401-413. [PMID: 34643525 DOI: 10.1051/orthodfr/2019030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The obstructive sleep apnea syndrome is a chronic condition characterized by repeated nocturnal pharyngeal collapse leading to poor-quality sleep and an increased risk of cardiovascular episodes. The classic management by continuous positive-pressure ventilation has its limitations and is not always well tolerated. The treatment alternative comprising an orthotic device is effective in 2/3 of cases, despite the dental limitations and risks inherent in long-term usage. Through a review of the literature, this paper describes the different surgical solutions used to correct obstructive sleep apnea syndrome in adults. The proposed corrections aim to maintain pharyngeal permeability during sleep either by reducing soft tissue volume or by enlarging the facial skeleton or, more recently, by acting on the tone of the pharyngeal dilator muscles. Among these different approaches, the highest success rate was reported for the maxillomandibular advancement procedure. This technique demands rigorous patient selection combined with an appropriate orthodontic work-up and management. Patient selection and the respective benefits and drawbacks of the different approaches are discussed. Indications are reported in the framework of current guidelines.
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Affiliation(s)
- Boris Petelle
- Service ORL et Chirurgie de la Face et du Cou, Hôpital Saint Antoine, GHU Paris Est, 184 rue du Faubourg Saint Antoine, 75012 Paris, France
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19
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Wu Q, Wang Y, Wang P, Xiang Z, Ye B, Li J. The inverted-L ramus osteotomy versus sagittal split ramus osteotomy in maxillomandibular advancement for the treatment of obstructive sleep apnea patients: A retrospective study. J Craniomaxillofac Surg 2019; 47:1839-1847. [PMID: 31699397 DOI: 10.1016/j.jcms.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 02/05/2023] Open
Abstract
This study aimed to compare the effectiveness and feasibility of inverted-L osteotomy (ILO) and sagittal split ramus osteotomy (SSRO) on obstructive sleep apnea (OSA) treatment. According to different surgery procedures, 28 OSA patients who underwent maxillomandibular advancement (MMA) were divided into 2 groups (group A: ILO, n = 9; group B: SSRO, n = 19). Polysomnography (PSG) and Epworth sleepiness scale (ESS) on T0, T1and T2 were used to evaluate the effectiveness of OSA treatments. Patients' airway structures and facial appearances were also evaluated. From T0 to T1, the mean apnea-hypopnea index (AHI,/per hour) dropped from 69.2 ± 8.4 to11.2 ± 2.4 (P < 0.01) in group A and from 54.6 ± 14.6 to 9.4 ± 5.4 (P < 0.01) in group B; LSpO2 (lowest pulse oxygen saturation, %) increased from 66.5 ± 7.7% to 88.2 ± 4.6 (P < 0.01) and from 76.6 ± 10.7%to 89.4 ± 2.4% (P < 0.01) while the mean ESS score decreased by 51% in group A and 44% in group B. Most patients (group A: 88.9%; group B: 84.3%) were satisfied with their postoperative appearance. Mild relapse was observed in both groups on T2. This study concluded that MMA containing ILO and MMA containing SSRO are both feasible and effective for selected OSA patients.
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Affiliation(s)
- Qionghui Wu
- State Key Laboratory of Oral Diseases and Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, China
| | - Yu Wang
- State Key Laboratory of Oral Diseases and Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, China
| | - Peng Wang
- State Key Laboratory of Oral Diseases and Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, China
| | - Zichao Xiang
- State Key Laboratory of Oral Diseases and Department of Oral and Maxillofacial Surgery, West China College of Stomatology, Sichuan University, Chengdu, China
| | - Bin Ye
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Orthognathic & TMJ Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jihua Li
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & Dept. of Orthognathic & TMJ Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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Proothi M, Grazina VJR, Gold AR. Chronic insomnia remitting after maxillomandibular advancement for mild obstructive sleep apnea: a case series. J Med Case Rep 2019; 13:252. [PMID: 31409402 PMCID: PMC6693215 DOI: 10.1186/s13256-019-2182-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 06/27/2019] [Indexed: 12/21/2022] Open
Abstract
Background Chronic insomnia and obstructive sleep apnea are both common sleep disorders. Chronic insomnia is thought to result from stress-related physiologic hyperarousal (somatic arousal) that makes it difficult for an individual to fall or stay asleep. Obstructive sleep apnea is thought to result from obstructive respiratory events causing arousals, sleep fragmentation, and recurrent oxygen desaturation. Although the two disorders seem different, they predispose to the same long-term, stress-related illnesses, and when they occur in the same individual, each affects the other’s response to treatment; they interact. This report of three cases describes patients with both chronic insomnia and obstructive sleep apnea in whom the chronic insomnia remitted with no specific treatment following treatment of obstructive sleep apnea with maxillomandibular advancement. Case presentations Our three Caucasians patients each presented with severe, chronic insomnia associated with somatic arousal and fatigue occurring either alone, in association with bipolar disorder, or with temporomandibular joint syndrome. Polysomnography revealed that each patient also had mild obstructive sleep apnea, despite only one snoring audibly. One patient experienced a modest improvement in her somatic arousal, insomnia severity, and fatigue with autotitrating nasal continuous positive airway pressure, but the other two did not tolerate nasal continuous positive airway pressure. None of the patients received treatment for insomnia. All three patients subsequently underwent maxillomandibular advancement to treat mild obstructive sleep apnea and experienced prolonged, complete resolution of somatic arousal, chronic insomnia, and fatigue. The patient with bipolar disorder also experienced complete remission of his symptoms of depression during the 1 year he was followed postoperatively. Conclusions These three cases lend support to the hypothesis that chronic insomnia and obstructive sleep apnea share a pathophysiology of chronic stress. Among patients with obstructive sleep apnea, the stress response is directed at inspiratory airflow limitation during sleep (hypopnea, snoring, and inaudible fluttering of the throat). Therefore, when chronic insomnia and obstructive sleep apnea occur in one individual, aggressive treatment of obstructive sleep apnea may lead to a reduction in chronic stress that causes the patient’s chronic insomnia to remit.
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Affiliation(s)
- Michael Proothi
- Stony Brook University Sleep Disorders Center, Renaissance School of Medicine at Stony Brook University, 240 Middle Country Road, Smithtown, NY, 11787, USA.,Department of Oral and Maxillofacial Surgery, Stony Brook University School of Dental Medicine, Stony Brook, NY, 11794-8705, USA.,Stony Brook Oral and Facial Surgery, 207 Hallock Road #2, Stony Brook, NY, 11790, USA
| | - Victor J R Grazina
- Bach and Grazina Orthodontics, 235 Osborn Avenue #2, Riverhead, NY, 11901, USA
| | - Avram R Gold
- Stony Brook University Sleep Disorders Center, Renaissance School of Medicine at Stony Brook University, 240 Middle Country Road, Smithtown, NY, 11787, USA. .,Department of Medicine, Renaissance School of Medicine at Stony Brook University, 101 Nicolls Road, Stony Brook, NY, 11794, USA.
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21
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Chen YF, Ko EC, Zaghi S, Yoon A, Williams R, Riley R, Liu SYC. Optimizing mandibular sagittal split of large maxillomandibular advancements for obstructive sleep apnea: patient and surgical factors. Clin Oral Investig 2019; 24:1359-1367. [PMID: 31332567 DOI: 10.1007/s00784-019-03017-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Maxillomandibular advancement (MMA) confers consistent and high rates of surgical success for obstructive sleep apnea (OSA). In the era of value-based medicine, identifying factors that affect the stability of rigid fixation and allow rapid return to function are important targets for improvement. The aim of this study was to identify patient and surgical factors associated with mandibular sagittal split outcomes associated with optimal postoperatively skeletal stability. STUDY DESIGN Retrospective cohort study. MATERIALS AND METHODS Forty-six subjects (43 males and 3 females) with postoperative CT scans including three-dimensional reconstruction from which mandibular split patterns could be analyzed were enrolled. Patient factors (age and polysomnographic measures) and surgical factors (extent of osteotomy prior to controlled fracture) were assessed. Outcome measures include (1) bone thickness for rigid fixation and (2) area of passive bony overlap after advancement. RESULTS Age and severity of disease did not contribute significantly to optimal mandibular split patterns. For optimal area for passive bony overlap and thickness of buccal and lingual plates for rigid fixation, the most important factors are related to surgical technique. CONCLUSIONS Anterior osteotomy just to the midline of inferior border and horizontal osteotomy to the mandibular foramen are associated with split patterns that result in optimal rigid fixation and passive bony overlap for OSA patients undergoing MMA. CLINICAL RELEVANCE Optimal surgical technique has the most significant influence in allowing rapid return to function after MMA in patients with OSA.
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Affiliation(s)
- Yu Feng Chen
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Standford, CA, 94305, USA.,Division of Oral and Maxillofacial Surgery, Kaohsiung Medical University Hospital, No. 100 Tzyou 1st Road, Kaohsiung, 80708, Taiwan.,School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, No. 100 ShihChuan 1st Road, Kaohsiung, 80708, Taiwan
| | - Edward Chengchun Ko
- Division of Oral and Maxillofacial Surgery, Kaohsiung Medical University Hospital, No. 100 Tzyou 1st Road, Kaohsiung, 80708, Taiwan.,School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, No. 100 ShihChuan 1st Road, Kaohsiung, 80708, Taiwan
| | - Soroush Zaghi
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Standford, CA, 94305, USA.,UCLA Santa Monica medical Center, 1250 16th St, Santa Monica, CA, 90404, USA
| | - Audrey Yoon
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Standford, CA, 94305, USA.,Department of Pediatric Dentistry, UCLA School of Dentistry, 10833 Le Conte Ave, CHS 20-137, Los Angeles, CA, 90095, USA
| | - Ryan Williams
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Standford, CA, 94305, USA
| | - Robert Riley
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Standford, CA, 94305, USA
| | - Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, 801 Welch Road, Standford, CA, 94305, USA.
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22
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Abstract
Whereas the original Stanford protocol relied on a tiered approach to care to avoid unnecessary surgery, it did not address the issue of surgical relapse, a common concern among sleep medicine specialists. With 3 decades of experience since the original 2-tiered Powell-Riley protocol was introduced and the role of evolving skeletal techniques and upper airway stimulation, we are pleased to present our current protocol. This update includes emphasis on the facial skeletal development with impact on function including nasal breathing, and the incorporation of upper airway stimulation. The increased versatility of palatopharyngoplasty as an adjunctive procedure is also discussed.
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Affiliation(s)
- Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology, Stanford University School of Medicine, 801 Welch Road, Stanford, California 94304, USA.
| | - Michael Awad
- Division of Sleep Surgery, Department of Otolaryngology, Stanford University School of Medicine, 801 Welch Road, Stanford, California 94304, USA
| | - Robert Riley
- Division of Sleep Surgery, Department of Otolaryngology, Stanford University School of Medicine, 801 Welch Road, Stanford, California 94304, USA
| | - Robson Capasso
- Division of Sleep Surgery, Department of Otolaryngology, Stanford University School of Medicine, 801 Welch Road, Stanford, California 94304, USA
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23
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Affiliation(s)
- Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology, Stanford Sleep Surgery Fellowship, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94304, USA.
| | - Robert Wayne Riley
- Division of Sleep Surgery, Department of Otolaryngology, Stanford Sleep Surgery Fellowship, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94304, USA
| | - Anthony Pogrel
- Department of Oral and Maxillofacial Surgery, University of California San Francisco, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Christian Guilleminault
- Department of Psychiatry and Behavioral Sciences, Stanford Center for Sleep Sciences and Medicine, Stanford University School of Medicine, 450 Broadway St, Redwood City, CA 94063, USA
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24
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Abstract
Maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) has remained a reliable and highly effective surgical intervention since its introduction in 1989. Modifications have been made to maximize skeletal movement and upper airway stability without compromising facial balance. Contemporary indications of recommending MMA prior to other soft tissue surgery are described. MMA poses unique challenges to surgeons. There are patient-related factors, including OSA, a chronic inflammatory condition with associated cardiovascular and metabolic comorbidity. Perioperative management is more complex than routine orthognathic patients. Key details are shared from a 3-decade experience at Stanford.
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Affiliation(s)
- Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology, Stanford Sleep Surgery Fellowship, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94304, USA.
| | - Michael Awad
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford Hospital and Clinics, 801 Welch Road, Stanford, CA 95304, USA
| | - Robert Wayne Riley
- Division of Sleep Surgery, Department of Otolaryngology, Stanford Sleep Surgery Fellowship, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94304, USA
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25
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Paris M, Jean S, Bouchard C. Maxillomandibular Advancement: The Canadian Experience. Atlas Oral Maxillofac Surg Clin North Am 2019; 27:37-42. [PMID: 30717922 DOI: 10.1016/j.cxom.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Mélinda Paris
- Service de chirurgie buccale et maxillo-faciale, CHU de Québec-Université Laval, Hôpital de l'Enfant-Jésus, 1401 18e rue, Québec city, Québec G1J 1Z4, Canada.
| | - Simon Jean
- Service de chirurgie buccale et maxillo-faciale, CHU de Québec-Université Laval, Hôpital de l'Enfant-Jésus, 1401 18e rue, Québec city, Québec G1J 1Z4, Canada
| | - Carl Bouchard
- Service de chirurgie buccale et maxillo-faciale, CHU de Québec-Université Laval, Hôpital de l'Enfant-Jésus, 1401 18e rue, Québec city, Québec G1J 1Z4, Canada
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26
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Cheng-Hui Lin C, Wang PF, Ray Han Loh S, Lau HT, Sheng-Ping Hsu S. Maxillomandibular Rotational Advancement: Airway, Aesthetics, and Angle's Considerations. Sleep Med Clin 2019; 14:83-89. [PMID: 30709537 DOI: 10.1016/j.jsmc.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Obstructive sleep apnea is a medical syndrome with multifactorial pathophysiology. Surgery can be the primary treatment option when anatomic factors are identified with narrowing at specific or general levels of pharyngeal airway. The surgeries are directed to the etiologic anatomic structure to achieve greatest effectiveness. Body weight, Mallampati scale, and tonsil grade are key evaluations to select effective surgical procedures. Surgical weight reduction, maxillomandibular advancement, and pharyngeal soft tissue surgeries are considered for the patient with obesity, maxillomandibular retrognathism, and tonsillar hypertrophy, respectively. Tailored surgical planning can meet the patients needs for airway, esthetics, and normal Angle's occlusion.
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Affiliation(s)
- Clement Cheng-Hui Lin
- Department of Plastic and Reconstructive Surgery, Craniofacial Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; School of Medicine, Chang Gung University, 259 Wenhua 1st Road, Guishan District, Taoyuan 333, Taiwan.
| | - Po-Fang Wang
- Department of Plastic and Reconstructive Surgery, Craniofacial Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; School of Medicine, Chang Gung University, 259 Wenhua 1st Road, Guishan District, Taoyuan 333, Taiwan
| | - Shaun Ray Han Loh
- Department of Plastic and Reconstructive Surgery, Craniofacial Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; Department of Otolaryngology, Singhealth Duke-NUS Sleep Centre, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Hung Tuan Lau
- Department of Plastic and Reconstructive Surgery, Craniofacial Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; Department of Otolaryngology (ENT)-Head and Neck Surgery, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore
| | - Sam Sheng-Ping Hsu
- Department of Plastic and Reconstructive Surgery, Craniofacial Center, Chang Gung Memorial Hospital, No. 5, Fuxing Road, Guishan District, Taoyuan 333, Taiwan; Esthetic Dent Clinic, No.380, Section 4, Xinyi Road, Da'an District, Taipei 106, Taiwan
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27
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Abstract
Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with uvulopalatopharyngoplasty, tongue-base surgeries, including the genioglossus advancement (GA), sliding genioplasty, and hyoid myotomy and suspension, have been developed to target hypopharyngeal obstruction. Total airway surgery consisting of maxillomandibular advancement (MMA) with/without GA has shown significant success. Skeletal procedures for OSA with or without a palatal procedure is a proven technique for relieving airway obstruction during sleep. A case study demonstrating the utility of virtual surgical planning for MMA surgery is presented.
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Affiliation(s)
- José E Barrera
- Department of Surgery, Uniformed Services University, Bethesda, MD, USA; Department of Otolaryngology, University of Texas Health Sciences Center, San Antonio, TX, USA; Texas Facial Plastic Surgery and ENT, 14603 Huebner Road, Building 1, San Antonio, TX 78209, USA.
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Susarla SM, Mundinger GS, Kapadia H, Fisher M, Smartt J, Derderian C, Dorafshar A, Hopper RA. Subcranial and orthognathic surgery for obstructive sleep apnea in achondroplasia. J Craniomaxillofac Surg 2017; 45:2028-2034. [PMID: 29108917 DOI: 10.1016/j.jcms.2017.09.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/22/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Obstructive sleep apnea (OSA) is a common problem in patients with achondroplasia. The purpose of this study was to assess changes in airway volumes following various degrees of facial skeletal advancement. METHODS This was a retrospective evaluation of patients with achondroplasia who underwent facial skeletal advancement for obstructive sleep apnea. Patients were treated with either an isolated Le Fort III distraction (LF3) or Le Fort II distraction with or without subsequent Le Fort I and bilateral sagittal split osteotomies (LF2 ± LF1/BSSO). Demographic, cephalometric, volumetric, and polysomnographic variables were recorded pre- and postoperatively. RESULTS Six patients with achondroplasia underwent midface advancement for treatment of OSA (2 LF2 + LF1/BSSO, 2 LF2, 2 LF3). Patients undergoing LF2 + LF1/BSSO had consistent volumetric improvements at the nasopharyngeal and oropharyngeal levels (Δ ≥ +347% and ≥+253%, respectively). Patients undergoing LF2 alone had consistent improvement in the nasopharyngeal airway alone (Δ ≥ +214%). Patients undergoing LF3 alone had consistent, but less dramatic, changes in nasopharyngeal volume (Δ ≥ +97.1%). All patients undergoing LF2 distraction (with or without LF1/BSSO) had a ≥50% reduction in the apnea-hypopnea index (AHI) postoperatively; there was no improvement in AHI with LF3 alone. CONCLUSION In patients with achondroplasia-associated OSA there are variable improvements in airway volume. This preliminary report suggests that LF2 distraction, with or without subsequent LF1/BSSO, may provide consistent reductions in AHI relative to LF3 distraction.
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Affiliation(s)
- Srinivas M Susarla
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Gerhard S Mundinger
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Hitesh Kapadia
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Mark Fisher
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - James Smartt
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Christopher Derderian
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Amir Dorafshar
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Richard A Hopper
- Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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29
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Ferraz O, Guimarães TM, Rossi RR, Cunali PA, Fabbro CD, Chaves CM, Maluly M, Bittencourt L, Tufik S. Effectiveness of Maxillomandibular advancement (MMA) surgery in sleep apnea treatment: Case report. ACTA ACUST UNITED AC 2017; 9:134-139. [PMID: 28123648 PMCID: PMC5241606 DOI: 10.1016/j.slsci.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 07/05/2016] [Accepted: 07/21/2016] [Indexed: 11/18/2022]
Abstract
Obstructive sleep apnea (OSA) is characterized by episodes of pharyngeal collapse during sleep. Craniofacial alterations such as retrognathia are often found in OSA patients. Maxillomandibular advancement (MMA) surgeries increase the pharyngeal space and are a treatment option for OSA. The aim of this study was to present a successful case of MMA surgery in the treatment of OSA. A patient with moderate OSA (apnea-hypopnea index (AHI)=25.2) and mandibular retrognathism and Maxillomandibular asymmetry underwent MMA surgery. The apnea-hypopnea index (AHI) were considerably improved after six months (IAH =6.7) and one year of treatment (IAH=0.2).
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Affiliation(s)
- Otávio Ferraz
- Correspondence to: Departamento de Psicobiologia, Universidade Federal de São Paulo, Napoleão de Barros Street, 925, Vila Clementino, CEP 04021-002, São Paulo, Brazil.
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30
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Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a secondary cause of intracranial hypertension (IH). Decreased jugular venous drainage has been seen in patients with idiopathic IH. CLINICAL PRESENTATION A complex case of a 48-year-old female whose idiopathic IH was put into remission after counterclockwise maxillomandibular advancement (CC-MMA), despite persistence of her OSA. CONCLUSION This case highlights the relationship between OSA and IH and points to the significant morbidity that can result from mild OSA and from what are considered borderline intracranial pressures. This indicates the need for a high index of suspicion for actual underlying pathology that can be surgically corrected when patients manifest symptoms of a somatic syndrome. This is the first report in the medical literature of clinical elimination of IH by CC-MMA. The authors propose that this positive outcome was effected via mandibular advancement producing a decrease in jugular venous resistance, allowing improved absorption of cerebrospinal fluid.
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Affiliation(s)
- Deborah Wardly
- a Independent, Department of Pediatrics , Las Vegas , NV , USA
| | - Larry M Wolford
- b Departments of Oral and Maxillofacial Surgery and Orthodontics , Texas A & M University Health Science Center, Baylor College of Dentistry , Dallas , TX , USA.,c Departments of Oral and Maxillofacial Surgery and Orthodontics , Baylor University Medical Center , Dallas , TX , USA.,d Private Practice , Dallas , TX , USA
| | - Venkat Veerappan
- e Department of Neurology , Southern Hills Hospital , Las Vegas , NV , USA.,f Department of Neurology , Touro University , Las Vegas , NV , USA
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31
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Faria AC, Garcia LV, Santos AC, Eckeli AL, Garcia DM, Mello-Filho FV. Dynamic comparison of pharyngeal stability during sleep in patients with obstructive sleep apnea syndrome treated with maxillomandibular advancement. Sleep Breath 2016; 21:25-30. [PMID: 27225872 DOI: 10.1007/s11325-016-1362-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/11/2016] [Accepted: 05/18/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare the dynamic differences occurring in the pharynx during sleep after maxillomandibular advancement (MMA) surgery for the treatment of patients with obstructive sleep apnea syndrome. METHODS This was a prospective, cross-sectional study conducted on 20 patients (15 men and 5 women) with a polysomnography diagnosis of obstructive sleep apnea (OSA) submitted to surgical treatment with MMA. All patients were submitted to magnetic resonance (MR) during propofol-induced sleep before and 6 months after surgery. Thirty linear measurements (30 sections) were obtained over time in the retrolingual (RL) region to compare their variability before and after MMA. RESULTS The mean linear anteroposterior increase of the pharynx during induced sleep after MMA was 66 % in the RL region (P < 0.01). The coefficient of variation of the linear measurements was 117.5 % before surgery, being reduced to 51 % after surgery. CONCLUSIONS MMA promoted an important increase of the pharynx during induced sleep and a more significant change in the variability of its lumen. With a lower variation in the diameter of the organ during the respiratory movements, there is greater airway stability and a consequent maintenance of the pharyngeal lumen that reduces or even prevents pharyngeal collapse.
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Affiliation(s)
- Ana Celia Faria
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, University of São Paulo, Ribeirão Preto, SP, Brazil. .,Faculty of Medicine of Ribeirão Preto, University of São Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirão Preto, SP, Brazil.
| | - Luis Vicente Garcia
- Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Antonio Carlos Santos
- Center of Imaging Sciences and Medical Physics, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Alan Luiz Eckeli
- Department of Neurology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Denny Marcos Garcia
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, University of São Paulo, Ribeirão Preto, SP, Brazil.,Craniofacial Research Support Center, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Francisco Verissimo Mello-Filho
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, University of São Paulo, Ribeirão Preto, SP, Brazil.,Craniofacial Research Support Center, University of São Paulo, Ribeirão Preto, SP, Brazil
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32
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Islam S, Taylor C, Ormiston IW. Effect of preoperative continuous positive airway pressure duration on outcomes after maxillofacial surgery for obstructive sleep apnoea. Br J Oral Maxillofac Surg 2014; 53:183-6. [PMID: 25532967 DOI: 10.1016/j.bjoms.2014.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
Abstract
Continuous positive airway pressure (CPAP) remains the first-line treatment for obstructive sleep apnoea (OSA), and is known to result in various physiological changes. The objective of this study was to evaluate the association between duration of preoperative CPAP therapy and outcome after maxillomandibular advancement (MMA) for OSA. We retrospectively analysed consecutive patients treated at our institution, and divided them into 2 groups based on duration of treatment with CPAP: short-term (up to 12 months) and long-term use (12 months or more). We controlled for baseline demographic and clinical characteristics. We compared postoperative scores for the apnoea/hypopnoea index (AHI) and the Epworth sleepiness scale (ESS), and lowest recorded oxygen saturation between groups. In 43 patients data were available on the preoperative use of CPAP, and in 37 of them preoperative and postoperative polysomnographic data were also available for inclusion. Most had bimaxillary advancement with genioplasty. Differences between the groups in mean reduction in the AHI and lowest oxygen saturation were not significant, and operative success rates were comparable. After operation, the reduction in ESS scores was significantly greater in the long-term group than in the short-term group (mean (SD) 8(3) compared with 2 (2), respectively, p<0.001). Our results suggest that the duration of use of CPAP preoperatively does not significantly influence objective outcome measures. The reduction in AHI scores after MMA was equivalent in both groups. The long-term group seemed to fare better than the short-term group on subjective outcome measures.
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Affiliation(s)
- Shofiq Islam
- Department of Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
| | - Christopher Taylor
- Department of Chest Medicine, Salisbury District Hospital, Wiltshire SP2 8BJ, UK
| | - Ian W Ormiston
- Department of Maxillofacial Surgery, Leicester Royal Infirmary, Leicester LE1 5WW, UK
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Bianchi A, Betti E, Tarsitano A, Morselli-Labate AM, Lancellotti L, Marchetti C. Volumetric three-dimensional computed tomographic evaluation of the upper airway in patients with obstructive sleep apnoea syndrome treated by maxillomandibular advancement. Br J Oral Maxillofac Surg 2014; 52:831-7. [PMID: 25129655 DOI: 10.1016/j.bjoms.2014.07.101] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 07/24/2014] [Indexed: 11/18/2022]
Abstract
Obstructive sleep apnoea syndrome is the periodic reduction or cessation of airflow during sleep together with daytime sleepiness. Its diagnosis requires polysomnographic evidence of 5 or more episodes of apnoea or hypopnoea/hour of sleep (apnoea/hypopnoea index, AHI). Volumetric 3-dimensional computed tomographic (CT) reconstruction enables the accurate measurement of the volume of the airway. Nasal continuous positive airway pressure (CPAP) is the conventional non-surgical treatment for patients with severe disease. Operations on the soft tissues that are currently available give success rates of only 40%-60%. Maxillomandibular advancement is currently the most effective craniofacial surgical technique for the treatment of obstructive sleep apnoea in adults. However, the appropriate distance for advancement has not been established. Expansion of the air-flow column volume did not result in an additional reduction in AHI, which raises the important issue of how much the maxillomandibular complex should be advanced to obtain an adequate reduction in AHI while avoiding the risks of overexpansion or underexpansion. We have shown that there is a significant linear relation between increased absolute upper airway volume after advancement and improvement in the AHI (p=0.013). However, increases in upper airway volume of 70% or more achieved no further reduction in the AHI, which suggests that the clinical improvement in AHI reaches a plateau, and renders further expansion unnecessary. This gives a new perspective to treatment based on the prediction of changes in volume, so the amount of sagittal advancement can be tailored in each case, which replaces the current standard of 1cm.
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Affiliation(s)
- Alberto Bianchi
- Oral and Maxillofacial Surgery Unit, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Enrico Betti
- Post-graduate School of Maxillofacial Surgery, University of Bologna, Bologna Italy.
| | - Achille Tarsitano
- Maxillofacial Surgery Unit, Department of Biomedical Science and Neuromotor Science, S. Orsola Malpighi University Hospital, Alma Mater Studiorum - University of Bologna, Bologna Italy
| | | | - Lorenzo Lancellotti
- Post-graduate School of Maxillofacial Surgery, University of Bologna, Bologna Italy
| | - Claudio Marchetti
- Professor of Maxillofacial Surgery, Department of Biomedical Science and Neuromotor Science, Dental School and S. Orsola Malpighi University Hospital, Alma Mater Studiorum - University of Bologna, Bologna Italy
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Islam S, Aleem F, Ormiston IW. Does the Kushida morphometric model predict outcomes following maxillomandibular advancement surgery for obstructive sleep apnoea? J Craniomaxillofac Surg 2014; 42:1675-8. [PMID: 24969763 DOI: 10.1016/j.jcms.2014.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/13/2014] [Accepted: 05/13/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The primary aim of this study was to explore the predictive potential of the preoperative Kushida index score and subsequent outcome following maxillomandibular advancement surgery (MMA). Secondarily we looked at how well the Kushida values of our OSA patients matched the morphometric models diagnostic thresholds. METHODS We performed a retrospective analysis of patients who underwent MMA for OSA at our institution. Kushida morphometric scores were calculated using the described formula: P + (Mx - Mn) + 3 × OJ + 3 × [Max (BMI - 25)] × (NC ÷ BMI). Regression analysis was performed to explore the possible association between Kushida index score and outcome variables of postoperative apnoea/hypopnea indices (AHI) and Epworth Sleepiness Scores (ESS). RESULTS We identified 28 patients with complete data available for analysis. The mean age was 45 years (SD 6) with mean BMI of 28 (SD 3). All, but one patient underwent bi-maxillary procedure with or without genioplasty, with a mean advancement of 8.5 mm (SD 2). The mean Kushida index score in our sample was 79 (SD 14). 89% of patients had postoperative AHI <15 in keeping with surgical success. We found no statistically significant relationship with Kushida morphometric model variables and overall score with either of our outcome variables. CONCLUSION The mean Kushida index score in our patients was in the range consistent with the morphometric models diagnostic cut-off for OSA. Kushida's morphometric model does not appear to be a good predictor of postoperative success in individuals following MMA. The morphometric model represents a clinical adjunct in the initial diagnostic work-up of OSA patients referred for surgery.
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Affiliation(s)
- Shofiq Islam
- Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, East Midlands, LE1 5WW, UK.
| | - Fahd Aleem
- Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, East Midlands, LE1 5WW, UK
| | - Ian W Ormiston
- Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, East Midlands, LE1 5WW, UK
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Islam S, Uwadiae N, Ormiston IW. Orthognathic surgery in the management of obstructive sleep apnoea: experience from maxillofacial surgery unit in the United Kingdom. Br J Oral Maxillofac Surg 2014; 52:496-500. [PMID: 24793413 DOI: 10.1016/j.bjoms.2014.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
Abstract
In the United Kingdom, maxillofacial techniques are underused in the treatment of obstructive sleep apnoea (OSA). We retrospectively analysed the details and relevant clinical data of consecutive patients who had operations for OSA at the maxillofacial unit in Leicester between 2002 and 2012. They had been referred from the local sleep clinic after investigation and diagnosis, and in all cases treatment with continuous positive airway pressure (CPAP) had failed. We compared preoperative and postoperative apnoea/hypopnoea indices (AHI), scores for the Epworth sleepiness scale (ESS), and lowest oxygen saturation to measure surgical success (AHI of less than 15 and a 50% reduction in the number of apnoeas or hypopnoea/hour) and surgical cure (AHI of less than 5). We identified 51 patients (mean age 44 years, range 21-60) with a mean (SD) body mass index (BMI) of 29 (3.4). Most patients had bimaxillary advancement with genioplasty (n=42). Differences in mean (SD) preoperative and postoperative values were significant for all 3 outcome measures (AHI: 42 (17) to 8 (7) p<0.001; ESS: 14 (4) to 5 (4) p<0.001; lowest oxygen saturation: 76% (11%) to 83% (7%); p=0.006). On the postoperative sleep study 85% of patients met the criteria for surgical success. Our experience has confirmed that bimaxillary advancement results in a high rate of success in patients with OSA. The operation has a role in the management of selected patients in the UK who do not adhere to CPAP.
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Affiliation(s)
- Shofiq Islam
- Department of Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, East Midlands LE1 5WW, UK.
| | - Nosa Uwadiae
- Department of Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, East Midlands LE1 5WW, UK
| | - Ian W Ormiston
- Department of Maxillofacial Surgery, Leicester Royal Infirmary, Infirmary Square, Leicester, East Midlands LE1 5WW, UK
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Hsieh YJ, Liao YF, Chen NH, Chen YR. Changes in the calibre of the upper airway and the surrounding structures after maxillomandibular advancement for obstructive sleep apnoea. Br J Oral Maxillofac Surg 2014; 52:445-51. [PMID: 24629456 DOI: 10.1016/j.bjoms.2014.02.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 02/07/2014] [Indexed: 11/27/2022]
Abstract
Maxillomandibular advancement (MMA) is effective in the treatment of obstructive sleep apnoea. We aimed to assess changes in the calibre of the upper airway, facial skeleton, and surrounding structural position after MMA and their association with improvement in symptoms. Sixteen consecutive adults with moderate-to-severe apnoea were treated by primary MMA. Polysomnography and computed tomography (CT) of the head and neck were done before and at least 6 months after MMA. The calibre of the upper airway, the facial skeleton, and the surrounding structures were measured with image analysis software. After MMA, patients had a significant reduction in their apnoea-hypopnoea index (31.2 (18.8)number of events (n)/hour (h)). The mean (SD) volume of the airway increased significantly in the velopharynx (p<0.01), oropharynx (p=0.001), and hypopharynx (p<0.001) (by 2.3 (2.4), 2.1 (2.6), and 1.7 (1.1)cm(3), respectively) and the length of the airway was significantly decreased (by 3.1 (3.5)mm p<0.01). The soft palate (p<0.001), tongue (p<0.001), and hyoid (p=0.001) moved significantly anteriorly (by 4.4 (2.0), 7.5 (2.8), and 5.7 (5.0)mm, respectively), and these movements were related to the MMA (r=0.6-0.8). The improvement in the apnoea-hypopnoea index was associated with both maxillary advancement and anterior movements of the soft palate and hyoid (r=0.6-0.7). The results of this study suggest that MMA increases the volume in the upper airway and reduces its length. Improvement in obstructive sleep apnoea is associated with the extent of the anterior movements of the maxilla, soft palate, and hyoid.
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Affiliation(s)
- Yuh-Jia Hsieh
- Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Fang Liao
- Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Ning-Hung Chen
- Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Ray Chen
- Craniofacial Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Craniofacial Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan; Sleep Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
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Seehra J, Sherriff M, Winchester L. Craniofacial characteristics of successful responders to mandibular advancement splint therapy: a pilot study. Br J Oral Maxillofac Surg 2014; 52:314-6. [PMID: 24636249 DOI: 10.1016/j.bjoms.2014.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 01/31/2014] [Indexed: 11/15/2022]
Abstract
Cephalometric variables that can be used to identify patients with obstructive sleep apnoea who are suitable for mandibular advancement splints and surgical maxillomandibular advancement are lacking. The aim of this pilot study was to describe the craniofacial characteristics of patients whose symptoms of obstructive sleep apnoea were successfully treated with mandibular advancement splints and who were subsequently considered for maxillomandibular advancement. We retrospectively compared the craniofacial characteristics of our patients with data from 2 previously published studies. There were significant differences between the 2 groups for ANB (p<0.000), overjet (p<0.0001), Go-Me (p<0.0002), and ANS-PNS (p<0.0009). Patients, whose symptoms improve with the use of mandibular advancement splints and are potential candidates for maxillomandibular advancement, may have unique craniofacial features consisting of bimaxillary retrusion characterised by a shorter maxilla and mandible, and a greater class II skeletal tendency. The results of this study should be viewed as a pilot. Further research is required.
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Affiliation(s)
| | - Martyn Sherriff
- School of Oral and Dental Sciences, Bristol Dental Hospital, University of Bristol and Kings College London Dental Institute at Guy's, King's College and St Thomas' Hospitals
| | - Lindsay Winchester
- Queen Victoria Hospital NHS Foundation Trust, Holtye Road, East Grinstead, West Sussex RH19 3DZ, UK
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GIARDA M, BRUCOLI M, ARCURI F, BENECH R, BRAGHIROLI A, BENECH A. Efficacy and safety of maxillomandibular advancement in treatment of obstructive sleep apnoea syndrome. Acta Otorhinolaryngol Ital 2013; 33:43-6. [PMID: 23620639 PMCID: PMC3631807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 11/14/2012] [Indexed: 11/30/2022]
Abstract
To assess the effectiveness of maxillomandibular adavancement for treatment of adults with obstructive sleep apnoea, we report the results obtained after maxillomandibular advancement. A group of 16 patients were studied before surgery, at 6 months after surgery and at followup. The analysis included: upper airway endoscopy during Mueller's manoeuvre, lateral cephalometry, polysomnography and Epworth Sleepiness Scale. The results of surgical treatment were divided into "surgical success" and "surgical cure". The former was defined as an AHI < 20 events/hour and a > 50% reduction in AHI after surgical procedure, while the latter was defined as an AHI < 5 events/hour after surgical procedure. At follow-up, all patients had AHI < 20 events/hour with a surgical success rate of 100%. The surgical cure rate was 37.5%, with 6 patients having an AHI < 5 events/hour. Surgical success and long term stability of outcomes confirm the efficacy and safety of MMA for treatment of obstructive sleep apnoea syndrome. However, a continuous follow-up of these patients is necessary to control their lifestyle and to detect possible relapse.
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Affiliation(s)
- M. GIARDA
- Maxillofacial Unit, Piemonte Orientale University; Novara, Italy;,Address for correspondence: Mariangela Giarda, S.C.D.U. di Chirurgia Maxillo-Facciale, Ospedale Maggiore della Carità, corso Mazzini 18, 28100 Novara, Italy. Tel. +39 0321 3733893/3733783/3733895. Fax +39 0321 3733893. E-mail:
| | - M. BRUCOLI
- Maxillofacial Unit, Piemonte Orientale University; Novara, Italy
| | - F. ARCURI
- Maxillofacial Unit, Piemonte Orientale University; Novara, Italy
| | - R. BENECH
- Maxillofacial Unit, Piemonte Orientale University; Novara, Italy
| | | | - A. BENECH
- Maxillofacial Unit, Piemonte Orientale University; Novara, Italy
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