Maxillomandibular Advancement Surgery in a Site-Specific Treatment Approach for Obstructive Sleep Apnea in 50 Consecutive Patients

doi:10.1378/chest.116.6.1519

Chest

Volume 116, Issue 6, December 1999, Pages 1519-1529

https://doi.org/10.1378/chest.116.6.1519 Get rights and content

Objective

To report the efficacy of maxillomandibular advancement (MMA) surgery, with a description of several innovations, as a site-specific treatment of obstructive sleep apnea syndrome (OSAS) in selected cases with disproportionate velo-orohypopharyngeal anatomy.

Design

Clinical series of 50 consecutive cases. Setting:Surgery was performed in a hospital operating room, and perioperative management was provided in an intensive care environment. Except for polysomnography (PSG), which was performed and interpreted by independent sleep facilities/physicians, all pre- and postoperative evaluations were accomplished in a solo office private practice setting.

Patients

Patients were referred for MMA evaluation when applicable conservative therapies such as nasal continuous positive airway pressure (nCPAP) were not tolerated, refused, or unsuccessful. Case selection was based primarily on the sites of disproportionate upper airway anatomy.

Interventions

MMA consisted of a Lefort I osteotomy, bilateral sagittal split ramus osteotomies, and a new modified procedure called an anterior inferior mandibular osteotomy with indirect hyoid suspension. Some patients also received concomitant adjunctive nonpharyngeal procedures. Measurements and results: Obtained at a mean of 5.2 months postoperatively, revealed significant improvement in all cases. Mean BPs (n = 50) were lowered, subjective symptoms were ameliorated, and mean body mass index (n = 50) was reduced. Cephalometric analysis (n = 50), with several new modifications including standardization for phases of respiration, quantified structural changes in soft-tissue and bony landmarks. Postoperative PSG results (n = 50) showed dramatic improvement over preoperative data (n = 50), with therapeutic values similar to nCPAP (n = 42). Mean values improved from preoperative to postoperative vs nCPAP for apnea index (34.5 to 1.0 vs 2.0, respectively), apnea-hypopnea index (59.2 to 4.7 vs 5.4, respectively), lowest arterial oxyhemoglobin desaturations (72.7% to 88.6% vs 88.6%, respectively), and number of desaturations < 90% (118.8 to 6.6 vs 2.4, respectively). The success rate was 100%.

Conclusion

MMA is highly successful and safe and may be a definitive primary single-staged surgical treatment of selected OSAS cases with diffusely complex or multiple sites of disproportionate velo-orohypopharyngeal anatomy.

Section snippets

Presurgical Evaluation and Treatment Planning

Patients were evaluated for MMA only if (1) they exhibited OSAS diagnosed by independent nocturnal polysomnography (PSG) (inclusion criteria of an apnea-hypopnea index [AHI] > 15 or an apnea index[ AI] > 5 and a lowest arterial oxyhemoglobin desaturation [LSAT]< 90%) that was clinically significant (inclusion criteria of stated excessive daytime sleepiness [EDS]); (2) all applicable conservative therapies (eg, nCPAP, weight loss, positional therapy, reduction of late evening sedative-hypnotic

Results

Demographic data of the 50 MMA patients are summarized in Table 2. Forty-four patients were male and six were female. The mean age was 42.7 years, with a range of 19 to 66 years. The postoperative data presented in Tables 3 – 6 were obtained at the longest complete follow-up evaluation. The mean length of follow-up was 5.2 months, with the longest at 4 years 3 months postoperatively. PSG results are summarized in Table 3 and illustrated in Figures 4 and 5. Postoperative results (n = 50) show

Discussion

A comprehensive review of the OSA surgery literature³³ showed that UPPP has been one of the most commonly performed, yet one of the least effective, surgeries for OSAS. Using the criteria of postoperative AHI < 20 or AI < 10 or > 50% reduction in either value, 137 of 337 patients from 37 independent case series were successful responders, for a combined success rate of only 41%. Furthermore, surgery directly on the pharyngeal tissues, eg, soft palate, may produce life-threatening postoperative

Conclusion

This clinical series of 50 consecutive OSAS patients reports a 100% success rate of MMA, often performed concomitantly with adjunctive nonpharyngeal procedures, as a safe primary single-staged type of site-specific surgical treatment for selected patients with diffusely complex or multiple sites of disproportionate velo-orohypopharyngeal anatomy. Although there is variation in the OSAS literature as to what specific criteria determine success, these results support previously reported data that

Appendix

PSGs were performed and interpreted at the following facilities, which are listed alphabetically: Astwani Neurology, P.C., Sleep Disorders Lab, Dublin, GA; Athens Regional Medical Center, Neurodiagnostics and Sleep Lab, Athens, GA; Cape Fear Memorial Hospital, Inc., Sleep Disorders Center, Wilmington, NC; Cobb Hospital, Sleep Center, Austell, GA; Dekalb Medical Center, Sleep Disorders Center, Decatur, GA; Dunwoody Medical Center, Sleep/Wake Center, Atlanta, GA; Floyd Medical Sleep Disorders

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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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The study sample consisted of 20 patients who have completed presurgical orthodontics using Invisalign clear aligners. Initial (pretreatment) digital dental models, presurgical digital dental models, and ClinCheck prediction models were obtained. Presurgical models were superimposed onto initial ones using stable anatomic landmarks; ClinCheck models were superimposed onto presurgical models using surface best-fit superimposition. Five hundred forty-five teeth were measured for 3 angular movements (buccolingual torque, mesiodistal tip, and rotation) and 4 linear movements (buccolingual, mesiodistal, vertical, and total scalar displacement). The predicted tooth movement was compared with the achieved amount for each movement and tooth, using both percentage accuracy and numerical difference.
Average percentage accuracy (63.4% ± 11.5%) was higher than in previously reported literature. The most accurate tooth movements were buccal torque and mesial displacement compared with lingual torque and distal displacement, particularly for mandibular posterior teeth. Clinically significant inaccuracies were found for the buccal displacement of maxillary second molars, lingual displacement of all molars, intrusion of mandibular second molars, the distal tip of molars, second premolars, and mandibular first premolars, buccal torque of maxillary central and lateral incisors, and lingual torque of premolars and molars.
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Patient-reported outcome measures following maxillomandibular advancement surgery in patients with obstructive sleep apnoea syndrome
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Maxillomandibular advancement (MMA) is an effective treatment for obstructive sleep apnoea syndrome (OSAS) that is refractory to conventional treatment. However, it is a highly invasive procedure with several recognised side effects, and we know of few data on its effect on important patient-reported outcome measures (PROMS). Here we describe a case series of patients selected for MMA through our joint respiratory/maxillofacial surgery clinic, detailing the effect of MMA on objective physiological measurements and important PROMS. Patients with confirmed moderate/severe symptomatic OSAS who could not tolerate continuous positive airway pressure (CPAP) or mandibular advancement devices (MAD) were assessed in the clinic for consideration of MMA. Preoperative and postoperative airway measurements, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS) score, and quality of life (10-point Likert scale), were recorded. A customised questionnaire was administered postoperatively to assess selected psychosocial and functional domains (sleep quality, energy levels, appearance, ability to perform daily activities, and mood) and patient satisfaction using five-point Likert scales. Over an 18 month period, 39 patients were referred for consideration of MMA. Ten patients (7 men and 3 women, mean age 49.9, mean BMI 27.5) underwent surgery, which resulted in significant improvements in ESS, quality of life, AHI, and airway diameters. All patients reported improvements in all psychosocial/functional domains except appearance, in which five reported no change or worsened appearance. All subjects felt that MMA provided better symptom control than CPAP. The most commonly reported side effects were facial/lip numbness (9/10) and affected bite (6/10). MMA resulted in significant improvements in ESS, quality of life, and a range of PROMS, with a high level of patient satisfaction.
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Chest

Clinical InvestigationsSleep & BreathingMaxillomandibular Advancement Surgery in a Site-Specific Treatment Approach for Obstructive Sleep Apnea in 50 Consecutive Patients

Objective

Design

Patients

Interventions

Conclusion

Section snippets

Presurgical Evaluation and Treatment Planning

Results

Discussion

Conclusion

Appendix

Chest

Chest

Exp Neurol

Chest

Lancet

Chest

Chest

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Chest

Chest

Natural history, cardiac impact, and long-term follow-up of sleep apnea syndrome

A report of the National Commission on Sleep Disorders Research: wake up America; a national sleep alert

Pathophysiology of upper airway closure during sleep

JAMA

Sleep apnea-pathophysiology: upper airway and control of breathing

Pathogenesis of upper airway occlusion during sleep

J Appl Physiol

The influence of sleep on tensor palatini EMG and upper airway resistance in normal men

J Appl Physiol

Pharmacologic treatment of obstructive sleep apnea

J Lab Clin Med

Acute effects of transdermal nicotine on sleep architecture, snoring, and sleep-disordered breathing in non-smokers

Am J Respir Crit Care Med

The effects of transcutaneous electrical stimulation during wakefulness and sleep in patients with obstructive sleep apnea

Am Rev Respir Dis

How and why should we stabilize the upper airway?

Sleep

Nasal CPAP: follow-up of compliance and adverse effects

Sleep Res

Compliance and side effects in sleep apnea patients treated with nasal continuous positive airway pressure

West J Med

Objective monitoring of nasal CPAP usage in OSAS patients

Sleep Res

Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea

Am Rev Respir Dis

Nasal CPAP: an objective evaluation of patient compliance

Am J Respir Crit Care Med

Clinical Investigations
Sleep & Breathing
Maxillomandibular Advancement Surgery in a Site-Specific Treatment Approach for Obstructive Sleep Apnea in 50 Consecutive Patients