MAXILLOMANDIBULAR ADVANCEMENT FOR OBSTUCTIVE SLEEP APNEA SYNDROME

Man That Cannot Fall AsleepHere is a listing of articles regarding the successful use of orthognathic surgery – MMA (maxillomandibular advancement) to help in the treatment of OSA (obstructive sleep apnea). The expected success with these procedures can be evaluated with a cone beam scan and clinical examination. This is a big surgery and carries a number of risks and limitations, however the reported results are good.

I would still consider the UPPP (uvulopalatopharyngoplasty) if there is a significant secondary tonsilar drape. That procedure removes excess tissue from around the soft palate and throat to better open the airway. This needs to be done conservatively so as not to cause a “rigid palate”. Done well, it is an excellent procedure. The UPPP has been shown to improve breathing, but is again not a cure. 

The MMA has been shown to be the one best “treatment” for OSA. It should not be viewed as a cure, but for certain patients it helps a great deal in eliminating the need for CPAP. If I had OSA I would do it.

 

  1. Zaghi S, Holty JC, Certal V, Abdullatif J, Guilleminault C, Powell NB, Riley RW, Camacho M. Maxillomandibular advancement for treatment of obstructive sleep apnea: A meta-analysis. JAMA Otolaryngol Head Neck Surg. 2015 Nov 25:1-9. http://dx.doi.org/10.1001/jamaoto.2015/2678.

A meta-analysis that confirms the effectiveness and efficacy of MMA for OSAS, even for patients who have failed nonsurgical therapy, and other surgical procedures.

 

  1. Goodday RH, Bourque SE, Edwards PB. Objective and subjective outcomes following maxillomandibular advancement surgery for treatment of patients with extremely severe obstructive sleep apnea (Apnea-Hypopnea Index >100). J Oral Maxillofac Surg. 2015 Jul 26. pii: S0278-2391(15)01034-4. http://dx.doi.org/10.1016/j.joms.2015.07.016.

A novel study documenting the efficacy of MMA for extreme OSAS (AHI>100) as initial phase I therapy.

 

  1. Camacho M, Liu SY, Certal V, Capasso R, Powell NB, Riley RW. Large maxillomandibular advancements for obstructive sleep apnea: An operative technique evolved over 30 years. J Craniomaxillofac Surg. 2015 Sep;43(7):1113-8. http://dx.doi.org/10.1016/j.jcms.2015.05.015. Epub 2015 Jun 2.

A step-by-step guide of the specifics of the MMA procedure as performed by this group of experienced OSAS surgeons (Riley-Powell MMA technique).

 

  1. Liu SY, Huon LK, Powell NB, Riley R, Dr. Chaiyoon Cho HG, Torre C, Capasso R. Lateral pharyngeal wall tension after maxillomandibular advancement for obstructive sleep apnea is a marker for surgical success: observations from drug-induced sleep endoscopy. J Oral Maxillofac Surg. 2015 Augmentin 875 mg bid 1 week;73(8):1575-82. http://dx.doi.org/10/.1016/j.joms.2015/01.028. Epub 2015 Feb 7.

Since MMA has its greatest effect at the lateral pharyngeal walls, lateral pharyngeal wall stability can be used as a predictor for successful outcomes following MMA in OSAS.

 

  1. Butterfield KJ, Marks PL, McLean L, Newton J. Linear and volumetric airway changes after maxillomandibular advancement for obstructive sleep apnea. J Oral Maxillofac Surg. 2015 June;73(6):1133-42. http://dx.doi.org/10.1016/j.joms.2014.11.020. Epub 2014 Dec 13.

This study documents the positive airway changes and improved sleep quality outcomes obtained following MMA for OSAS.

 

  1. Boyd SB, Walters AS, Waite P, Harding SM, Song Y. Long-term effectiveness and safety of maxillomandibular advancement for treatment of obstructive sleep apnea. J Clin Sleep Med. 2015 Jul 15; 11 (7);699-708. http://dx.doi.org/10.5664/jcsm.4838.

Long-term (>2 year) follow-up of MMA in moderate-severe OSAS (mean AHI=49) showing significant improvement in outcomes with AHI reduction, mean BP reduction, and improved Epworth Sleepiness Scale ratings.

 

  1. Ubaldo ED, Greenlee GM, Moore J, Sommers E, Bollen AM. Cephalometric analysis and long-term outcomes of orthognathic surgical treatment for obstructive sleep apnoea. Int J Oral Maxillofac Surg. 2015 Jun;44(6):752-9. http://dx.doi.org/10.1016/j.jom.2015.01.022. Epub 2015 Feb 18.

Although the standard of MMA practice for OSAS requires 10 mm of advancement, this study documents that MMA of less than 10 mm is still effective in increasing posterior airway space and improving OSAS symptoms.

 

  1. Camacho M, Teixeira J, Abdullatif J, Acevedo JL, Certal V, Capasso R, Powell NB. Maxillomandibular advancement and tracheostomy for morbidly obese obstructive sleep apnea: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2015 Apr;152(4);619-30. http://dx.doi.org/10.1177/0194599814568284. Epub 2015 Feb 2.

This systematic review and meta=analysis showed that data regarding the efficacy of MMA and tracheostomy for the morbidly obese OSAS patient is lacking, and definitive conclusions could not be made based upon the limited literature in this area (6 studies for MMA and 6 studies for tracheostomy).

 

  1. Lee SH, Kaban LB, Lahey ET. Skeletal stability of patients undergoing maxillomandibular advancement for treatment of obstructive sleep apnea. J Oral Maxillofac Surg. 2015 Apr;73(4):694-700. http://dx.doi.org/10.1016/j.joms.2014/10.018. Epub 2014 Oct 29.

Retrospective study of 25 OSAS patients who underwent MMA and genial tubercle advancement with follow-up greater than 2 years, with a mean maxillary advancement of 9.48 mm and mean mandibular advancement of 10.85mm. Although there were some cephalometric changes noted from T1 to T2 indicative of minor maxillary relapse (no more than 1 degree of change), these were no clinically significant (no malocclusion). This study indicates that MMA greater than 10 mm is skeletally stable long-term.

 

  1. Butterfield KJ, Marks PL, McLean L, Newton J. Pharyngeal airway morphology in healthy individuals and in obstructive sleep apnea patients treated with maxillomandibular advancement: a comparative study. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015 Mar;119(3):285-92. http://dx.doi.org/10.1016/j.oooo.2014.11.016. Epub 2014 Dec 5.

Retrospective evaluation of the airway morphology of 12 OSAS who underwent MMA vs. 12 control patients showing significant differences between the OSAS vs. control airways, and also showing significant improvements in the airway of the OSAS patients following MMA.

 

  1. Islam S, Taylor CJ, Ormiston IW. The predictive value of obstructive sleep apnoea severity on clinical outcomes following maxillomandibular advancement surgery. Br J Oral Maxillofac Surg. 2015 Mar;53(3):263-7. http://dxdoi.org/10.1016/j.bjoms.2014/12.005. Epub 2015 Jan 8.

Retrospective study comparing the outcomes of MMA in 2 matched groups:mild-moderate OSAS (AHI < 30) vs. severe OSAS (AHI = 30 or greater) patients. There was no significant difference in postoperative AHI between the two groups, but there was a high success rate in both groups (AHI<15), with 82% success in the mild-moderate group and 86% success in the severe group. Although the severe group had better improvement in subjective symptoms, the preoperative AHI may not be a good predictor of outcome following MMA for OSAS.

 

  1. Islam S, Aleem F, Ormiston IW. Subjective assessment of facial aesthetics after maxillofacial orthognathic surgery for obstructive sleep apnoea. Br J Oral Maxillofac Surg. 2015 Mar;53(3):235-8. http://dx.doi.org/10.1016/j.bjoms.2014.11.018. Epub 2014 Dec 23.

Concern about unesthetic facial changes following MMA for OSAS patients is a real concern, especially for the older patient population. This study evaluated the subjective change in facial appearance in 26 patients, 24 men and 2 women with a mean age of 45 years using a VAS scale, and also assessing postoperative AHI and ESS (Epworth Sleepiness Scale). 54% indicated an improvement in facial appearance, 15% were neutral, and 31% reported a lower score. These scores did not correlate with surgical outcome changes in AHI or ESS.

 

  1. Knudsen TB, Laulund AS, Ingerslev J, Homoe P, Pinholt EM. Improved apnea-hypopnea index and lowest oxygen saturation after maxillomandibular advancement with or without counterclockwise rotation in patients with obstructive sleep apnea: a meta-analysis. J Oral Maxillofac Surg. 2015 Apr;73(4):719-26. http://dx.doi.org/10.1016/j.joms.2014.08.006. Epub 2014 Aug 11.

This systematic review with meta-analysis identified 21 RCT with 4 studies that met the criteria to conclude that MMA with CCW results in significantly improved outcomes, using AHI reduction and increase in LSAT (lowest oxygen saturation), than MMS without CCW.

 

  1. Islam S, Taylor CJ, Ormiston IW. Effects of maxillomandibular advancement on systemic blood pressure in patients with obstructive sleep apnoea. Br J Oral Maxillofac Surg. 2015 Jan:53;(1):34-8. http://dx.doi.org/10.1016/j.bjoms.2014.09.008. Epub 2014 Oct 2.

Retrospective study of 45 OSAS patients who underwent MMA showing a significant reduction in systolic BP from a mean of 131 mmHg to 127 mmHg (P < .001). In addition to the positive effects of MMA on OSAS, BP reduction can also be an additional benefit of MMA.