Oral appliances and hypomandibular surgery in the treatment of snoring and obstructive sleep apnea

Abstract

This course is designed for oral and maxillofacial surgeons to expand understanding of sleep disorders. An overview of sleep disorders, including techniques of evaluation and multiple modalities of treatment will be reviewed. Patients with primary snoring and/or obstructive sleep apnea frequently fail to respond to or are not appropriate candidates for behavior measures such as weight loss or change in sleep position. Frequently, those individuals also cannot tolerate or refuse treatment with nasal CPAP. Therefore, many types of oral appliances have been used successfully to move the base of the tongue forward in order to enlarge the upper airway. Despite considerable variation of the design of these appliances, the positive clinical effects have been remarkably consistent. The American Sleep Disorders Association review in 1995 concluded that, in patients studied, the mean apnea/hypopnea index (AHI) was reduced from 47 to 19, with approximately half of the patients treated, achieving an AHI of less than 10. Overall compliance seemed significantly higher than nasal CPAP. As a result, they produced practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. For those treating obstructive sleep apnea and upper airway resistance syndrome, oral appliances offer a reasonable non-surgical approach and/or presurgical evaluation tool for a variety of patients. Oral and maxillofacial surgeons working in conjunction with other sleep specialists are uniquely trained to offer this service. Since all conservative medical measures used to manage snoring and sleep disordered breathing, including CPAP, BiPAP, oral appliances, and weight loss, etc, have limitations such as patient tolerance and patient compliance, combined surgical procedures offer encouraging results in the treatment of patients with moderate to severe obstructive sleep apnea. Although maxillomandibular osteotomy appears to offer impressive success rates, consent for such surgery is mediated by patient acceptance, the severity of symptoms, and the level of upper airway collapse. Since no single surgical procedure, except tracheostomy, consistently and completely opens the upper airway, we have developed a philosophy directed toward surgery, which not only would achieve high acceptance rates but offers significant success in a wide variety of patients. Multiple potential sites of airway occlusion include the soft palate, lateral pharyngeal walls, and base of the tongue; thus uvulopharyngopalatoplasty (UPPP) in conjunction with skeletal mobilization techniques to advance the anterior mandibular attachments of the tongue and suprahyoid musculature can improve both oral and hypopharyngeal cross-sectional anatomy. Genioglossus advancement via mortised genioplasty allows a large soft tissue pedicle to be significantly advanced and rigidly fixated. Several genioglossus advancement techniques will be discussed in detail. The outcome data of several hundred patients treated at the University of Pennsylvania Center for Sleep Disorders will be reviewed in detail.