Maxillary Mandibular Advancement Research Articles

Comparing Treatment Effectiveness and Patient-Reported Outcome Measures of Four Treatment Options for Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP), mandibular advancement device (MAD), upper airway stimulation (UAS), and maxillomandibular advancement (MMA) are techniques to reduce apnea hypopnea index (AHI) in obstructive sleep apnea (OSA) patients. Current literature does not include a direct comparison of the 4 methods. The purpose of this study is to measure and compare the efficacy of 4 common OSA treatments: CPAP, MAD, UAS, MMA. This retrospective cohort study examines data from 119 patients treated at Thomas Jefferson University Hospital in Philadelphia receiving CPAP, MAD, UAS, or MMA between January 2018 and December 2020. Patients were excluded for significant medical comorbidities, body mass index ≥45, cognitive limitations, central/mixed apnea history, or pregnancy. The primary predictor variable was type of OSA intervention: CPAP, MAD, UAS, MMA. Treatments were assigned by treating physicians per their presenting OSA severity. The primary outcome variable was efficacy defined as the therapeutic response to treatment measured using mean disease alleviation, a calculated variable (percentage) which employs post-treatment AHI adjusted by compliance (a measure of a patient's device use). Secondary therapeutic measures included remaining AHI and patient-reported outcome measures: Epworth Sleepiness Scale, Sleep Apnea Quality of Life Index, Patient-reported Apnea Questionnaire. Demographic covariates included age, sex, height, weight, socioeconomic status, level of education, neck size, race, and body mass index. Clinical covariates included pretreatment AHI, AHI change, O2 nadir, adjusted compliance, and compliance. Multivariate statistics were computed with alpha level of 0.05, including a regression with the primary outcome variables, treatment variables, and potential covariates. The sample included 119 subjects (mean age=56.12, standard deviation [SD]=5.81) with males at n=72 (60%). MMA demonstrated greatest mean disease alleviation (M=36.08, SD=28.56), compared to UAS (M=22.88, SD=3.16), MAD (M=6.80, SD=8.13), and CPAP (M=5.00, SD=14.80), analysis of variance: P<.001. Both surgical treatments displayed significantly greater effectiveness than CPAP and MAD, suggesting that offering surgical alternatives sooner, particularly to those with severe OSA, may be logical in formulating more effective treatment guidelines.

Investigation of the effects of bimaxillary surgery on the pharyngeal airway space

Aim: To examine the pharyngeal airway space (PAS) changes in patients with skeletal Class III anomalies treated with two different bimaxillary surgery (BMS) techniques. Methodology: A total of 27 patients (15 females, 12 males) treated with BMS were divided into two groups: Group 1 (n=16, mean age: 20.67±2.82 years) consisted of patients who underwent maxillary-mandibular advancement (MMA), and Group 2 (n=11, mean age: 23.87±7.72 years) consisted of patients who underwent maxillary advancement and mandibular setback (MAMS). Cone-beam computed tomography (CBCT) records were taken immediately before (T1) and at least 5 months after (T2) BMS. To evaluate the postoperative PAS changes, the parameters of total volume (TV), upper volume (UV), lower volume (LV), and minimal axial area (Min-Ax) were evaluated using NemoCeph 10.4.2 software. Results: In Group 1, postoperative increases in the TV, NV, OV, and Min-Ax were determined as 4.5%, 6.6%, 3.07%, and 5.1%, respectively, but these increases were not statistically significant (p &gt; 0.05). In Group 2, the following increases were determined: 10.4% in TV, 18.4% in NV, and 5.5% in OV. A postoperative decrease of 6.2% was determined for Min-Ax. These increases and decreases were not statistically significant (p &gt; 0.05). There was no statistically significant difference between groups 1 and 2 in any pre- and postoperative parameters (p &gt; 0.05). Conclusion: Neither of the BMS techniques caused any significant change in the PAS parameters. How to cite this article: Koç E, Akkurt A. Investigation of the effects of bimaxillary surgery on the pharyngeal airway space. Int Dent Res 2022;12(3):130-6. https://doi.org/10.5577/intdentres.2022.vol12.no3.4 Linguistic Revision: The English in this manuscript has been checked by at least two professional editors, both native speakers of English.

Persistent Daytime Sleepiness after Successful Maxillary-Mandibular Advancement Surgery: A Clinical Case Report

Background: Continuous positive airway pressure is a cost-effective treatment of obstructive sleep apnea (OSA), but in case of craniofacial anomalies, which have a recognized role in OSA development, maxillary-mandibular advancement surgery is a recommended therapeutic option. Clinical Presentation: We describe a patient with severe OSA (apnea-hypopnea index = 42) treated by maxillary-mandibular advancement (MMA) surgery. Effective results were confirmed by polysomnography at 6 months post-surgery with normalization of the polysomnographic parameters (apnea-hypopnea index = 17) but due to persistent sleepiness, the patient was unable to resume his work. Conclusion: Maxillary-mandibular surgery can be a valid option for treating severe OSA associated with craniofacial anomalies. However, our results emphasize the need of critically assessing surgical approaches and the need to redefine success for OSA management.

The effect of maxillary-mandibular advancement surgery on two-dimensional cephalometric analysis, polysomnographic and patient-reported outcomes in 32 patients with sleep disordered breathing: A retrospective cohort study

This retrospective study evaluated the effect of bimaxillary advancement surgery on pre- and postoperative 2D cephalometric soft- and hard tissue measurements, polysomnography (PSG) and patient-reported snoring scores including Epworth sleepiness scale (ESS) after multidisciplinary treatment planning in 32 patients with obstructive sleep apnea or sleep disordered breathing (OSAS/SDB). Apnea-hypopnea index significantly improved with a mean difference of 18.32 ± 13.97 (P = 0.004). ESS, snoring intensity and snoring severity scores all significantly improved after surgery. The preoperative surgical planning was achieved based on 2D pre- and postoperative cephalometric comparison. Most 2D cephalometric measurements did not correlate with postoperative PSG findings. Amount of maxillary and mandibular advancement measured on 2D cephalograms did correlate with postoperative time below 88% oxygen saturation on PSG. In conclusion: bimaxillary advancement surgery has clinically significant favourable results in patients with OSAS/SDB both measured by PSG and with patient-reported outcomes after careful multidisciplinary treatment planning. Current 2D cephalometric airway analysis insufficiently predicted the effect of maxillomandibular advancement surgery in patients with OSAS/SDB.

Treatment of Obstructive Sleep Apnea Syndrome through Orthodontics and Orthognathic Surgery: A Case Report with a Five Year Follow-Up

Introduction: Obstructive sleep apnea (OSA) results from the presence of abnormal soft and hard tissues in the upper airway, which cause the collapse of the oropharynx in the deeper stages of sleep. Different treatment modalities have been proposed for OSA, aiming to offer a better quality of life for the patients. Orthognathic surgery via maxillary-mandibular advancement (MMA) decreases the collapse of soft and hard tissue structures during sleep and has a high success rate. The facial and occlusal improvement, the enhancement on respiratory function and the less morbid postoperative period are some advantages responsible for the growing acceptance of this technique. Case report: This case reports a combination of orthodontic treatment and orthognathic surgery via MMA in a 51 year old man with OSA. The initial polysomnography showed an apnea-hypopnea index of 49.2 and arousal index of 21.7. Follow-up polysomnography performed 15 months after surgery revealed significant improvement. The apneahypopnea index decreased to 2.9 and the arousal index to 12.3. The patient reported significant improvements in life quality, sleep quality, and nasal breathing capacity, as well as a decrease in daytime sleepiness and snoring. Thus far, the patient has been under postoperative follow-up for 5 years and 6 months, without any complaints of breathing difficulties during the day or night. Conclusion: The combination of orthodontic and surgical treatment via MMA may be a favorable alternative treatment for improving the respiratory symptoms of patients with OSA and is highly indicated for patients with maxillary-mandibular discrepancies.

Tongue base suspension procedures for obstructive sleep apnea syndrome

It is generally accepted that obstructive sleep apnea syndrome (OSA) results from the combination of a structurally small upper airway and abnormal airway collapsibility during sleep. Treatment of OSA, therefore, is directed at preventing airway collapse. For those patients who do not respond to conservative medical management such as positional therapy and weight loss, or are unable to tolerate or comply with positive pressure ventilation (continuous positive airway pressure, bilevel positive airway pressure, and other modalities) or mandibular advancement devices, surgical intervention remains the last option. Surgical treatments that target tongue base and hypopharyngeal collapse traditionally included partial glossectomy, midline glossectomy, linguoplasty, mandibular osteotomy with genioglossus advancement, and maxillary-mandibular advancement. Many of these procedures are associated with extreme morbidity and are not readily accepted by patients as treatment options. In search of minimally invasive alternatives, otolaryngologists began looking at other potential methods of anterior displacement and stabilization of the base of tongue.

Role of bimaxillary surgery in treatment of high respiratory obstructive sleep apnea syndrome

High respiratory obstructive sleep apnea syndrome (OSAS) is a potentially disabling condition, characterized by excessive daytime sleepiness, disruptive snoring, recurrent episodes of apnea (or hypopnea) and nocturnal hypoxemia. It is a sign of increased pharyngeal airflow resistance (apnea hypopnea index (AHI ≥ 5). Twelve patients suffering from mild-to-severe OSAS received CPAP treatment and the ANB angle of their cephalometric analysis is < 1 degree and therefore, diagnosed as a hidden maxillo-mandibular skeletal deformity. In this study, an innovative technique is designed to modify the maxillary mandibular advancement (MMA) surgical principle method and applied to treat these cases. While tracheal, nasal and uvulo-palatal tissues were not collapsing and obstructing the upper airway region, skeletal advancements was used to create and enlarge tongue room space resulting a patent posterior airway space (PAS). Digitally measured diameter at the epiglottis region in oro-pharyngeal airway space, was implemented, assuming a cylindrical model, to determine the total air volume change. Results showed a marked positive air flow gain (approximately 1.1 ± 0.2 cm3; 12 months postoperative) with statistical significant differences (p < 0.01). Thus it has been concluded that MMA is very useful in managing severe class III skeletal deformity having OSAS via increasing the total air column volume gain in the upper oro-pharyngeal airway space at the epiglottis region. It may, therefore, be advocated that it could be considered as a standard surgical treatment after failure of CPAP existed.

Modified Maxillary Osteotomy With Distraction to Preserve Velopharyngeal Function in the Cleft Patients

Statement: Patients with cleft palates have significanlty narrow anterior-posterior dimensions of the pharynx at the level of the maxillary plane and narrowest dimensions at the level of the hyoid, as compared to non cleft palate patients. The anatomically narrow upper airways in these patients place them at increase risk for obstructive sleep apnea (OSA). Maxillary mandibular advancement (MMA) surgery is an effective method of treating OSA. Although MMA has been found to be effective in treatment of OSA, it places patients with cleft palates at an increased risk for velopharyngeal dysfunction. Some investigators have demonstrated that velopharyngeal function is adversely affected during maxillary advancement in the cleft palate patients. We present a series of cases in which a modified maxillary osteotomy was devised to enable MMA and concurrently minimizing changes in their velopharygeal function. Materials and Methods: This is a prospective study that enrolled cleft palate and cleft lip patients. Inclusion criteria include patients that have had prior repair of cleft palate and or cleft lip, have a hypoplastic maxilla in the anterior-posterior dimension. Patients enrolled in the study, underwent comprehensive work up which included CT scan, and fabrication of stereolythic models. Cephalometric and model surgery were completed to predict the direction and the distance of the movements required. All patients had preoperative evaluation of their velopharyngeal function. Patients underwent a modified Le Fort 1 osteotomy with placement of KLS Martin unidirectional maxillary distractors. Once the planned distraction distance had been attained, the distractors were removed after consolidation. Postoperative clinical evaluation was used to determine changes in velopharyngeal function. Method of Data Analysis: Standard descriptive statistics were used to examine the distribution of key variables. Results: Patients who underwent distraction of the maxilla via the modified Lefort 1 osteotomy demonstrated an average advancement of 8mm. Clinical examination and naso-pharyngoscopy revealed no detrimental changes to their velopharyngeal function. Conclusion: The modified osteotomy allows for maxillary advancement without adversely affecting the patients velopharyngeal function.

Maxillary-mandibular advancement for obstructive sleep apnea

Surgical treatment of obstructive sleep apnea syndrome may, in many cases, need to address obstruction at the level of the palate and the base of tongue. By careful evaluation and a stepwise surgical approach, those individuals who require more aggressive advancement of the hypopharyngeal airway may be identified. Maxillary-mandibular advancement is an effective mechanism to maximize this airway space. Surgical treatment of obstructive sleep apnea syndrome may, in many cases, need to address obstruction at the level of the palate and the base of tongue. By careful evaluation and a stepwise surgical approach, those individuals who require more aggressive advancement of the hypopharyngeal airway may be identified. Maxillary-mandibular advancement is an effective mechanism to maximize this airway space.

Obstructive sleep apnea syndrome: A surgical protocol for dynamic upper airway reconstruction

A surgical protocol for dynamic upper airway reconstruction in the treatment of obstructive sleep apnea syndrome is presented. Two hundred thirty-nine consecutively treated patients were evaluated. All patients underwent a presurgical evaluation that included a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polygraphic monitoring. The goal of the presurgical evaluation was to document sleep apnea and isolate the area of obstruction. The treatment was then directed to the obstructive site. The surgical protocol included two phases. Phase 1 was a conservative approach and included uvulopalatopharyngoplasty and/or mandibular osteotomy with genioglossus advancement-hyoid myotomy and suspension. Polysomnography was repeated at 6 months and patients with unsuccessful surgical results were offered maxillary-mandibular advancement osteotomy. Results were based on the postoperative polysomnograms, and included assessing changes in both sleep architecture and sleep-disordered breathing. The surgical results were compared with results in patients who were using nasal continuous positive airway pressure. The surgical success rate for the 239 patients entered into phase 1 therapy was 61% (145 patients). Twenty-four patients who failed phase 1 treatment elected phase 2 treatment. The surgical success rate of this phase was 100%.

Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients.

Three hundred six consecutively treated surgical patients with obstructive sleep apnea syndrome were evaluated from a group of 415 patients. One hundred nine patients were excluded because they failed to obtain a postoperative polysomnogram or were lost to followup. All patients received a physical examination, cephalometric analysis, fiberoptic examination, and polysomnography before treatment to document OSAS and determine the areas of obstruction. A two-phase surgical protocol was used for the reconstruction of the upper airway. Phase I surgery consisted of a uvulopalatopharyngoplasty (UPPP) for palatal obstruction and genioglossus advancement with hyoid myotomy-suspension for base of tongue obstruction. Failures of phase I were offered phase 2 reconstruction, which consisted of maxillary-mandibular advancement osteotomy. One hundred twenty-one patients were treated with nasal continuous positive airway pressure (CPAP) before surgery and this was the primary method of evaluating surgical success. Results were reported on the polysomnogram performed a minimum of 6 months after surgery and compared to the preoperative polysomnogram and the second night nasal CPAP study. The polysomnographic results included respiratory disturbance index (RDI), lowest oxyhemoglobin saturation (LSAT), and sleep architecture parameters. Surgery was considered a success if it was equivalent to nasal CPAP or the postoperative RDI was less than 20 with normal oxygenation. The overall success rate, which included patients that dropped from the protocol, was 76.5%, with a mean followup of 9.3 months (SD, 6.7). The preoperative RDI, nasal CPAP RDI, and postoperative RDI were 55.8 (SD, 26.7), 7.2 (SD, 5.4), and 9.2 (SD, 7.5), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)