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A Comparison of Isolated Maxillomandibular Advancement and Staged Surgery for the Treatment of Obstructive Sleep Apnea
Oral Abstract Session 3 cleft lip/palate (UCCL/P, BCCL/P). The only difference between these two groups was the presence of a repaired cleft of the secondary palate. Comparison may provide insight into the etiology of impaired facial growth in patients with repaired cleft lip/palate. Materials and Methods: This was a retrospective, cross-sectional study of non-syndromic patients with UCCLA, BCCLA, UCCL/P, and BCCL/P treated at Children’s Hospital Boston who had a lateral cephalogram after age 5 years and no dentofacial orthopedic manipulation. Angular and linear measurements of the midfacial region were made on traced lateral cephalograms. Methods of Data Analysis: Paired t-tests were used to compare facial measurements of study subjects to age and sex matched controls from the Michigan Growth Study. An age and sex adjusted multivariate analysis of variance (MANOVA) tested the differences in facial measures across groups. Results: The distribution of cleft types in 73 (36 males and 37 females) patients with a mean age of 11.12 years (range 6-16) was: UCCLA (n⫽25), BCCLA (n⫽7), UCCL/P (n⫽14), BCCL/P (n⫽27). When compared to age-matched controls the UCCLA and BCCLA groups showed no significant difference in midfacial position. The maxilla in patients with UCCL/P and BCCL/P was significantly smaller and more retruded than controls (p ⬍ 0.05) and in those with UCCLA and BCCLA (p ⬍ 0.05). There were no significant differences in maxillary size and position between UCCLA vs BCCLA and UCCL/P vs BCCL/P. There was also no difference in mandibular position among the groups. Conclusion: Patients with UCCLA and BCCLA have normal midfacial growth while the maxilla in patients with UCCL/P and BCCL/P is small and retrusive. This study suggests that the presence or repair of the secondary palate may be responsible for midfacial retrusion in patients with cleft lip/palate. References Mars M, Houston WJ: A preliminary study of facial growth and morphology in unoperated male unilateral cleft lip and palate subjects over 13 years of age. Cleft Palate J 27:7, 1990 Capelozza Filho L, Normando AD, da Silva Filho OG: Isolated influences of lip and palate surgery on facial growth: comparison of operated and unoperated male adults with UCLP. Cleft Palate Craniofac J 33:51, 1996
A Comparison of Isolated Maxillomandibular Advancement and Staged Surgery for the Treatment of Obstructive Sleep Apnea Scott B. Boyd, DDS, PhD, Nashville, TN (West AM) Statement of the Problem: Obstructive sleep apnea (OSA) is a common primary sleep disorder, occurring in up to 9% of women and 24% of men ages 30 to 60. AAOMS • 2009
Maxillomandibular advancement (MMA) is a surgical procedure that has been reported to be effective in the treatment of OSA, with short term success rates of 75100%. MMA has been used as an isolated procedure or as a component of staged surgery, which includes performance of uvulopalatopharyngoplasty (UPPP) prior to MMA. It is unknown whether performance of staged surgery provides any additional benefit beyond isolated MMA. The purpose of this study is to compare the clinical effectiveness of MMA performed alone to staged surgical therapy. Materials and Methods: This is a retrospective study derived from a cohort of 57 patients who have undergone MMA for the treatment of OSA at Vanderbilt Medical Center between 1997 and 2007. Patients were divided into two groups; those who underwent UPPP prior to MMA (n⫽28) and those who had isolated MMA (n⫽29). The same surgical procedures were used to complete MMA in both groups. The majority of patients were males (82%) and there was no significant difference in age between groups (MMA⫽43.8 years vs UPPP/ MMA⫽44.2 years). All subjects underwent standard overnight polysomnography (PSG) at the preoperative and postoperative (3-6 months after surgery) time intervals. The apnea-hypopnea index (AHI) was used as the primary outcome measure. Results of the PSG study were used to define the presence and severity of OSA and to determine the clinical effectiveness of treatment by assessing changes in AHI after surgery. For the purposes of this study, a preoperative AHI ⬎30 was classified as severe OSA and an AHI ⬎15 and ⬍30 was considered moderate. Surgical treatment was classified as clinically effective if the postoperative AHI was 15 or less. Methods of Data Analysis: Descriptive statistical analysis was performed for all variables and reported as mean ⫾ SD. A two-sided independent samples t-test was used to evaluate differences in AHI between the two groups, and a paired t-test was used to assess within group changes in AHI at the preoperative and postoperative time intervals. For all analyses, a P-value ⬍ 0.05 was considered statistically significant. Results: Preoperatively, over 80% of patients in each group had severe OSA, with the remaining 20% having moderate OSA. There was no statistically significant difference in AHI between the groups prior to surgery (MMA ⫽ 52.1 ⫾ 22.2 vs UPPP/MMA ⫽ 57.5 ⫾ 30). There was a significant reduction in AHI following surgery for each group (MMA ⫽ 10.2 ⫾ 7.4 vs UPPP/MMA ⫽ 12.6 ⫾ 11.6), so a high level of clinical effectiveness was observed for each of the procedures. There were no significant differences in outcome (changes in AHI) between the two groups. Conclusion: Both MMA performed alone and staged surgery (UPPP followed by MMA), are clinically effective treatment for patients with severe OSA. Comparison of 43
Oral Abstract Session 3 the two groups did not identify any significant benefit to performing UPPP prior to MMA. Therefore, strong consideration should be given to performance of MMA as the first or primary surgical procedure for patients with severe OSA. MMA performed alone would have the additional important benefits of decreasing overall treatment time and exposing the patient to less surgical risk. References Prinsell JR. Maxillomandibular advancement surgery in a site specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 1999; 116: 1519-1529 Riley RW, Powell NB, Guilleminault C. Maxillary, mandibular, and hyoid advancement for treatment of obstructive sleep apnea. A review of 40 patients. J Oral Maxillofac Surg 1990; 48:20-26
Three-Dimensional Computed Tomographic Airway Analysis of Patients With Obstructive Sleep Apnea Treated by Maxillomandibular Advancement Zachary R. Abramson, BS, Boston, MA (Bouchard C; Susarla S; Troulis MJ; Kaban LB) Statement of the Problem: Using 3-dimensional CT data, it has been demonstrated that the presence of obstructive sleep apnea (OSA) is associated with increased overall airway length relative to controls and that severity of OSA is inversely related to lateral to anteroposterior dimension ratio (at retroglossal level). However, there is little data documenting changes in these airway parameters following maxillomandibular advancement (MMA). The purpose of this study is to document changes in upper airway size and shape, following MMA. Materials and Methods: This is a retrospective case series of patients with OSA treated at Massachusetts General Hospital, Department of Oral and Maxillofacial Surgery from March 2005 through January 2009. Patients were included if: 1) the diagnosis of OSA was confirmed by overnight polysomnogram (PSG), 2) maxillomandibular advancement was performed and 3) pre and postoperative 3-D airway CT scans were available. All scans were imported into a CT analyzing computer software to create digital 3-D reconstructions of the airway. Parameters of airway size [volume (VOL), surface area (SA), length (L), mean cross-sectional area (mean CSA), minimum retropalatal (RP), minimum retroglossal (RG), minimum cross-sectional area (min CSA), and lateral (LAT) and anteroposterior (AP) retroglossal airway dimensions] were measured and analyzed. Evaluation of airway shape included LAT/AP and RP/RG ratios, uniformity (U), and sphericity, a measure of compactness (⌿). Descriptive statistics were computed for all variables. Pre and post-operative airway data were analyzed using a non-parametric paired samples test (Wilcoxon Signed44
Rank test). Pre and post-operative sleep and breathing related symptoms (i.e. snoring, daytime somnolence, attention deficit, fatigue) were recorded. For all analyses, p-values ⬍ 0.05 were considered statistically significant. Methods of Data Analysis: [see above] Results: There were 44 OSA patients treated during this period, of which 6 (M:F⫽ 3:3, ages 13-51, mean 29) met the inclusion criteria. Indications for MMA included severe OSA and intolerance of nasal Continuous Positive Airway Pressure (CPAP). The most common symptom reported preoperatively was daytime somnolence (n ⫽ 4), followed by snoring (n ⫽ 3), morning headaches (n ⫽ 2) and falling asleep while driving (n ⫽ 2). Mean pre-operative RDI and LSAT were 35.5 (range 16 to 51) and 87 (range 73 to 93), respectively. Following MMA, multiple airway parameters of size showed significant increases including LAT (p ⫽ 0.028), VOL (p ⫽ 0.028), RG (p ⫽ 0.046), RP (p ⫽ 0.028), min CSA (p ⫽ 0.028), avg CSA (p ⫽ 0.028), and SA (p ⫽ 0.028). Airway length was significantly decreased following MMA (p ⫽ 0.028). None of the parameters of airway shape were altered significantly by MMA. Post-operatively, five of six patients reported resolution of their symptoms and CPAP was discontinued. One patient, after initial improvement, developed chronic sinusitis, post-nasal drip, and sustained a maxillary fracture from blunt trauma, is still under treatment. Conclusion: The results of this preliminary study indicate that MMA appears to produce significant changes in airway size and shape that suggest a decrease in upper airway resistance. This study is ongoing and data will be updated as patients who meet the inclusion criteria are added. References Abramson ZR: Three-Dimensional CT Analysis of Airway Anatomy in Patients With Obstructive Sleep Apnea. Educational Summaries and Outlines - Scientific Sessions and Exhibition, AAOMS 90th Annual Meeting. J Oral and Maxillofac Surg. Volume 66, Issue 8, Supplement 1, (August 2008) pg. 60 Fairburn SC, Waite PD, Vilos G, et al: Three-dimensional changes in upper airways of patients with obstructive sleep apnea following maxillomandibular advancement. J Oral Maxillofac Surg. 2007 Jan; 65(1):6-12 This study was funded in part by the Hanson Foundation (Boston, MA), The MGH Department of OMFS Education and Research Fund and Synthes CMF, (West Chester, PA).
Radiographic Changes Following Distraction Osteogenesis of the Maxilla in Cleft Lip and Palate Patients Using a Rigid External Distractor Steven Fletcher, DDS, Iowa City, IA (Broadbent MW; Burton RG; Morgan TA) AAOMS • 2009
A Comparison of Isolated Maxillomandibular Advancement and Staged Surgery for the Treatment of Obstructive Sleep Apnea Scott B. Boyd, DDS, PhD, Nashville, TN (West AM) Statement of the Problem: Obstructive sleep apnea (OSA) is a common primary sleep disorder, occurring in up to 9% of women and 24% of men ages 30 to 60. AAOMS • 2009
Maxillomandibular advancement (MMA) is a surgical procedure that has been reported to be effective in the treatment of OSA, with short term success rates of 75100%. MMA has been used as an isolated procedure or as a component of staged surgery, which includes performance of uvulopalatopharyngoplasty (UPPP) prior to MMA. It is unknown whether performance of staged surgery provides any additional benefit beyond isolated MMA. The purpose of this study is to compare the clinical effectiveness of MMA performed alone to staged surgical therapy. Materials and Methods: This is a retrospective study derived from a cohort of 57 patients who have undergone MMA for the treatment of OSA at Vanderbilt Medical Center between 1997 and 2007. Patients were divided into two groups; those who underwent UPPP prior to MMA (n⫽28) and those who had isolated MMA (n⫽29). The same surgical procedures were used to complete MMA in both groups. The majority of patients were males (82%) and there was no significant difference in age between groups (MMA⫽43.8 years vs UPPP/ MMA⫽44.2 years). All subjects underwent standard overnight polysomnography (PSG) at the preoperative and postoperative (3-6 months after surgery) time intervals. The apnea-hypopnea index (AHI) was used as the primary outcome measure. Results of the PSG study were used to define the presence and severity of OSA and to determine the clinical effectiveness of treatment by assessing changes in AHI after surgery. For the purposes of this study, a preoperative AHI ⬎30 was classified as severe OSA and an AHI ⬎15 and ⬍30 was considered moderate. Surgical treatment was classified as clinically effective if the postoperative AHI was 15 or less. Methods of Data Analysis: Descriptive statistical analysis was performed for all variables and reported as mean ⫾ SD. A two-sided independent samples t-test was used to evaluate differences in AHI between the two groups, and a paired t-test was used to assess within group changes in AHI at the preoperative and postoperative time intervals. For all analyses, a P-value ⬍ 0.05 was considered statistically significant. Results: Preoperatively, over 80% of patients in each group had severe OSA, with the remaining 20% having moderate OSA. There was no statistically significant difference in AHI between the groups prior to surgery (MMA ⫽ 52.1 ⫾ 22.2 vs UPPP/MMA ⫽ 57.5 ⫾ 30). There was a significant reduction in AHI following surgery for each group (MMA ⫽ 10.2 ⫾ 7.4 vs UPPP/MMA ⫽ 12.6 ⫾ 11.6), so a high level of clinical effectiveness was observed for each of the procedures. There were no significant differences in outcome (changes in AHI) between the two groups. Conclusion: Both MMA performed alone and staged surgery (UPPP followed by MMA), are clinically effective treatment for patients with severe OSA. Comparison of 43
Oral Abstract Session 3 the two groups did not identify any significant benefit to performing UPPP prior to MMA. Therefore, strong consideration should be given to performance of MMA as the first or primary surgical procedure for patients with severe OSA. MMA performed alone would have the additional important benefits of decreasing overall treatment time and exposing the patient to less surgical risk. References Prinsell JR. Maxillomandibular advancement surgery in a site specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 1999; 116: 1519-1529 Riley RW, Powell NB, Guilleminault C. Maxillary, mandibular, and hyoid advancement for treatment of obstructive sleep apnea. A review of 40 patients. J Oral Maxillofac Surg 1990; 48:20-26
Three-Dimensional Computed Tomographic Airway Analysis of Patients With Obstructive Sleep Apnea Treated by Maxillomandibular Advancement Zachary R. Abramson, BS, Boston, MA (Bouchard C; Susarla S; Troulis MJ; Kaban LB) Statement of the Problem: Using 3-dimensional CT data, it has been demonstrated that the presence of obstructive sleep apnea (OSA) is associated with increased overall airway length relative to controls and that severity of OSA is inversely related to lateral to anteroposterior dimension ratio (at retroglossal level). However, there is little data documenting changes in these airway parameters following maxillomandibular advancement (MMA). The purpose of this study is to document changes in upper airway size and shape, following MMA. Materials and Methods: This is a retrospective case series of patients with OSA treated at Massachusetts General Hospital, Department of Oral and Maxillofacial Surgery from March 2005 through January 2009. Patients were included if: 1) the diagnosis of OSA was confirmed by overnight polysomnogram (PSG), 2) maxillomandibular advancement was performed and 3) pre and postoperative 3-D airway CT scans were available. All scans were imported into a CT analyzing computer software to create digital 3-D reconstructions of the airway. Parameters of airway size [volume (VOL), surface area (SA), length (L), mean cross-sectional area (mean CSA), minimum retropalatal (RP), minimum retroglossal (RG), minimum cross-sectional area (min CSA), and lateral (LAT) and anteroposterior (AP) retroglossal airway dimensions] were measured and analyzed. Evaluation of airway shape included LAT/AP and RP/RG ratios, uniformity (U), and sphericity, a measure of compactness (⌿). Descriptive statistics were computed for all variables. Pre and post-operative airway data were analyzed using a non-parametric paired samples test (Wilcoxon Signed44
Rank test). Pre and post-operative sleep and breathing related symptoms (i.e. snoring, daytime somnolence, attention deficit, fatigue) were recorded. For all analyses, p-values ⬍ 0.05 were considered statistically significant. Methods of Data Analysis: [see above] Results: There were 44 OSA patients treated during this period, of which 6 (M:F⫽ 3:3, ages 13-51, mean 29) met the inclusion criteria. Indications for MMA included severe OSA and intolerance of nasal Continuous Positive Airway Pressure (CPAP). The most common symptom reported preoperatively was daytime somnolence (n ⫽ 4), followed by snoring (n ⫽ 3), morning headaches (n ⫽ 2) and falling asleep while driving (n ⫽ 2). Mean pre-operative RDI and LSAT were 35.5 (range 16 to 51) and 87 (range 73 to 93), respectively. Following MMA, multiple airway parameters of size showed significant increases including LAT (p ⫽ 0.028), VOL (p ⫽ 0.028), RG (p ⫽ 0.046), RP (p ⫽ 0.028), min CSA (p ⫽ 0.028), avg CSA (p ⫽ 0.028), and SA (p ⫽ 0.028). Airway length was significantly decreased following MMA (p ⫽ 0.028). None of the parameters of airway shape were altered significantly by MMA. Post-operatively, five of six patients reported resolution of their symptoms and CPAP was discontinued. One patient, after initial improvement, developed chronic sinusitis, post-nasal drip, and sustained a maxillary fracture from blunt trauma, is still under treatment. Conclusion: The results of this preliminary study indicate that MMA appears to produce significant changes in airway size and shape that suggest a decrease in upper airway resistance. This study is ongoing and data will be updated as patients who meet the inclusion criteria are added. References Abramson ZR: Three-Dimensional CT Analysis of Airway Anatomy in Patients With Obstructive Sleep Apnea. Educational Summaries and Outlines - Scientific Sessions and Exhibition, AAOMS 90th Annual Meeting. J Oral and Maxillofac Surg. Volume 66, Issue 8, Supplement 1, (August 2008) pg. 60 Fairburn SC, Waite PD, Vilos G, et al: Three-dimensional changes in upper airways of patients with obstructive sleep apnea following maxillomandibular advancement. J Oral Maxillofac Surg. 2007 Jan; 65(1):6-12 This study was funded in part by the Hanson Foundation (Boston, MA), The MGH Department of OMFS Education and Research Fund and Synthes CMF, (West Chester, PA).
Radiographic Changes Following Distraction Osteogenesis of the Maxilla in Cleft Lip and Palate Patients Using a Rigid External Distractor Steven Fletcher, DDS, Iowa City, IA (Broadbent MW; Burton RG; Morgan TA) AAOMS • 2009