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Diagnosis, Treatment Planning, and Surgical Correction of Obstructive Sleep Apnea
J Oral Maxillofac Surg 67:2183-2196, 2009
Diagnosis, Treatment Planning, and Surgical Correction of Obstructive Sleep Apnea Reginald Goodday, DDS, MSC, FRCD(C)* The aim of this report is to present the scientific rationale for considering maxillomandibular advancement as the surgical treatment of choice in selected patients with obstructive sleep apnea syndrome; review the treatment planning that will identify those patients who would benefit from this procedure; review the surgical techniques; and review the patient outcomes after maxillomandibular advancement surgery. Patients with obstructive sleep apnea syndrome who have demonstrable retropositioning of the maxilla and mandible should be informed of maxillomandibular advancement as the primary surgical treatment for obstructive sleep apnea syndrome. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:2183-2196, 2009 A recent editorial by Leon Assael1 explained the term “paradigm shift” as describing an irrefutable scientific discovery that is the complete undoing of previously accepted knowledge. Once the shift is completed, all previous understanding of the clinical, scientific topic is abandoned and is supplanted by new knowledge/ new understanding.1 In the opinion of William H. Bell, one of the trends that will drive the next paradigm shift in orthognathic surgery is the use of maxillomandibular advancement (MMA) as the preferred treatment of obstructive sleep apnea syndrome (OSAS).1 This trend should result in successful outcomes after a single surgical procedure for OSAS patients with skeletal abnormalities. Several treatment options recommended to OSAS patients have been based on trial and error. A literature search in PubMed under the heading “Obstructive Sleep Apnea and Treatment” yielded more than 5,400 reports. A breakdown of these studies revealed approximately 13 nonsurgical options. Some of these options have been very imaginative, such as sleeping in a supine, knees-up position, tongue and palatal muscle training by intraoral electrical neurostimula*Chair, Department of Oral and Maxillofacial Sciences, Dalhousie University, Halifax, NS, Canada. Address correspondence and reprint requests to Dr Goodday: Department of Oral and Maxillofacial Sciences, Dalhousie University, 5981 University Avenue, Suite 5132, Halifax, NS B2Y 4L3 Canada; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6710-0017$36.00/0 doi:10.1016/j.joms.2009.03.035
tion, and oral sprays. In many cases, these options are suggested, not because they are successful, but to give patients an alternative so they do not have to undergo a surgical procedure. The surgical options totaled approximately 19 procedures and included surgery in 8 regions of the head and neck, including the pharynx, hyoid, tonsil, tongue, palate, turbinates, nasal septum, and nasal valve. However, considering the biologic foundation of many of these treatment options will reveal little basis for achieving a successful outcome. This is because in most studies the criteria for the diagnosis of an existing anatomic abnormality were not clear. To recommend the best treatment option, the clinician needs to understand the underlying pathologic features and not recommend treatment solely by familiarity with certain surgical procedures. OSAS can be caused by an underlying abnormality that narrows or obstructs the airway. It is, therefore, logical to attempt to identify an anatomic abnormality before instituting treatment, surgical or otherwise. The problem for the clinician considering surgery of the soft tissues of the oropharynx is that accepted parameters have not been established to allow the surgeon to identify abnormalities in the size or position of the tongue and soft palate. It thus becomes a very subjective decision to perform surgery on either the palate or tongue, and soft tissue surgery on these 2 areas is often based on trial and error—a “let us try it and see” option. For example, if surgery on the palate is not successful in curing the OSAS, “phase II” treatment is undertaken to advance the mandible and/or maxilla.
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correct the underlying skeletal deformity contributing to his OSA. Studies to localize the site of functional obstruction in the upper airway have shown that rarely is a single anatomic site of occlusion present but, more commonly, multiple sites of upper airway obstruction are present during episodes of hypopnea and apnea.3 Therefore, surgical treatment that addresses only 1 site will be predisposed to a low success rate when treating a multisite problem. The 2 major sites of obstruction are in the retropalatal and retroglossal regions (Fig 2, red arrows).4
Surgical Management When considering the surgical options, UPPP is considered the primary or first-stage surgical treatment for OSAS in many regions of North America. UPPP was originally described in 1981 by Fujita et al,5 who recommended it as the sole treatment for OSAS. It continues to be popular despite reviews reporting improvement in fewer than 50% of patients and complete control of OSAS in fewer than 25% of patients.6 The reason for the very low success rate of UPPP is that it addresses only 1 site of a multisite problem. The soft tissue changes are unpredictable and can be detrimental, because they can cause narrowing of the pharyngeal airway. Clinical examination of the UPPP
FIGURE 1. OSAS patient with obvious dentofacial deformity who had undergone UPPP that failed. A, Profile view. B, Lateral cephalometric radiograph. Note, obtuse nasolabial angle (140°) and retroclined maxillary incisor teeth, typical findings in patient with retrognathia. Note, relatively narrow retropalatal and retroglossal airway after UPPP surgery. Reprinted, with permission, from Goodday.2 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
If an anatomic abnormality is present, such as in Figure 1,2 it should not be ignored. This patient had obvious clinical and radiographic findings indicating he had a skeletal abnormality and his maxilla and mandible were retropositioned. The view of his convex facial profile, the retroclined maxillary incisors, and an obtuse nasal labial angle of 140° suggested that both his maxilla and mandible were in an abnormal position. Despite these obvious findings, he had undergone uvulopalatopharyngoplasty (UPPP), which was unsuccessful and resulted in a short, thick palate and a decrease in the retropalatal pharyngeal airway. Treatment required additional surgery to
FIGURE 2. Anatomic regions of pharyngeal airway. Upper airway closure in most patients with obstructive sleep apnea occurs in the retropalatal and retroglossal regions. Reprinted, with permission, from Goodday.4 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 3. A, B, Clinical view of soft palate with corresponding radiographs in 2 OSAS patients who had undergone UPPP surgery that failed resulting in shorter and thicker soft palate than normal, with retropalatal pharyngeal airway that does not appear improved. Reprinted, with permission, from Goodday.7
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patient will reveal a soft palate that appears shorter and has a firm scar band on the inferior surface. Lateral cephalometric radiographs will reveal that although the soft palate is much shorter, it is also much thicker, which can result in a narrower retropalatal pharyngeal airway. Figure 3 demonstrates the clinical and radiographic soft tissue changes in the drape of the soft palate in patients who continued to have OSAS after UPPP.7 In some patients who have undergone UPPP, their snoring might be improved because of the decreased vibration of the soft palate; however, the patient will still be obstructed secondary to the narrow retropalatal air way. However, this first surgical experience, which most patients find very painful, in addition to being unsuccessful, discourages many patients who would benefit from MMA from considering a second surgical procedure. The use of orthognathic surgery to treat OSAS began toward the end of the 1970s when mandibular surgery was reported to have reversed the symptoms of sleep apnea. Since then, this procedure has become widely accepted.8,9 Advancement of the mandible repositions several muscles forward, including the anterior belly of the digastric, mylohyoid, genioglossus, and geniohyoid muscles. All these muscles help pull the tongue upward, forward, and away from the pharynx (Fig 4).10 Advancing the maxilla pulls the soft tissue of the palate forward and upward. This also pulls the palato-
glossal muscles and increases the tongue support. Both movements increase the available tongue space and have a positive influence on the pharyngeal airway (Fig 5).11
Diagnosis and Treatment Planning The cephalometric radiograph, although rarely used by other specialties, is very valuable because it demonstrates both bony and soft tissue abnormalities related to the soft palate, pharyngeal airway, and
FIGURE 4. View of genioglossus muscles, which help pull tongue upward and forward away from pharynx with advancement procedure. Reprinted, with permission, from Goodday.10 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 5. A, Pre- and B, postoperative lateral cephalometric radiograph demonstrating significant improvement in pharyngeal airway after MMA surgery. Reprinted, with permission, from Goodday.11 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
maxillomandibular complex. If the radiographic and clinical examinations of the soft tissues of the pharynx reveal a narrow airway in conjunction with retrognathia of the maxilla and mandible, the patient should be considered a candidate for MMA surgery. Because an underlying skeletal abnormality is sometimes hard to detect clinically, it is reasonable for an oral and maxillofacial surgeon to assess these patients. The surgeon’s goal is to optimize the advancement of the deficient structures while maintaining a normal facial balance for each patient. It is therefore beneficial to use a cephalometric analysis, which will clearly demonstrate all the maxillofacial abnormalities and provide a visual treatment objective. An example of such an analysis is the architectural and structural craniofacial analysis of Delaire et al12 (Fig 6).13 With this analysis, the surgeon can predict the movements of the maxilla and mandible that can be achieved to enlarge the pharyngeal airway while staying within the range of normal facial balance for each patient. Before advancing a patient’s maxilla and mandible 14 to 15 mm, one should ensure that a cosmetic concern for the patient will not result. The clinician should ensure that the objective of treating the abnormal airway is not made at the cost of poor aesthetics. The movement of abnormal structures into a more normal position should result in a favorable change in terms of the facial appearance14 (Fig 7).15 The lines of the Delaire analysis that analyze the anteroposterior balance of the face include line C3
FIGURE 6. Delaire’s architectural and structural craniofacial cephalometric analysis, which constructs visual treatment objective and is useful in predicting movements of maxilla and mandible that can be achieved to enlarge pharyngeal airway while staying within range of normal facial balance. Reprinted, with permission, from Goodday.13 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 7. Usually, movement of maxilla and mandible to normal facial balance position will result in actual improvement in facial aesthetics. A1, Frontal view, before surgery; A2, Frontal view, after surgery; B1, profile view, before surgery; B2, profile view, after surgery; C1, oblique view, before surgery; C2, oblique view, after surgery; D1, lateral cephalometric radiograph before MMA; D2, lateral cephalometric radiograph after MMA showing improvement in pharyngeal airway. Reprinted, with permission, from Goodday.15 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
and CF1. The surgeon constructs line CF1 to line C3 at 85% to 95%, with the surgical objective of having the nasopalatine canal, distal slope of the maxillary canine, apex of the lower incisor tooth and men-
ton, all lie on this line to ensure facial balance. The red template, which indicates the predicted movement, has all the points on CF1, which has been drawn 95° to C3. The distance from the blue tem-
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plate to red indicates the required surgical advancement (Fig 8).16 Cases to illustrate the use of this analysis to plan the surgical movements in treating OSA patients are shown in Figure 9.17 In these cases, the black arrows identify the width of the pharynx before surgery and again after surgery. The white arrows on the preoperative cephalogram identify the deficiency of the maxilla and mandible in millimeters. This is the amount of anterior movement needed to normalize the skeleton. A review of the published data did not reveal the proportion of the total OSAS population who might be candidates for MMA surgery. However, of 574 patients referred to our department to assess the presence of an underlying anatomic abnormality, the De-
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laire cephalometric analysis revealed that 386 patients (67%) had an existing skeletal abnormality that would benefit from MMA.
Perioperative Treatment and Surgical Technique Maxillary and mandibular advancement can be achieved using a Le Fort I maxillary osteotomy and a bilateral sagittal split osteotomy of the mandible, respectively (Fig 10).18 Unless a Class II or III malocclusion is present that is being corrected at the surgery, synchronous advancement of the maxilla and mandible should be performed to maintain the preoperative occlusion. A concomitant advancement genioplasty should be done in cases of anterior mandibular defi-
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FIGURE 8. Line CF1. A, Normally line CF1 passes through frontal sinus, point FM, point NP (nasopalatine canal), distal slope of occlusal edge of crown of upper canine, apex of lower incisor, and point Me (Menton), osseous point of contact between posterior border of symphysis and inferior border of mandible. B, CF1 can be constructed by drawing this line at an angle ⱕ95° to C3 through point FM. Surgeon can then measure distance between NP and line CF1 knowing that if maxilla is advanced so that NP lies on line with CF1, maxilla will be within limits of normal facial balance. Surgeon should also measure distance between Me and CF1 knowing this is the amount of surgical advancement that can be performed while keeping mandible within limits of normal facial balance. Reprinted, with permission, from Goodday.16 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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ciency, as determined by the preoperative cephalometric tracing. Using the visual treatment objective, the prediction tracing is completed and the definitive movements are determined before surgery. To guarantee the movements are achieved during surgery, it is necessary to perform model surgery that accurately produces the planned surgical cuts. An intermediate splint is then fabricated to use interoperatively to position the bone segments. After the maxilla is stabilized, the mandible is advanced to the fixated maxilla (Fig 11).19
When performing genioplasty, it is best to design the osseous cuts to allow precision of movement, ease of positioning, and placement of fixation to stabilize the mobilized osseous segment. The cut through the inner or lingual cortex should be high so that a significant portion of the genioglossus and geniohyoid muscles remain fixed to the advanced segment (Fig 12).20 Occasionally, a cephalometric radiograph will reveal constriction of the retropalatal airway; however, the maxilla cannot be significantly advanced and remain within the range of normal facial balance. When
FIGURE 9. Patients with OSAS treated with MMA using Delaire cephalometric analysis to determine magnitude of movement of maxilla and mandible. A, Female patient balanced at 90° CF1/C3. B, Male patient balanced at 95° CF1/C3. C, Female patient balanced at 86° CF1/C3. A1-C1, Profile view before surgery. A2-C2, Profile view after surgery. A3-C3, Before surgery, cephalometric radiographs. A4-C4, After surgery cephalometric radiographs. Reprinted, with permission, from Goodday.17 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 10. A, Le Fort 1 maxillary osteotomy. B, Bilateral sagittal split osteotomy. Reprinted, with permission, from Goodday.18 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
the examination of the soft tissue reveals an acute nasolabial angle such that one is limited in the amount the maxilla can be advanced, one option is to perform a segmental Le Fort I with removal of the transverse segment of bone that contains the first bicuspid teeth. This will allow an approximately 7-mm advancement of the posterior maxilla and its attached soft tissue, in addition to the advancement allowed in the anterior segment, which will keep the outcome within the normal facial balance (Fig 13).21 When advancing the maxilla 10 mm or more, it is common for the only bony contact to be in the regions of the zygomatic buttress and the piriform aperture. If the bony contact is insufficient, the surgeon can consider the use of bone harvested from the mandible or chin and placed in the region of the large step created in the lateral wall of the maxilla to reduce the potential for fibrous union (Fig 14).22
Patient Outcomes Cases to illustrate the use of MMA to treat OSA patients are shown in Figure 15.23 The Delaire cephalometric analysis was used in each case to determine
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the advancements required for the maxilla and mandible. Achievement of the planned surgical movements was confirmed by placing the preoperative cephalometric tracing over the postsurgical radiograph and noting the position of the anatomic landmarks to the CF1. Ideally, the points (ie, FM, NP, apex, ME) will align with this line of anterior facial balance. Using the Delaire analysis to plan the surgical movements and perform precise surgery with fixation techniques, as previously described, appears to produce positive outcomes. In a prospective study comparing the effectiveness of continuous positive airway pressure (CPAP) with MMA with respect to mood changes and cognitive dysfunction, 8 OSA patients who qualified for surgical treatment with MMA were treated with CPAP during the waiting period for surgery. All these patients underwent an evaluation of sleep, mood, cognitive complaints, and subjective symptoms. The tests, including polysomnography, were performed at enrollment, after 3 months of CPAP treatment and again 6 months after MMA surgery. The mean apnea hypopnea index (AHI) decreased significantly with CPAP and remained low after MMA surgery. The subjective ratings of sleepiness did not significantly improve until after surgery. The self-reported measures of depressive symptoms showed improvement, with significant symptom decrease after surgery compared with after CPAP. These results confirm those of previous reports of the effectiveness of CPAP in the treatment of OSAS; however, the outcomes after MMA were as positive or better, particularly regarding the self-reported mood and sleepiness symptoms.24 The measurement of success after surgical treatment should include the patient’s assessment of the surgical result. To obtain this information from patients, a self-administered questionnaire was completed by 24 subjects who had undergone MMA for OSAS. The questionnaire included the Epworth sleepiness scale (a standard measure for the assessment of daytime sleepiness) and questions regarding the preoperative and postoperative symptoms of OSAS. In addition, patients were asked to comment about whether their maxillofacial surgery was worthwhile. The questionnaire was completed a mean of 24 months after surgery and revealed a significant reduction between the preoperative (15.7 ⫾ 5.79) and postoperative (7.18 ⫾ 5.78) Epworth sleepiness scores (P ⬍ .001). This represented an improvement in daytime sleepiness from levels seen in severe OSAS to levels similar to those in normal controls. Statistically significant reductions (P ⬍ .05) were observed in the number of patients reporting problems with memory, concentration, and stress. Of the patients who had snored preoperatively, 90% had either
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FIGURE 11. Use of model surgery and intermediate splint to guarantee 14-mm advancement of maxilla. A, Model surgery of maxillary advancement. B, Intermediate splint used to position maxilla at surgery. C, Profile view of patient before MMA. D, Profile view after 14 mm advancement of maxilla and concomitant advancement of mandible. Reprinted, with permission, from Goodday.19 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
stopped snoring (45%) or reported a reduction in snoring severity (45%). The surgery was considered worthwhile by 83.3% of the patients.25 These results were confirmed in a second study in which a group of 20 patients who had undergone MMA therapy were interviewed a mean of 31.8 months postoperatively. Subjectively, the elimination
of excess daytime sleepiness, snoring, and witnessed apnea events was statistically significant (P ⬍ .05). Of the 20 patients, 90% reported they would undergo MMA again, and all 20 patients (100%) would recommend the treatment to others with OSAS. This is testimony to the success of MMA as a surgical option to treat OSAS, and such a high level of patient satis-
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FIGURE 12. Genioplasty. A, Genioplasty using tenon to control advancement and aid in placement of rigid fixation. B, Radiograph demonstrating lingual cut of genioplasty to allow advancement of portion of genial muscles. Reprinted, with permission, from Goodday.20 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
faction is encouraging to those patients considering this treatment option.26 In the same group of patients, objective measurements to determine the treatment outcomes were evaluated. The preoperative AHI was compared with the AHI 10 months (mean) after surgery. The mean AHI decreased from 46.5 to 9.3 (P ⬍ .001), and 70% of the patients actually achieved an AHI of less than 10 postoperatively.26 One positive outcome after MMA surgery is the elimination of the need for CPAP after surgery. A
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review of 59 patients who had used CPAP before MMA surgery was conducted. All expressed dissatisfaction with CPAP, and the reason for seeking alternative treatment in almost all cases was to eliminate the need for CPAP. The most common question the surgeon is asked when discussing the risks and benefits of MMA is “if I have this done will I still need to use CPAP?” In the review of 59 patients, 55 (93%) did not require CPAP after surgery and only 4 did.27 This finding identifies the major benefit the patient can consider when deciding on treatment options. Anesthetists in many surgical centers are concerned about potential airway obstruction after MMA surgery in patients with sleep apnea. Both the anesthetist and surgeon should know whether immediate postoperative changes in the pharyngeal airway after this procedure will subject OSA patients to increased risks of airway obstruction during the perioperative period. To address this concern, the radiographic changes in the pharynx of OSA patients during the period of maximal edema after orthognathic surgery were assessed. Standardized cephalometry was taken preoperatively and 24 to 48 hours postoperatively in 25 consecutive MMA patients. The preoperative and postoperative pharyngeal airways were traced, and the minimal distance between the posterior pharyngeal wall and soft palate and between the posterior pharyngeal wall and the base of the tongue was reviewed and recorded. An increase in the mean distance from the posterior pharyngeal wall of the soft palate of more than 5 mm and an increase in the mean distance from the posterior pharyngeal wall to the base of the tongue of almost 6 mm was found. Postoperative edema did not affect the anteroposterior dimension on the cephalometric radiograph. These findings support the presence of favorable changes in the pharyngeal airway during the immediate postoperative period after orthognathic surgery.28 These findings have been supported by another study, which assessed the immediate postoperative airway using pulse oximetry data. In 19 MMA patients, preoperative pulse oximetry data were compared with data gathered within the 48 hours immediately after surgery. Desaturation was defined as at least a 5% change for 10 seconds. These OSAS patients had an average of 15.2 desaturations per hour before surgery, which had decreased to an average of 1.3/hour immediately after surgery.29 A review of the lateral cephalometric radiographs of OSAS patients who had previously undergone UPPP will typically reveal a short, thick soft palate. In patients in whom UPPP failed to eliminate the symptoms of OSAS, this anatomic alteration could potentially lead to velopharyngeal insufficiency in OSAS patients after MMA. To evaluate the effect of MMA on treatment outcomes and symptoms of velopharyngeal
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FIGURE 13. Patient with severe OSAS. Cephalometric radiograph reveals constriction of both retropalatal and retroglossal airways. Clinical examination reveals acute nasolabial angle and cephalometric analysis confirms maxilla can only be advanced 3 mm. Menton, however, can be moved anteriorly 13 mm. Model surgery confirms removal of transverse segment of bone containing first bicuspid teeth will allow 7-mm advancement of posterior maxilla, in addition to 3-mm advancement of anterior segment for overall advancement of 10 mm of posterior border of hard palate. A, Pretreatment profile view. B, Pretreatment cephalometric analysis. C, Model surgery with first bicuspids removed and posterior segment advanced. D, Articulated models used for intermediate splint showing much greater advancement of posterior segment compared with anterior movement. E, Intraoperative view of vertical osteotomy cuts to allow removal of bony segment from first bicuspid region. F, Intraoperative view of transverse cuts to allow removal of bone from floor of nose. G, Preoperative cephalometric radiograph confirming surgical movement necessary to achieve facial balance and revealing constricted oropharyngeal airway. H, Postoperative cephalometric radiograph demonstrating surgical objectives were achieved, with patient having normal facial balance and pharyngeal airway improved significantly. I, Preoperative profile view. J, Postoperative profile view. Reprinted, with permission, from Goodday.21 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
insufficiency in OSAS patients with previous UPPP, a review of 14 patients who had previously undergone UPPP that failed was undertaken. In this group, statistically significant reductions in excess daytime
sleepiness, snoring, and witnessed apnea events were recorded after MMA surgery. Two patients experienced occasional nasal regurgitation after MMA, which had resolved within 1 year. One patient re-
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FIGURE 14. A, Bony cuts to allow harvesting of bone from anterior mandible. B, Anterior mandible donor site. C, Bone stock from chin. D, Cephalometric radiograph of OSAS patient after MMA using bone harvested from chin. Reprinted, with permission, from Goodday.22 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
ported slightly hypernasal speech after MMA. In this group of UPPP patients, velopharyngeal incompetence was not a problem. Although UPPP is often promoted as a simple procedure with minimal pain and morbidity, 66% of these patients thought that UPPP was more painful and recovery more difficult than that with the MMA procedure. Most interesting was the finding that 100% of the subjects reported they would undergo MMA again. Only 1 of the 14 patients would undergo UPPP again and that was because the UPPP decreased the frequency of his sore throats. It had no effect on his OSAS.30 This finding, plus the low success rate of UPPP, calls into question the use of UPPP as first-stage surgical treatment. When patients are advised that advancement of the maxilla and mandible will improve the airway, most patients inquire about the effects of surgery on their facial appearance. To help answer this question, a survey of 20 patients after surgery was conducted. The responses revealed that 85% observed a change. Of these 20 patients, 50% thought the change was favorable, 30% were indifferent to the change, and 15% did not observe a change at all.30
Another subjective outcome study of 70 MMA patients revealed that 47 of the patients (67%) reported a favorable change in their facial features after MMA, 14 (20%) were indifferent to the change in their facial appearance, 6 (9%) did not notice a change, and 3 (4%) found the changes unfavorable.31 Controversy exists regarding the need to perform a concomitant bone graft to ensure stability and favorable bone healing at the maxillary osteotomy site in MMA patients. Bone grafting increases the operative time, expense, and morbidity. Complete data were gathered from 131 patients who underwent maxillomandibular surgery without a concomitant iliac crest bone graft. The average maxillary advancement was 8.7 mm. Four patients developed fibrous malunion of the maxilla. All were successfully treated with an iliac crest bone graft as a second procedure.31 Thus, all patients should be informed that approximately 3% of patients might require a second procedure involving a hip graft to stabilize the maxilla. Oral and maxillofacial surgeons have considerable experience and expertise in performing maxillary and mandibular osteotomies to correct dentofacial defor-
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FIGURE 15. OSAS patients treated with MMA using Delaire cephalometric analysis to determine magnitude of movement of maxilla and mandible. A, Female patient balanced at 90° CF1/C3. B, Male patient balanced at 95° CF1/C3. C, Male patient balanced at 90° CF1/C3. A1-C1, Profile view before surgery. A2-C2, Profile view after surgery. A3-C3, Preoperative cephalometric radiograph. A4-C4, Postoperative cephalometric radiograph. Note, significant improvement in retropalatal and retropharyngeal airway and normal facial balance demonstrated by alignment of points (FM, NP, apex, Me) on line of anterior facial balance CF1 after surgery. Reprinted, with permission, from Goodday.23 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
mities. Application of the same surgical principles and technique to MMA procedures will allow predictable and successful outcomes for OSAS. Sleep apnea patients who have demonstrable retropositioning of the maxilla and mandible should be informed of MMA as the primary surgical treatment of OSAS.
References 1. Assael LA: The biggest movement; orthognathic Surgery undergoes another paradigm shift. J Oral Maxillofac Surg 66:419, 2008 2. Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell
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WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 440 Rama AN, Tekwani SH, Kushida CA: Sites of obstruction in obstructive sleep apnea. Chest 122:1139, 2002 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 438 Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: Uvulopalatopharyngoplasty. Otalaryngol Head Neck Surg 89: 923, 1981 Sher AE, Schechtman KB, Piccirillo JF: An American Sleep Disorders Association review: The efficacy of surgical modifi-
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cations of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 19:156, 1996 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 440 Hochban W, Brandnburg U, Peter JH: Surgical maxillofacial treatment of obstructive sleep apnea. Plast Reconstr Surg 99: 619, 1997 Prinsell JR: Maxillomandibular advancement surgery in a sitespecific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 116:1519, 1999 Goodday R: Orthognathic surgery for obstructive sleep apnea, in Turvey TA, Scully R, Waite PD, et al (eds): Oral and Maxillofacial Surgery (ed 2). New York, Saunders Elsevier, 2008, p 321 Goodday R: Orthognathic surgery for obstructive sleep apnea, in Turvey TA, Scully R, Waite PD, et al (eds): Oral and Maxillofacial Surgery (ed 2). New York, Saunders Elsevier, 2008, p 322 Delaire J, Schendel SA, Tulasne JF: An architectural and structural craniofacial analysis: A new lateral cephalometric analysis. Oral Surg Oral Med Oral Pathol 52:226, 1981 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 442 Goodday R, Gregoire C: Facial appearance following surgical treatment for obstructive sleep apnea syndrome. Gen Dent 56:51, 2008 Goodday R: Orthognathic surgery for obstructive sleep apnea, in Turvey TA, Scully R, Waite PD, et al (eds): Oral and Maxillofacial Surgery (ed 2). New York, Saunders Elsevier, 2008, p 323 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 444 Goodday R: Orthognathic surgery for obstructive sleep apnea, in Turvey TA, Scully R, Waite PD, et al (eds): Oral and Maxillofacial Surgery (ed 2). New York, Saunders Elsevier, 2008, p 335 Goodday R: Orthognathic surgery for obstructive sleep apnea, in Turvey TA, Scully R, Waite PD, et al (eds): Oral and Maxillofacial Surgery (ed 2). New York, Saunders Elsevier, 2008, p 327 Goodday R: Orthognathic surgery for obstructive sleep apnea, in Turvey TA, Scully R, Waite PD, et al (eds): Oral and Maxil-
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lofacial Surgery (ed 2). New York, Saunders Elsevier, 2008, p 328 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 446 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 447 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 448 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 449 Rajda M, Eskes G, Morrison D, et al: Effects of obstructive sleep apnea and subsequent treatment on mood and cognition. World Association of Sleep Medicine, First Congress, Berlin, Germany, October 13-15, 2005 Robertson C: Subjective evaluation of orthognathic surgical outcomes in OSAS patients. J Oral Maxillofac Surg 58 (suppl 1):57, 2000 Robertson CG, Goodday RH, Rajda M, et al: Subjective and objective treatment outcomes of maxillomandibular advancement for the treatment of obstructive sleep apnea syndrome. J Oral Maxillofac Surg 61:76, 2003 (suppl 1) Gregoire C, Goodday R, Robertson C: The effect of maxillomandibular advancement surgery on controlled positive airway pressure (CPAP) use in patients with obstructive sleep apnea syndrome. J Oral Maxillofac Surg 63:48, 2005 (suppl 1) Robertson C, Goodday RH, Precious DS, et al: Post-surgical pharyngeal airway changes following orthognathic surgery in OSAS patients. J Oral Maxillofac Surg 57:80, 1999 (suppl 1) Powell J, Yim D, Morrison A, et al: Oxygen saturations in patients undergoing maxillomandibular advancement surgery for obstructive sleep apnea: A preoperative to postoperative comparison. J Oral Maxillofac Surg 62:57, 2004 (suppl 1) Robertson CG: Subjective and objective treatment outcomes of maxillomandibular advancement for the treatment of obstructive sleep apnea syndrome: Master’s thesis. Halifax, Nova Scotia, Dalhousie University, 2003 Gregoire C: Patient outcomes following maxillomandibular advancement surgery to treat obstructive sleep apnea syndrome: Master’s thesis. Halifax, Nova Scotia, Dalhousie University, 2008
Diagnosis, Treatment Planning, and Surgical Correction of Obstructive Sleep Apnea Reginald Goodday, DDS, MSC, FRCD(C)* The aim of this report is to present the scientific rationale for considering maxillomandibular advancement as the surgical treatment of choice in selected patients with obstructive sleep apnea syndrome; review the treatment planning that will identify those patients who would benefit from this procedure; review the surgical techniques; and review the patient outcomes after maxillomandibular advancement surgery. Patients with obstructive sleep apnea syndrome who have demonstrable retropositioning of the maxilla and mandible should be informed of maxillomandibular advancement as the primary surgical treatment for obstructive sleep apnea syndrome. © 2009 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 67:2183-2196, 2009 A recent editorial by Leon Assael1 explained the term “paradigm shift” as describing an irrefutable scientific discovery that is the complete undoing of previously accepted knowledge. Once the shift is completed, all previous understanding of the clinical, scientific topic is abandoned and is supplanted by new knowledge/ new understanding.1 In the opinion of William H. Bell, one of the trends that will drive the next paradigm shift in orthognathic surgery is the use of maxillomandibular advancement (MMA) as the preferred treatment of obstructive sleep apnea syndrome (OSAS).1 This trend should result in successful outcomes after a single surgical procedure for OSAS patients with skeletal abnormalities. Several treatment options recommended to OSAS patients have been based on trial and error. A literature search in PubMed under the heading “Obstructive Sleep Apnea and Treatment” yielded more than 5,400 reports. A breakdown of these studies revealed approximately 13 nonsurgical options. Some of these options have been very imaginative, such as sleeping in a supine, knees-up position, tongue and palatal muscle training by intraoral electrical neurostimula*Chair, Department of Oral and Maxillofacial Sciences, Dalhousie University, Halifax, NS, Canada. Address correspondence and reprint requests to Dr Goodday: Department of Oral and Maxillofacial Sciences, Dalhousie University, 5981 University Avenue, Suite 5132, Halifax, NS B2Y 4L3 Canada; e-mail: [email protected] © 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6710-0017$36.00/0 doi:10.1016/j.joms.2009.03.035
tion, and oral sprays. In many cases, these options are suggested, not because they are successful, but to give patients an alternative so they do not have to undergo a surgical procedure. The surgical options totaled approximately 19 procedures and included surgery in 8 regions of the head and neck, including the pharynx, hyoid, tonsil, tongue, palate, turbinates, nasal septum, and nasal valve. However, considering the biologic foundation of many of these treatment options will reveal little basis for achieving a successful outcome. This is because in most studies the criteria for the diagnosis of an existing anatomic abnormality were not clear. To recommend the best treatment option, the clinician needs to understand the underlying pathologic features and not recommend treatment solely by familiarity with certain surgical procedures. OSAS can be caused by an underlying abnormality that narrows or obstructs the airway. It is, therefore, logical to attempt to identify an anatomic abnormality before instituting treatment, surgical or otherwise. The problem for the clinician considering surgery of the soft tissues of the oropharynx is that accepted parameters have not been established to allow the surgeon to identify abnormalities in the size or position of the tongue and soft palate. It thus becomes a very subjective decision to perform surgery on either the palate or tongue, and soft tissue surgery on these 2 areas is often based on trial and error—a “let us try it and see” option. For example, if surgery on the palate is not successful in curing the OSAS, “phase II” treatment is undertaken to advance the mandible and/or maxilla.
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correct the underlying skeletal deformity contributing to his OSA. Studies to localize the site of functional obstruction in the upper airway have shown that rarely is a single anatomic site of occlusion present but, more commonly, multiple sites of upper airway obstruction are present during episodes of hypopnea and apnea.3 Therefore, surgical treatment that addresses only 1 site will be predisposed to a low success rate when treating a multisite problem. The 2 major sites of obstruction are in the retropalatal and retroglossal regions (Fig 2, red arrows).4
Surgical Management When considering the surgical options, UPPP is considered the primary or first-stage surgical treatment for OSAS in many regions of North America. UPPP was originally described in 1981 by Fujita et al,5 who recommended it as the sole treatment for OSAS. It continues to be popular despite reviews reporting improvement in fewer than 50% of patients and complete control of OSAS in fewer than 25% of patients.6 The reason for the very low success rate of UPPP is that it addresses only 1 site of a multisite problem. The soft tissue changes are unpredictable and can be detrimental, because they can cause narrowing of the pharyngeal airway. Clinical examination of the UPPP
FIGURE 1. OSAS patient with obvious dentofacial deformity who had undergone UPPP that failed. A, Profile view. B, Lateral cephalometric radiograph. Note, obtuse nasolabial angle (140°) and retroclined maxillary incisor teeth, typical findings in patient with retrognathia. Note, relatively narrow retropalatal and retroglossal airway after UPPP surgery. Reprinted, with permission, from Goodday.2 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
If an anatomic abnormality is present, such as in Figure 1,2 it should not be ignored. This patient had obvious clinical and radiographic findings indicating he had a skeletal abnormality and his maxilla and mandible were retropositioned. The view of his convex facial profile, the retroclined maxillary incisors, and an obtuse nasal labial angle of 140° suggested that both his maxilla and mandible were in an abnormal position. Despite these obvious findings, he had undergone uvulopalatopharyngoplasty (UPPP), which was unsuccessful and resulted in a short, thick palate and a decrease in the retropalatal pharyngeal airway. Treatment required additional surgery to
FIGURE 2. Anatomic regions of pharyngeal airway. Upper airway closure in most patients with obstructive sleep apnea occurs in the retropalatal and retroglossal regions. Reprinted, with permission, from Goodday.4 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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A
FIGURE 3. A, B, Clinical view of soft palate with corresponding radiographs in 2 OSAS patients who had undergone UPPP surgery that failed resulting in shorter and thicker soft palate than normal, with retropalatal pharyngeal airway that does not appear improved. Reprinted, with permission, from Goodday.7
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patient will reveal a soft palate that appears shorter and has a firm scar band on the inferior surface. Lateral cephalometric radiographs will reveal that although the soft palate is much shorter, it is also much thicker, which can result in a narrower retropalatal pharyngeal airway. Figure 3 demonstrates the clinical and radiographic soft tissue changes in the drape of the soft palate in patients who continued to have OSAS after UPPP.7 In some patients who have undergone UPPP, their snoring might be improved because of the decreased vibration of the soft palate; however, the patient will still be obstructed secondary to the narrow retropalatal air way. However, this first surgical experience, which most patients find very painful, in addition to being unsuccessful, discourages many patients who would benefit from MMA from considering a second surgical procedure. The use of orthognathic surgery to treat OSAS began toward the end of the 1970s when mandibular surgery was reported to have reversed the symptoms of sleep apnea. Since then, this procedure has become widely accepted.8,9 Advancement of the mandible repositions several muscles forward, including the anterior belly of the digastric, mylohyoid, genioglossus, and geniohyoid muscles. All these muscles help pull the tongue upward, forward, and away from the pharynx (Fig 4).10 Advancing the maxilla pulls the soft tissue of the palate forward and upward. This also pulls the palato-
glossal muscles and increases the tongue support. Both movements increase the available tongue space and have a positive influence on the pharyngeal airway (Fig 5).11
Diagnosis and Treatment Planning The cephalometric radiograph, although rarely used by other specialties, is very valuable because it demonstrates both bony and soft tissue abnormalities related to the soft palate, pharyngeal airway, and
FIGURE 4. View of genioglossus muscles, which help pull tongue upward and forward away from pharynx with advancement procedure. Reprinted, with permission, from Goodday.10 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 5. A, Pre- and B, postoperative lateral cephalometric radiograph demonstrating significant improvement in pharyngeal airway after MMA surgery. Reprinted, with permission, from Goodday.11 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
maxillomandibular complex. If the radiographic and clinical examinations of the soft tissues of the pharynx reveal a narrow airway in conjunction with retrognathia of the maxilla and mandible, the patient should be considered a candidate for MMA surgery. Because an underlying skeletal abnormality is sometimes hard to detect clinically, it is reasonable for an oral and maxillofacial surgeon to assess these patients. The surgeon’s goal is to optimize the advancement of the deficient structures while maintaining a normal facial balance for each patient. It is therefore beneficial to use a cephalometric analysis, which will clearly demonstrate all the maxillofacial abnormalities and provide a visual treatment objective. An example of such an analysis is the architectural and structural craniofacial analysis of Delaire et al12 (Fig 6).13 With this analysis, the surgeon can predict the movements of the maxilla and mandible that can be achieved to enlarge the pharyngeal airway while staying within the range of normal facial balance for each patient. Before advancing a patient’s maxilla and mandible 14 to 15 mm, one should ensure that a cosmetic concern for the patient will not result. The clinician should ensure that the objective of treating the abnormal airway is not made at the cost of poor aesthetics. The movement of abnormal structures into a more normal position should result in a favorable change in terms of the facial appearance14 (Fig 7).15 The lines of the Delaire analysis that analyze the anteroposterior balance of the face include line C3
FIGURE 6. Delaire’s architectural and structural craniofacial cephalometric analysis, which constructs visual treatment objective and is useful in predicting movements of maxilla and mandible that can be achieved to enlarge pharyngeal airway while staying within range of normal facial balance. Reprinted, with permission, from Goodday.13 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 7. Usually, movement of maxilla and mandible to normal facial balance position will result in actual improvement in facial aesthetics. A1, Frontal view, before surgery; A2, Frontal view, after surgery; B1, profile view, before surgery; B2, profile view, after surgery; C1, oblique view, before surgery; C2, oblique view, after surgery; D1, lateral cephalometric radiograph before MMA; D2, lateral cephalometric radiograph after MMA showing improvement in pharyngeal airway. Reprinted, with permission, from Goodday.15 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
and CF1. The surgeon constructs line CF1 to line C3 at 85% to 95%, with the surgical objective of having the nasopalatine canal, distal slope of the maxillary canine, apex of the lower incisor tooth and men-
ton, all lie on this line to ensure facial balance. The red template, which indicates the predicted movement, has all the points on CF1, which has been drawn 95° to C3. The distance from the blue tem-
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plate to red indicates the required surgical advancement (Fig 8).16 Cases to illustrate the use of this analysis to plan the surgical movements in treating OSA patients are shown in Figure 9.17 In these cases, the black arrows identify the width of the pharynx before surgery and again after surgery. The white arrows on the preoperative cephalogram identify the deficiency of the maxilla and mandible in millimeters. This is the amount of anterior movement needed to normalize the skeleton. A review of the published data did not reveal the proportion of the total OSAS population who might be candidates for MMA surgery. However, of 574 patients referred to our department to assess the presence of an underlying anatomic abnormality, the De-
A
laire cephalometric analysis revealed that 386 patients (67%) had an existing skeletal abnormality that would benefit from MMA.
Perioperative Treatment and Surgical Technique Maxillary and mandibular advancement can be achieved using a Le Fort I maxillary osteotomy and a bilateral sagittal split osteotomy of the mandible, respectively (Fig 10).18 Unless a Class II or III malocclusion is present that is being corrected at the surgery, synchronous advancement of the maxilla and mandible should be performed to maintain the preoperative occlusion. A concomitant advancement genioplasty should be done in cases of anterior mandibular defi-
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FIGURE 8. Line CF1. A, Normally line CF1 passes through frontal sinus, point FM, point NP (nasopalatine canal), distal slope of occlusal edge of crown of upper canine, apex of lower incisor, and point Me (Menton), osseous point of contact between posterior border of symphysis and inferior border of mandible. B, CF1 can be constructed by drawing this line at an angle ⱕ95° to C3 through point FM. Surgeon can then measure distance between NP and line CF1 knowing that if maxilla is advanced so that NP lies on line with CF1, maxilla will be within limits of normal facial balance. Surgeon should also measure distance between Me and CF1 knowing this is the amount of surgical advancement that can be performed while keeping mandible within limits of normal facial balance. Reprinted, with permission, from Goodday.16 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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ciency, as determined by the preoperative cephalometric tracing. Using the visual treatment objective, the prediction tracing is completed and the definitive movements are determined before surgery. To guarantee the movements are achieved during surgery, it is necessary to perform model surgery that accurately produces the planned surgical cuts. An intermediate splint is then fabricated to use interoperatively to position the bone segments. After the maxilla is stabilized, the mandible is advanced to the fixated maxilla (Fig 11).19
When performing genioplasty, it is best to design the osseous cuts to allow precision of movement, ease of positioning, and placement of fixation to stabilize the mobilized osseous segment. The cut through the inner or lingual cortex should be high so that a significant portion of the genioglossus and geniohyoid muscles remain fixed to the advanced segment (Fig 12).20 Occasionally, a cephalometric radiograph will reveal constriction of the retropalatal airway; however, the maxilla cannot be significantly advanced and remain within the range of normal facial balance. When
FIGURE 9. Patients with OSAS treated with MMA using Delaire cephalometric analysis to determine magnitude of movement of maxilla and mandible. A, Female patient balanced at 90° CF1/C3. B, Male patient balanced at 95° CF1/C3. C, Female patient balanced at 86° CF1/C3. A1-C1, Profile view before surgery. A2-C2, Profile view after surgery. A3-C3, Before surgery, cephalometric radiographs. A4-C4, After surgery cephalometric radiographs. Reprinted, with permission, from Goodday.17 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
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FIGURE 10. A, Le Fort 1 maxillary osteotomy. B, Bilateral sagittal split osteotomy. Reprinted, with permission, from Goodday.18 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
the examination of the soft tissue reveals an acute nasolabial angle such that one is limited in the amount the maxilla can be advanced, one option is to perform a segmental Le Fort I with removal of the transverse segment of bone that contains the first bicuspid teeth. This will allow an approximately 7-mm advancement of the posterior maxilla and its attached soft tissue, in addition to the advancement allowed in the anterior segment, which will keep the outcome within the normal facial balance (Fig 13).21 When advancing the maxilla 10 mm or more, it is common for the only bony contact to be in the regions of the zygomatic buttress and the piriform aperture. If the bony contact is insufficient, the surgeon can consider the use of bone harvested from the mandible or chin and placed in the region of the large step created in the lateral wall of the maxilla to reduce the potential for fibrous union (Fig 14).22
Patient Outcomes Cases to illustrate the use of MMA to treat OSA patients are shown in Figure 15.23 The Delaire cephalometric analysis was used in each case to determine
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the advancements required for the maxilla and mandible. Achievement of the planned surgical movements was confirmed by placing the preoperative cephalometric tracing over the postsurgical radiograph and noting the position of the anatomic landmarks to the CF1. Ideally, the points (ie, FM, NP, apex, ME) will align with this line of anterior facial balance. Using the Delaire analysis to plan the surgical movements and perform precise surgery with fixation techniques, as previously described, appears to produce positive outcomes. In a prospective study comparing the effectiveness of continuous positive airway pressure (CPAP) with MMA with respect to mood changes and cognitive dysfunction, 8 OSA patients who qualified for surgical treatment with MMA were treated with CPAP during the waiting period for surgery. All these patients underwent an evaluation of sleep, mood, cognitive complaints, and subjective symptoms. The tests, including polysomnography, were performed at enrollment, after 3 months of CPAP treatment and again 6 months after MMA surgery. The mean apnea hypopnea index (AHI) decreased significantly with CPAP and remained low after MMA surgery. The subjective ratings of sleepiness did not significantly improve until after surgery. The self-reported measures of depressive symptoms showed improvement, with significant symptom decrease after surgery compared with after CPAP. These results confirm those of previous reports of the effectiveness of CPAP in the treatment of OSAS; however, the outcomes after MMA were as positive or better, particularly regarding the self-reported mood and sleepiness symptoms.24 The measurement of success after surgical treatment should include the patient’s assessment of the surgical result. To obtain this information from patients, a self-administered questionnaire was completed by 24 subjects who had undergone MMA for OSAS. The questionnaire included the Epworth sleepiness scale (a standard measure for the assessment of daytime sleepiness) and questions regarding the preoperative and postoperative symptoms of OSAS. In addition, patients were asked to comment about whether their maxillofacial surgery was worthwhile. The questionnaire was completed a mean of 24 months after surgery and revealed a significant reduction between the preoperative (15.7 ⫾ 5.79) and postoperative (7.18 ⫾ 5.78) Epworth sleepiness scores (P ⬍ .001). This represented an improvement in daytime sleepiness from levels seen in severe OSAS to levels similar to those in normal controls. Statistically significant reductions (P ⬍ .05) were observed in the number of patients reporting problems with memory, concentration, and stress. Of the patients who had snored preoperatively, 90% had either
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FIGURE 11. Use of model surgery and intermediate splint to guarantee 14-mm advancement of maxilla. A, Model surgery of maxillary advancement. B, Intermediate splint used to position maxilla at surgery. C, Profile view of patient before MMA. D, Profile view after 14 mm advancement of maxilla and concomitant advancement of mandible. Reprinted, with permission, from Goodday.19 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
stopped snoring (45%) or reported a reduction in snoring severity (45%). The surgery was considered worthwhile by 83.3% of the patients.25 These results were confirmed in a second study in which a group of 20 patients who had undergone MMA therapy were interviewed a mean of 31.8 months postoperatively. Subjectively, the elimination
of excess daytime sleepiness, snoring, and witnessed apnea events was statistically significant (P ⬍ .05). Of the 20 patients, 90% reported they would undergo MMA again, and all 20 patients (100%) would recommend the treatment to others with OSAS. This is testimony to the success of MMA as a surgical option to treat OSAS, and such a high level of patient satis-
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FIGURE 12. Genioplasty. A, Genioplasty using tenon to control advancement and aid in placement of rigid fixation. B, Radiograph demonstrating lingual cut of genioplasty to allow advancement of portion of genial muscles. Reprinted, with permission, from Goodday.20 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
faction is encouraging to those patients considering this treatment option.26 In the same group of patients, objective measurements to determine the treatment outcomes were evaluated. The preoperative AHI was compared with the AHI 10 months (mean) after surgery. The mean AHI decreased from 46.5 to 9.3 (P ⬍ .001), and 70% of the patients actually achieved an AHI of less than 10 postoperatively.26 One positive outcome after MMA surgery is the elimination of the need for CPAP after surgery. A
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review of 59 patients who had used CPAP before MMA surgery was conducted. All expressed dissatisfaction with CPAP, and the reason for seeking alternative treatment in almost all cases was to eliminate the need for CPAP. The most common question the surgeon is asked when discussing the risks and benefits of MMA is “if I have this done will I still need to use CPAP?” In the review of 59 patients, 55 (93%) did not require CPAP after surgery and only 4 did.27 This finding identifies the major benefit the patient can consider when deciding on treatment options. Anesthetists in many surgical centers are concerned about potential airway obstruction after MMA surgery in patients with sleep apnea. Both the anesthetist and surgeon should know whether immediate postoperative changes in the pharyngeal airway after this procedure will subject OSA patients to increased risks of airway obstruction during the perioperative period. To address this concern, the radiographic changes in the pharynx of OSA patients during the period of maximal edema after orthognathic surgery were assessed. Standardized cephalometry was taken preoperatively and 24 to 48 hours postoperatively in 25 consecutive MMA patients. The preoperative and postoperative pharyngeal airways were traced, and the minimal distance between the posterior pharyngeal wall and soft palate and between the posterior pharyngeal wall and the base of the tongue was reviewed and recorded. An increase in the mean distance from the posterior pharyngeal wall of the soft palate of more than 5 mm and an increase in the mean distance from the posterior pharyngeal wall to the base of the tongue of almost 6 mm was found. Postoperative edema did not affect the anteroposterior dimension on the cephalometric radiograph. These findings support the presence of favorable changes in the pharyngeal airway during the immediate postoperative period after orthognathic surgery.28 These findings have been supported by another study, which assessed the immediate postoperative airway using pulse oximetry data. In 19 MMA patients, preoperative pulse oximetry data were compared with data gathered within the 48 hours immediately after surgery. Desaturation was defined as at least a 5% change for 10 seconds. These OSAS patients had an average of 15.2 desaturations per hour before surgery, which had decreased to an average of 1.3/hour immediately after surgery.29 A review of the lateral cephalometric radiographs of OSAS patients who had previously undergone UPPP will typically reveal a short, thick soft palate. In patients in whom UPPP failed to eliminate the symptoms of OSAS, this anatomic alteration could potentially lead to velopharyngeal insufficiency in OSAS patients after MMA. To evaluate the effect of MMA on treatment outcomes and symptoms of velopharyngeal
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FIGURE 13. Patient with severe OSAS. Cephalometric radiograph reveals constriction of both retropalatal and retroglossal airways. Clinical examination reveals acute nasolabial angle and cephalometric analysis confirms maxilla can only be advanced 3 mm. Menton, however, can be moved anteriorly 13 mm. Model surgery confirms removal of transverse segment of bone containing first bicuspid teeth will allow 7-mm advancement of posterior maxilla, in addition to 3-mm advancement of anterior segment for overall advancement of 10 mm of posterior border of hard palate. A, Pretreatment profile view. B, Pretreatment cephalometric analysis. C, Model surgery with first bicuspids removed and posterior segment advanced. D, Articulated models used for intermediate splint showing much greater advancement of posterior segment compared with anterior movement. E, Intraoperative view of vertical osteotomy cuts to allow removal of bony segment from first bicuspid region. F, Intraoperative view of transverse cuts to allow removal of bone from floor of nose. G, Preoperative cephalometric radiograph confirming surgical movement necessary to achieve facial balance and revealing constricted oropharyngeal airway. H, Postoperative cephalometric radiograph demonstrating surgical objectives were achieved, with patient having normal facial balance and pharyngeal airway improved significantly. I, Preoperative profile view. J, Postoperative profile view. Reprinted, with permission, from Goodday.21 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
insufficiency in OSAS patients with previous UPPP, a review of 14 patients who had previously undergone UPPP that failed was undertaken. In this group, statistically significant reductions in excess daytime
sleepiness, snoring, and witnessed apnea events were recorded after MMA surgery. Two patients experienced occasional nasal regurgitation after MMA, which had resolved within 1 year. One patient re-
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FIGURE 14. A, Bony cuts to allow harvesting of bone from anterior mandible. B, Anterior mandible donor site. C, Bone stock from chin. D, Cephalometric radiograph of OSAS patient after MMA using bone harvested from chin. Reprinted, with permission, from Goodday.22 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
ported slightly hypernasal speech after MMA. In this group of UPPP patients, velopharyngeal incompetence was not a problem. Although UPPP is often promoted as a simple procedure with minimal pain and morbidity, 66% of these patients thought that UPPP was more painful and recovery more difficult than that with the MMA procedure. Most interesting was the finding that 100% of the subjects reported they would undergo MMA again. Only 1 of the 14 patients would undergo UPPP again and that was because the UPPP decreased the frequency of his sore throats. It had no effect on his OSAS.30 This finding, plus the low success rate of UPPP, calls into question the use of UPPP as first-stage surgical treatment. When patients are advised that advancement of the maxilla and mandible will improve the airway, most patients inquire about the effects of surgery on their facial appearance. To help answer this question, a survey of 20 patients after surgery was conducted. The responses revealed that 85% observed a change. Of these 20 patients, 50% thought the change was favorable, 30% were indifferent to the change, and 15% did not observe a change at all.30
Another subjective outcome study of 70 MMA patients revealed that 47 of the patients (67%) reported a favorable change in their facial features after MMA, 14 (20%) were indifferent to the change in their facial appearance, 6 (9%) did not notice a change, and 3 (4%) found the changes unfavorable.31 Controversy exists regarding the need to perform a concomitant bone graft to ensure stability and favorable bone healing at the maxillary osteotomy site in MMA patients. Bone grafting increases the operative time, expense, and morbidity. Complete data were gathered from 131 patients who underwent maxillomandibular surgery without a concomitant iliac crest bone graft. The average maxillary advancement was 8.7 mm. Four patients developed fibrous malunion of the maxilla. All were successfully treated with an iliac crest bone graft as a second procedure.31 Thus, all patients should be informed that approximately 3% of patients might require a second procedure involving a hip graft to stabilize the maxilla. Oral and maxillofacial surgeons have considerable experience and expertise in performing maxillary and mandibular osteotomies to correct dentofacial defor-
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FIGURE 15. OSAS patients treated with MMA using Delaire cephalometric analysis to determine magnitude of movement of maxilla and mandible. A, Female patient balanced at 90° CF1/C3. B, Male patient balanced at 95° CF1/C3. C, Male patient balanced at 90° CF1/C3. A1-C1, Profile view before surgery. A2-C2, Profile view after surgery. A3-C3, Preoperative cephalometric radiograph. A4-C4, Postoperative cephalometric radiograph. Note, significant improvement in retropalatal and retropharyngeal airway and normal facial balance demonstrated by alignment of points (FM, NP, apex, Me) on line of anterior facial balance CF1 after surgery. Reprinted, with permission, from Goodday.23 Reginald Goodday. Surgical Correction of OSAS. J Oral Maxillofac Surg 2009.
mities. Application of the same surgical principles and technique to MMA procedures will allow predictable and successful outcomes for OSAS. Sleep apnea patients who have demonstrable retropositioning of the maxilla and mandible should be informed of MMA as the primary surgical treatment of OSAS.
References 1. Assael LA: The biggest movement; orthognathic Surgery undergoes another paradigm shift. J Oral Maxillofac Surg 66:419, 2008 2. Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell
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WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 440 Rama AN, Tekwani SH, Kushida CA: Sites of obstruction in obstructive sleep apnea. Chest 122:1139, 2002 Goodday R: Treatment of obstructive sleep apnea by immediate surgical lengthening of the maxilla and mandible, in Bell WH, Guerrero CA (eds): Distraction Osteogenesis of the Facial Skeleton. Hamilton, ON, Canada, BC Decker, 2007, p 438 Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: Uvulopalatopharyngoplasty. Otalaryngol Head Neck Surg 89: 923, 1981 Sher AE, Schechtman KB, Piccirillo JF: An American Sleep Disorders Association review: The efficacy of surgical modifi-
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