Maxillomandibular Advancement Improves Multiple Health-Related and Functional Outcomes in Patients With Obstructive Sleep Apnea: A Multicenter Study.

PURPOSE: To comprehensively determine the effectiveness and safety of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA). PATIENTS AND METHODS: We designed and implemented a prospective multicenter cohort study to evaluate OSA patients who underwent MMA. The primary outcome measures and associated instruments included sleepiness (Epworth Sleepiness Scale [ESS]), quality of life (QOL) (Functional Outcomes of Sleep Questionnaire [FOSQ]), sleep-disordered breathing (apnea-hypopnea index), cardiovascular risk (office blood pressure and levels of high-sensitivity C-reactive protein), and neurocognitive performance (psychomotor vigilance testing [PVT]). The outcomes were measured preoperatively and approximately 6 months postoperatively. Other variables were grouped into the following categories: demographic and pre-MMA use of continuous positive airway pressure. Descriptive and bivariate statistics were computed. RESULTS: The sample was composed of 30 adult patients (63% men; mean age, 45.9 ± 9.8 years). The median length of follow-up was 6.7 months (range, 4.3 to 12.7 months). The ESS score decreased from a mean of 13.3 to 4.9 (P < .001). The FOSQ score increased from a mean of 14.1 to 18.3 (P < .001). The apnea-hypopnea index decreased from a mean of 39.6 to 7.9 events per hour (P < .001). Mean diastolic blood pressure decreased from 83 to 79.7 mm Hg (P = .025). PVT response times improved after MMA (P = .04). Few treatment-related adverse events occurred, which had minimal impact on the QOL. Additional improvements in sleepiness (mean ESS score change, -7.6; P < .001), QOL (mean FOSQ score change, 3.9; P < .001), and PVT (mean change, 0.5; P = .004) occurred after MMA for patients using continuous positive airway pressure before surgery. CONCLUSIONS: MMA is a highly effective and safe treatment for OSA, which predictably leads to significant improvements in sleepiness, QOL, sleep-disordered breathing, and neurocognitive performance, as well as a reduction in cardiovascular risk (blood pressure).

Effectiveness of treatment apnea-hypopnea index: a mathematical estimate of the true apnea-hypopnea index in the home setting.

PURPOSE: To present a new measurement instrument, the Effectiveness of Treatment Apnea-Hypopnea Index (ET-AHI), which the authors developed to determine an estimate of the therapeutic control of obstructive sleep apnea (OSA). MATERIALS AND METHODS: The authors retrospectively evaluated a cohort of patients with OSA who initially attempted to use continuous positive airway pressure (CPAP) therapy and subsequently underwent maxillomandibular advancement (MMA) surgery. The ET-AHI calculations were performed to estimate the level of CPAP adherence that would be necessary to achieve equivalence with the MMA surgical result and to reach effective AHIs of 5 and 15. RESULTS: The sample was composed of 37 adult patients (mean age, 44.2 ± 9.0 yr; 73% men) with moderate to severe OSA (baseline AHI, 56.3 ± 22.6). CPAP therapy was highly efficacious (CPAP titration AHI, 4.3 ± 5.9), but no patient could adequately adhere to treatment. MMA produced a significant decrease in OSA (AHI after MMA, 11.6 ± 7.4). The ET-AHI calculations predicted that an 86% adherence rate with CPAP would be necessary to achieve equivalence with MMA, whereas adherence rates of 99% and 79% may be required to achieve effective AHIs of 5 and 15, respectively. CONCLUSIONS: The ET-AHI has the potential to significantly affect the care of patients with OSA because it may provide the treating clinician with a valuable tool to estimate the control of OSA for any therapeutic intervention. How closely the ET-AHI predicts the true effective AHI in the home setting requires further validation.

Comparative effectiveness of maxillomandibular advancement and uvulopalatopharyngoplasty for the treatment of moderate to severe obstructive sleep apnea.

PURPOSE: To directly compare the clinical effectiveness of maxillomandibular advancement (MMA) and uvulopalatopharyngoplasty (UPPP)--performed alone and in combination--for the treatment of moderate to severe obstructive sleep apnea (OSA). PATIENTS AND METHODS: The investigators designed and implemented a retrospective cohort study composed of patients with moderate to severe OSA (baseline AHI >15). The predictor variable was operative treatment and included MMA, UPPP, and UPPP followed by MMA (UPPP/MMA). The primary outcome variable was the apnea-hypopnea index (AHI) measured preoperatively and 3 months to 6 months postoperatively. Other variables were grouped into the following categories: demographic, respiratory, and sleep parameters. Descriptive and bivariate statistics were computed. RESULTS: The sample was composed of 106 patients grouped as follows: MMA (n = 37), UPPP (n = 34), and UPPP/MMA (n = 35) for treatment of OSA. There were no significant differences between the 3 groups for the study variables at baseline, except for AHI. Surgical treatment resulted in a significant decrease in AHI in each group: MMA (baseline AHI, 56.3 ± 22.6 vs AHI after MMA, 11.4 ± 9.8; P < .0001), UPPP/MMA (baseline AHI, 55.7 ± 49.2 vs AHI after UPPP/MMA, 11.6 ± 10.7; P < .0001), and UPPP (baseline AHI, 41.8 ± 28.0 vs AHI after UPPP, 30.1 ± 27.5; P = .0057). After adjusting for differences in baseline AHI, the estimated mean change in AHI was significantly larger for MMA compared with UPPP (MMA AHI, -40.5 vs UPPP AHI, -19.4; P = < .0001). UPPP/MMA was no more effective than MMA (P = .684). CONCLUSION: The results of this study suggest that MMA should be the surgical treatment option of choice for most patients with moderate to severe OSA who are unable to adequately adhere to CPAP.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis.

OBJECTIVE: To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA). DATA SOURCES: The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE. REVIEW METHODS: Three authors systematically reviewed the international literature through July 26, 2018. RESULTS: A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term. CONCLUSION: The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Controversies in Obstructive Sleep Apnea Surgery.

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

Treatment of a patient with multiple impacted teeth.

An impacted or missing permanent tooth can add significant complications to an otherwise straightforward case. When multiple impacted teeth are present, the case complexity increases further. Developing a treatment sequence, determining appropriate anchorage, and planning and executing sound biomechanics can be a challenge. The following case report illustrates a patient reportedly diagnosed with mild scleroderma as an adolescent. He presented for orthodontic treatment as an adult with multiple retained primary teeth and multiple impacted teeth. Diagnosis, treatment planning, and various methods of managing guided eruption of impacted teeth will be discussed. Following orthodontic treatment that required extraction of multiple primary and permanent teeth as well as exposure and ligation of multiple permanent teeth by an oral surgeon, the patient finished with a significantly improved functional and esthetic result.

Controversies in Obstructive Sleep Apnea Surgery.

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

Effective Apnea-Hypopnea Index ("Effective AHI"): A New Measure of Effectiveness for Positive Airway Pressure Therapy.

STUDY OBJECTIVES: To assess a new measure of positive airway pressure (PAP) effectiveness, the Effective AHI, which accounts for sleep disordered breathing events during the time PAP is (PAP On) and is not (PAP Off) being used. A secondary aim was to test the accuracy of the Watch-PAT 200 (WP) portable monitor for measurement of the Effective AHI. METHODS: A prospective two-center cohort study design was used to evaluate patients who had been prescribed PAP therapy for ≥ 2 months. The primary outcome measure was the Effective AHI as determined by an in-laboratory polysomnogram (PSG) where patients used their PAP machine as they did at home, and concomitantly wore the WP. The Effective AHI equals the sum of apneas and hypopneas with PAP On and PAP Off divided by hours of total sleep time. RESULTS: Twenty-eight adult patients (75% men, age 51.4 ± 10.8 years [mean ± SD]) comprised the study sample. The mean Effective AHI of 18.3, was significantly lower than the mean Diagnostic AHI of 67.9 (P < 0.0001). All patients using PAP ≥ 6 h had an Effective AHI < 5. For patients using PAP < 6 h, Effective AHI scores < 5 only occurred in patients who slept in a non-supine position during PAP Off time; leaving 63.6% of patients with residual moderate-to-severe OSA. There was a high correlation between the PSG and WP for the Effective AHI (r = 0.871). CONCLUSIONS: Significant disease burden, as objectively measured by the Effective AHI, may still exist in many patients with severe OSA in whom PAP therapy is not utilized for the entire sleep period. The WP is a reasonably accurate device to measure the Effective AHI.

Long-Term Effectiveness and Safety of Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea.

STUDY OBJECTIVE: To determine the long-term clinical effectiveness and safety of maxillomandibular advancement (MMA) for the treatment of moderate to severe obstructive sleep apnea (OSA). METHODS: A prospective two-center cohort study design was used to evaluate OSA patients who underwent MMA > 2 years ago. The primary outcome measure was the apnea-hypopnea index (AHI). Secondary outcome measures included blood pressure (BP), sleepiness (Epworth Sleepiness Scale [ESS]), and quality of life (Functional Outcomes of Sleep Questionnaire [FOSQ]). RESULTS: 30 adult patients (80% men, age 50.5 ± 9.6 years [mean ± SD]) participated in the study. The AHI decreased from a mean of 49 to 10.9 events/h (p < 0.0001) at the time of long-term evaluation (6.6 ± 2.8 years after MMA), with 46.7% of patients obtaining an AHI < 5 and 83.4% of patients attaining an AHI ≤ 15 events/h. The mean diastolic BP decreased from 83.7 to 79.0 mm Hg (p < 0.05). ESS decreased from a mean of 12.1 to 6.0 (p < 0.01). FOSQ increased from a mean of 12.6 to 17.3 (p < 0.05). Few long-term treatment-related adverse events occurred, which had minimal impact on quality of life (QOL). CONCLUSIONS: MMA is a clinically effective and safe long-term treatment for most patients with moderate-to-severe OSA as demonstrated by significant decreases in AHI, diastolic BP, and subjective sleepiness, with concomitant significant improvements in QOL. The results of this small cohort study suggest that MMA should be considered as the alternative treatment of choice for patients with severe OSA who cannot fully adhere to CPAP therapy.

Management of obstructive sleep apnea by maxillomandibular advancement.

Obstructive sleep apnea (OSA) is a common primary sleep disorder. It is characterized by repetitive partial or complete upper airway collapse during sleep. Maxillomandibular advancement (MMA) is an orthognathic surgical procedure that has been used to manage OSA. The main objective of this article is to provide practical guidelines for evaluating and managing OSA patients by MMA. The presentation will focus on MMA for adults, as this is the most common and clinically effective application of MMA to treat OSA.

Facial soft tissue changes following maxillomandibular advancement for treatment of obstructive sleep apnea.

PURPOSE: The goal of this retrospective study was to evaluate the horizontal and vertical facial soft tissue changes occurring after maxillomandibular advancement (MMA) surgery to treat obstructive sleep apnea (OSA). PATIENTS AND METHODS: The study group comprised 31 consecutive adult patients with OSA who underwent MMA through Le Fort I osteotomy and bilateral sagittal split ramus osteotomies. Adjunctive maxillary procedures, consisting of piriformplasty, anterior nasal spine recontouring, alar base cinch, and V-Y closure of the upper lip, were used for all patients. A "best-fit" templating cephalometric technique was used to assess dentoskeletal movements and corresponding soft tissue changes. RESULTS: Maxillary movements (measured at point A) averaged 8.77 +/- 2.34 mm horizontally and 2.20 +/- 2.42 mm vertically. Mandibular movements (measured at point B) averaged 11.16 +/- 2.56 mm horizontally and 2.25 +/- 3.02 mm vertically. The horizontal upper lip soft tissue-to-hard tissue ratios averaged >0.90:1 (SLS/A, 0.97:1; Ls/U1fac, 0.96:1; Stm(s)/ls, 0.86:1). Upper lip length (Sn-Ls) increased by a clinically insignificant amount (0.37 mm). The nasolabial complex rotated in a counterclockwise rotation, with the nasolabial angle decreasing (3.87 degrees) due primarily to forward movement of the upper lip. Horizontal lower lip and chin soft tissue-to-hard tissue ratios averaged >0.90:1 (Stm(i)/li, 0.90:1; Li/Ii, 0.89:1; Pg'/Pg, 0.92:1; Me'/Me, 0.91:1). CONCLUSIONS: This study demonstrated that MMA in this selected group of OSA patients results in soft tissue movements producing a soft tissue-to-hard tissue ratio of about 0.90:1 for most anatomic sites of the upper lip, lower lip, and chin.