Is Intensive Care Unit Monitoring Necessary After Maxillomandibular Advancement for Management of Obstructive Sleep Apnea?

PURPOSE: Maxillomandibular advancement (MMA) is an accepted treatment modality for obstructive sleep apnea. The purpose of this study was to evaluate the incidence of complications requiring an intensive care unit (ICU) level of care and the necessity of routine overnight ICU airway monitoring after MMA. PATIENTS AND METHODS: This was a retrospective cohort study of patients undergoing MMA at Massachusetts General Hospital from 2003 to 2020. The primary predictor variable was postoperative admission to the ICU versus post anesthesia care unit (PACU) or ward. The primary outcome variable was grade IV or V complications as scored using the Clavien-Dindo classification system. The secondary outcome variables included postoperative SpO2 nadir and length of hospital stay. Descriptive and bivariate statistics were computed to measure the association between complications and predictor variables. RESULTS: The study sample consisted of 104 patients (74.0% male, mean age 37.6 ± 12.1 years), 61 of whom were admitted to the ICU (58.7%). During the initial 24 hours of airway monitoring, the mean SpO2 nadir was 93.7 ± 2.59% for patients admitted to the ICU compared with 94.0 ± 6.56% for patients admitted to the PACU or ward (P = .862). Patients experienced 2 grade IV complications (1.92%) and no grade V complications, with no statistical association between complications and postoperative admission location (P = 1.000). Age (P = .002) and operative time (P = .046) were the only variables statistically associated with grade IV or V complications. There was no difference in length of hospital stay between patients admitted to the ICU (2.64 ± 1.37 days) versus PACU or ward (2.58 ± 1.62 days). CONCLUSIONS: The incidence of complications requiring ICU-level care after MMA for obstructive sleep apnea is low. Additional studies are warranted to guide development of feasible, cost-effective perioperative protocols for patients undergoing MMA.

Is Maxillomandibular Advancement Associated With Comorbidity Reduction in Patients With Obstructive Sleep Apnea?

PURPOSE: This study investigated whether patients with documented obstructive sleep apnea (OSA) who have a decrease in apnea-hypopnea index (AHI) score and self-reported symptoms after maxillomandibular advancement (MMA) with genial tubercle advancement (GTA) also have a change in their medical comorbidity profile a minimum of 2 years postoperatively. Changes in the quantity of medical diagnoses, quantity of prescription medications, and average weight and body mass index (BMI) were assessed. PATIENTS AND METHODS: This is a retrospective cohort study of patients with a diagnosis of OSA (AHI score >5 on polysomnogram [PSG]) treated at the Massachusetts General Hospital (Boston, MA) with MMA and GTA from 2001 through 2015. Patients were identified through the oral and maxillofacial surgery patient data registry. Inclusion criteria were the availability of complete clinical records and requisite follow-up time. The primary predictor variable was operative status (preoperative or postoperative). The primary outcome variables were comorbidities reported to be associated with OSA and identified in the authors' previous study (J Oral Maxillofac Surg 76:1999.e1, 2018). Two-tailed paired t tests were used for continuous variables and χ2 or Fisher exact tests were used for categorical variables. RESULTS: Forty-six patients (39 men, 7 women) met the inclusion criteria. Average weight (206.7 ± 42.4 lb preoperatively; 213.8 ± 41.7 lb postoperatively; P = .014) and average BMI (30.0 ± 5.7 kg/m2 preoperatively; 30.9 ± 5.3 kg/m2 postoperatively; P = .041) significantly increased in patients postoperatively. No meaningful changes in the number of medical diagnoses or number of prescription medications were noted. Stratification of patients by BMI showed significant increases in weight (188.6 ± 21.5 lb preoperatively; 200.1 ± 27.9 lb postoperatively; P = .0085) and BMI (27.1 ± 1.44 kg/m2 preoperatively; 28.9 ± 3.52 kg/m2 postoperatively; P = .013) only in "overweight" patients. No other parameters were found to be relevant. CONCLUSIONS: Subjective improvement in OSA symptoms was reported by all patients and objective PSG improvement was reported for 71% of those evaluated. However, no relevant changes in comorbidity profile were found, suggesting that the medical conditions commonly observed with OSA are likely of multifocal etiology.

Conflicts of Interest in Clinical Guidelines: Lack of Authors and Disclosures in the AAOMS White Papers.

PURPOSE: The purpose of this study was to evaluate current state of authorship, financial disclosures, and conflicts of interest in position papers published by the American Association of Oral and Maxillofacial Surgeons (AAOMS). MATERIALS AND METHODS: This is a cross-sectional review of the position papers published by the AAOMS from 2013 to 2017. Primary outcome variables include position papers published by the AAOMS. Secondary outcome variables include declaration of authorship, financial disclosures, and financial payments. The Open Payments Database for financial disclosures was reviewed for the year the position paper was published and the immediate preceding year. RESULTS: Ten position papers were published by the AAOMS from 2013 to 2017. Of the 10 papers, authorship was listed in 3, and none explicitly addressed the presence or absence of financial disclosures or conflicts of interest. Contributors to 3 of the 3 authored papers were found at review of the Open Payments Database to have received industry funding in the year the position paper was published and the immediate preceding year. The remuneration ranged from less than $1,000 to $554,006.02. CONCLUSION: Position papers published by the AAOMS lack standardization for authorship and statements on potential financial disclosure. The authors suggest full disclosures of authorship and authors' conflicts of interest should be stated on all position papers to provide transparency to the process.

Does the Medical Comorbidity Profile of Obstructive Sleep Apnea Patients Treated With Maxillomandibular Advancement Differ From That of Obstructive Sleep Apnea Patients Managed Nonsurgically?

PURPOSE: Obstructive sleep apnea (OSA) patients with retrognathia and measurable anatomic airway determinants may represent a subset of OSA patients and have distinct comorbidity profiles. Our aim was to compare the medical comorbidities of OSA patients managed surgically with maxillomandibular advancement with those of nonsurgical patients. PATIENTS AND METHODS: In this cross-sectional retrospective study, patients for both cohorts were identified through the Massachusetts General Hospital oral and maxillofacial surgery data registry and the Massachusetts General Hospital Research Patient Data Registry. The inclusion criteria consisted of clinical records documenting body mass index (BMI), apnea-hypopnea index, respiratory disturbance index, and/or oxygen nadir. The primary predictor variable was the treatment modality chosen: surgical (maxillomandibular advancement) or nonsurgical. Demographic information and OSA parameters were evaluated. The primary outcome variable was the number of documented comorbidities in each group. Two-sample t tests were used for continuous variables, whereas χ2 or Fisher exact tests were used for categorical variables. RESULTS: The nonsurgical cohort consisted of 71 patients (67.6% men), and the surgical cohort consisted of 51 patients (84.3% men). Comparison of descriptive characteristics showed that the nonsurgical cohort had a higher average age (49 ± 9.4 years) than the surgical cohort (41 ± 10.7 years, P < .001). In addition, a higher average BMI was present in the nonsurgical group (42.3 ± 11.9 in nonsurgical group vs 29.7 ± 5.5 in surgical group, P < .001). Polysomnogram parameters were comparable with the exception of a higher Epworth Sleepiness Scale score in the surgical cohort (15.5 ± 5.30 in surgical group vs 9.90 ± 6.80 in nonsurgical group, P = .005). The nonsurgical cohort had a higher total number of comorbidities (7 ± 4 in nonsurgical group vs 4 ± 3 in surgical group, P < .001). Hypertension, cardiovascular disease, hyperlipidemia, pulmonary hypertension, obstructive pulmonary disease, and type 2 diabetes mellitus had higher prevalences within the nonsurgical group. CONCLUSIONS: The results of this study suggest that nonsurgically managed OSA patients tend to have more complex medical comorbidity profiles than those managed surgically. Obesity (BMI >30) was more prevalent in the nonsurgical cohort, which may be contributory. The additive contribution of OSA needs to be further elucidated.

Evaluation of Oral and Maxillofacial Surgery Residents' Operative Skills: Feasibility and Engagement Study Using SIMPL Software for a Mobile Phone.

PURPOSE: There are no universally accepted tools to evaluate operative skills of surgical residents in a timely fashion. The purpose of this study was to determine the feasibility of using a smartphone application, SIMPL (System for Improving and Measuring Procedural Learning), developed by a multi-institutional research collaborative, to achieve a high rate of timely operative evaluations and resident communication and to collect performance data. The authors hypothesized that these goals would be achieved because the process is convenient and efficient. MATERIALS AND METHODS: This was a prospective feasibility and engagement study using SIMPL to evaluate residents' operative skills. SIMPL requires the attending surgeon to answer 3 multiple-choice questions: 1) What level of help (Zwisch Scale) was required by the trainee? 2) What was the level of performance? 3) How complex was the case? The evaluator also can dictate a narrative. The sample was composed of 3 faculty members and 3 volunteer senior residents. Predictor variables were the surgeons, trainees, and procedures performed. Outcome variables included number and percentage of procedures performed by faculty-and-resident pairs assessed, time required to complete assessments, time lapsed to submission, percentage of assessments with narratives, and residents' response rates. RESULTS: From March through June 2016, 151 procedures were performed in the operating room by the faculty-and-resident teams. There were 107 assessments submitted (71%). Resident response (self-assessment) to faculty evaluations was 81%. Recorded time to complete assessments (n = 75 of 107) was shorter than 2 minutes. The time lapsed to submission was shorter than 72 hours (100%). Dictations were submitted for 35 evaluations (33%). Data for the type of help, performance, and complexity of cases were collected for each resident. CONCLUSIONS: SIMPL facilitates timely intraoperative evaluations of surgical skills, engagement by faculty and residents, and collection of detailed procedural data. Additional prospective trials to assess this tool further are planned.

Morbidity and Mortality Rates After Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea.

PURPOSE: To compare morbidity and mortality rates in obstructive sleep apnea (OSA) versus dentofacial deformity (DFD) patients undergoing equivalent maxillofacial surgical procedures. PATIENTS AND METHODS: Patients with OSA who underwent maxillomandibular advancement with genial tubercle advancement in the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery from December 2002 to June 2011 were matched to patients with DFD undergoing similar maxillofacial procedures during the same period. They were compared regarding demographic variables, medical comorbidities, perioperative management, intraoperative complications, early and late postoperative complications, and mortality rate. RESULTS: A study group of 28 patients with OSA and a control group of 26 patients with DFD were compared. The patients with OSA were older (41.9 ± 12.5 years vs 21.7 ± 8.6 years), had a higher American Society of Anesthesiologists classification (2.0 ± 0.5 vs 1.3 ± 0.6), and had a higher body mass index (29.6 ± 4.7 kg/m(2) vs 23.0 ± 3.1 kg/m(2)). They also had a greater number of medical comorbidities (2.4 ± 2.3 vs 0.7 ± 1.0). More OSA patients than DFD patients had complications (28 [100%] vs 19 [73%], P = .003), and the total number of complications in the OSA group was higher (108 vs 33, P < .001). Of the complications, 13.9% in the OSA group and 3.0% in the DFD group were classified as major. The absolute risk of a complication was 3.9 for the OSA group versus 1.3 for the DFD group. The relative risk of complications in OSA patients compared with DFD patients was 3.0. No difference in mortality rate was found. CONCLUSIONS: The patients in the OSA group were older, had more comorbidities, and ultimately had a greater number of early, late, minor, and major complications than those in the DFD group. The incidence of death in both groups was zero. Maxillomandibular advancement appears to be a safe procedure regarding mortality rate, but OSA patients should be counseled preoperatively regarding the relative increased risk of complications.

Skeletal stability of patients undergoing maxillomandibular advancement for treatment of obstructive sleep apnea.

PURPOSE: To determine the long-term stability of maxillomandibular advancement (MMA) in patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: This was a retrospective cohort study of patients who underwent MMA and genial tubercle advancement (GTA) for treatment of OSA. Patients were included if they 1) were older than 19 years; 2) had a confirmatory polysomnogram; 3) underwent a Le Fort I osteotomy, bilateral sagittal split osteotomies, and GTA; 4) had adequate radiographic documentation; and 5) at least 11 months of follow-up. Exclusion criteria included previous orthognathic or other maxillofacial surgery. Predictor variables were the presence of OSA treated by MMA, pre- and postoperative orthodontia or no orthodontia, length of follow-up, and magnitude of advancement. The outcome variable was the stability of MMA judged by clinical examination and cephalometric measurements. Standardized lateral cephalometric measurements were performed preoperatively (T0), immediately postoperatively (T1), and at the latest follow-up beyond 11 months (T2). Differences in cephalometric measurements were calculated between time points (T0 to T1 and T1 to T2) for the overall group and for patients who had orthodontia (group 1) and those who did not (group 2). A correlation analysis using length of follow-up and magnitude of advancement as predictor variables of stability was completed. For all analyses, a P value less than .05 was considered statistically significant. RESULTS: During the 9-year study period, 120 patients with OSA were evaluated and 112 had operative treatment; 25 patients specifically had MMA and GTA, met the inclusion criteria, and formed the study sample. The mean maxillary and mandibular advancements (T1 vs T0) were 9.48 mm (range, 1.6 to 15.2 mm) and 10.85 mm (range, 6.3 to 15.8 mm), respectively. From T1 to T2, no occlusal changes occurred. Changes in the subgroup analyses included a decrease in the angle formed by the sella, nasion, and A point (SNA) and the angle formed by the nasion and A and B points (ANB) and an increase in the angle formed by the mandibular plane (gnathion and gonion) to a line from the sella to the nasion in group 1 and a decrease in ANB in group 2. The only statistical mean difference in cephalometric measurements between groups was in the distance between the condylion and the gnathion. There was no correlation between length of follow-up (mean, 27.84 months) and changes in cephalometric measurements. CONCLUSION: Results of this study indicate that although there were changes in the SNA and ANB from T1 to T2 suggesting maxillary relapse, the mean difference was no greater than 1° and no patients developed a malocclusion; therefore, the changes were considered clinically minor. Advancement of the maxillomandibular complex by 10 mm for treatment of OSA remains stable at a mean follow-up period longer than 2 years and preoperative orthodontic treatment does not appear to influence skeletal stability.

Primary intraosseous mucoepidermoid carcinoma of the mandible: radiographic evolution and clinicopathological features.

Mucoepidermoid carcinoma (MEC) can be rarely found as a primarily intraosseous lesion and mistaken for other intraosseous or odontogenic pathology. A 65-year-old man had a poorly defined radiolucency distal to the left mandibular second molar root. Periapical radiographs demonstrated a minor radiolucency from 2.5 years prior. An oral and maxillofacial surgeon felt the radiolucency represented periodontal disease, extracting tooth #18. The differential diagnosis of mixed radiolucent/radio-opaque mandibular lesions includes: (1) fibro-osseous lesion, (2) odontogenic and non-odontogenic cyst, (3) infection and inflammatory lesion, or (4) benign or malignant neoplasm (odontogenic, non-odontogenic, or metastatic). Histological analysis revealed low-grade MEC. A composite resection was performed with a 1 cm margin from first molar to ascending ramus. A buccal fat pad advancement flap covered the defect with an iliac crest bone graft placed later for a resulting osseous defect. Careful examination and diagnostic work-up for odontogenic cysts should be provided as they may harbour malignant tumours.