Three-dimensional comparison between the effects of mandibular advancement device and maxillomandibular advancement surgery on upper airway.

BACKGROUND: The efficacy of mandibular advancement devices (MAD) and maxillomandibular advancement (MMA) in improving upper airway (UA) patency has been described as being comparable to continuous positive airway pressure (CPAP) outcomes. However, no previous study has compared MAD and MMA treatment outcomes for the upper airway enlargement. This study aimed to evaluate three-dimensionally the UA changes and mandibular rotation in patients after MAD compared to MMA. METHODS: The sample consisted of 17 patients with treated with MAD and 17 patients treated with MMA matched by weight, height, body mass index. Cone-beam computed tomography from before and after both treatments were used to measure total UA, superior/inferior oropharynx volume and surface area; and mandibular rotation. RESULTS: Both groups showed a significant increase in the superior oropharynx volume after the treatments (p = 0.003) and the MMA group showed greater increase (p = 0.010). No statistical difference was identified in the MAD group considering the inferior volume, while the MMA group showed a significantly gain (p = 0.010) and greater volume (p = 0.024). Both groups showed anterior mandibular displacement. However, the mandibular rotation were statistically different between the groups (p < 0.001). While the MAD group showed a clockwise rotation pattern (-3.97 ± 1.07 and - 4.08 ± 1.30), the MMA group demonstrated a counterclockwise (2.40 ± 3.43 and 3.41 ± 2.79). In the MAD group, the mandibular linear anterior displacement was correlated with superior [p = 0.002 (r=-0.697)] and inferior [p = 0.004 (r = 0.658)] oropharynx volume, suggesting that greater amounts of mandibular advancement are correlated to a decrease in the superior oropharynx and an increase in the inferior oropharynx. In the MMA group, the superior oropharynx volume was correlated to mandibular anteroposterior [p = 0.029 (r=-0.530)] and vertical displacement [p = 0.047 (r = 0.488)], indicating greater amounts of mandibular advancement may lead to a lowest gain in the superior oropharynx volume, while a great mandibular superior displacement is correlated with improvements in this region. CONCLUSIONS: The MAD therapy led to a clockwise mandibular rotation, increasing the dimensions of the superior oropharynx; while a counterclockwise rotation with greater increases in all UA regions were showed in the MMA treatment.

Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis

Abstract Objectives To evaluate the effectiveness of maxillomandibular advancement surgery in the treatment of Obstructive Sleep Apnea by comparing the pre- and postoperative Apnea and Hypopnea Index, in addition to classifying the degree of evidence and risk of intervention bias. Methods A systematic review of the literature was carried out in the PUBMED, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE and COCHRANE platforms, including cohort studies with polysomnographic follow-up, without other associated pharyngeal or nasal surgical procedures. The risk of study bias was assessed using the Modified Delphi technique. Pre- and postoperative Apnea and Hypopnea Index data were plotted for meta-analysis, and the quality of evidence was assessed using the GRADE system. Results Of 1882 references, 32 articles were selected for full-text reading, of which four studies were included, totaling 83 adults with obstructive sleep apnea who underwent maxillomandibular advancement. The meta-analysis was in favor of the intervention (DM = −33.36, 95% CI −41.43 to −25.29, p< 0.00001), with a mean percentage reduction in the Apnea and Hypopnea Index of 79.5% after surgery, even though the level of evidence was classified as very low quality by the GRADE system. Conclusion The meta-analysis was in favor of the intervention, characterizing maxillomandibular advancement surgery as an effective treatment for obstructive sleep apnea in adults.

Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis.

OBJECTIVES: To evaluate the effectiveness of maxillomandibular advancement surgery in the treatment of Obstructive Sleep Apnea by comparing the pre- and postoperative Apnea and Hypopnea Index, in addition to classifying the degree of evidence and risk of intervention bias. METHODS: A systematic review of the literature was carried out in the PUBMED, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE and COCHRANE platforms, including cohort studies with polysomnographic follow-up, without other associated pharyngeal or nasal surgical procedures. The risk of study bias was assessed using the Modified Delphi technique. Pre- and postoperative Apnea and Hypopnea Index data were plotted for meta-analysis, and the quality of evidence was assessed using the GRADE system. RESULTS: Of 1882 references, 32 articles were selected for full-text reading, of which four studies were included, totaling 83 adults with obstructive sleep apnea who underwent maxillomandibular advancement. The meta-analysis was in favor of the intervention (DM = -33.36, 95% CI -41.43 to -25.29, p < 0.00001), with a mean percentage reduction in the Apnea and Hypopnea Index of 79.5% after surgery, even though the level of evidence was classified as very low quality by the GRADE system. CONCLUSION: The meta-analysis was in favor of the intervention, characterizing maxillomandibular advancement surgery as an effective treatment for obstructive sleep apnea in adults.

Efficiency of maxillomandibular advancement for the treatment of obstructive apnea syndrome: a comprehensive overview of systematic reviews.

OBJECTIVES: To evaluate the efficiency of maxillomandibular advancement using aggregated individual patient data from multiple studies. MATERIALS AND METHODS: This overview was structured according to the PICO strategy. It adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist and was recorded on the international prospective register of systematic reviews (PROSPERO-CRD42020206135). Searches were conducted in the PubMed/MEDLINE, Scopus, Embase, Web of Science, LILACS, and Cochrane databases for studies published until January 1, 2021. Data from the included studies were collected by one author, while another reviewed the compilation. RESULTS: Twelve systematic reviews were included. The outcome measures studied were the apnea-hypopnea index, respiratory disturbance index, mean oxygen saturation, lowest oxygen saturation, sleepiness data, posterior air space, sella-nasion point A angle, sella-nasion point B angle, surgical success, and surgical cure in patients who underwent surgery. The AMSTAR scale presented moderate evaluations, with grades varying between 6 and 10 points. The Glenny scale revealed that the study selection did not include all languages. Only three reviews identified quality assessments conducted by at least two reviewers and only five related possible searches for unpublished data. CONCLUSIONS: Bimaxillary advancement surgery improved respiratory indicators, sleepiness data, and increased upper airway size. However, it is necessary to standardize the surgical criteria to establish measurable efficiency of the procedure. CLINICAL RELEVANCE: This overview makes a critical analysis of the results of the selected systematic reviews with the aim of presenting the most clinically relevant data on the maxillomandibular advancement for treating obstructive apnea syndrome, with a focus on improving respiratory, anatomical, and quality of life indices. There are no overviews that approach this theme from a well-structured perspective.

Impact of counterclockwise rotation of the occlusal plane on the mandibular advancement, pharynx morphology, and polysomnography results in maxillomandibular advancement surgery for the treatment of obstructive sleep apnea patients.

PURPOSE: Evaluate the impact of counterclockwise rotation of the occlusal plane (CCWROP) on pharynx morphology and polysomnography in maxillomandibular advancement (MMA) surgery to treat obstructive sleep apnea (OSA) patients. METHODS: Prospective clinical trial of patients with OSA treated by MMA. Computed tomography and polysomnography were performed pre- and postoperatively and the parameters were compared. The surgery classified the patients into two groups: with (R) and without (NR) CCWROP. RESULTS: The study sample comprised 38 individuals: R (n = 19) and NR (n = 19). An anterior mandible advancement of 0.71 mm was identified for each degree of CCWROP (p < 0.001). As for polysomnography, the apnea-hypopnea index was reduced by 80% and 62% in R and NR, showing final values of 6.8 and 13.0, respectively. The apnea index changed equally in both groups. Reduction of 68 and 26% in the hypopnea index was observed for R and NR, respectively, with no statistically significant difference. Total volume increased by 45% in R and 30% in NR. Retropalatal and retrolingual volumes increased by 49% and 4% in R and 43% and 15% in NR, respectively. The minimum axial area increased by 92% in the retropalatal region and 97% in the retrolingual region in R, whereas these increases were of 76% and 31% in NR, respectively. CONCLUSION: Anterior mandibular advancement of 0.71 mm for each degree of CCWROP is of great importance for surgical planning. As a result of this resource, individuals in R presented better results than those in NR in all parameters assessed, especially regarding the retrolingual region.

Obstructive sleep apnea in adults

ABSTRACT Introduction: Obstructive Sleep Apnea and Hypopnea Syndrome (OSAS) is a highly prevalent disease with serious consequences for the patients' lives. The treatment of the condition is mandatory for the improvement of the quality of life, as well as the life expectancy of the affected individuals. The most frequent treatments provided by dentistry are mandibular advancement devices (MAD) and orthognathic surgery with maxillomandibular advancement (MMA). This is possibly the only treatment option which offers high probability of cure. Objective: The present article provides a narrative review of OSAS from the perspective of 25 years of OSAS treatment clinical experience. Conclusion: MADs are a solid treatment option for primary snoring and mild or moderate OSAS. Patients with severe apnea who are non-adherent to CPAP may also be treated with MADs. Maxillomandibular advancement surgery is a safe and very effective treatment option to OSAS.

RESUMO Introdução: a Síndrome da Apneia e Hipopneia Obstrutiva do Sono (SAOS) é uma doença muito prevalente e que traz importantes consequências para a vida dos seus portadores. O tratamento da condição é relevante para a melhora do bem-estar geral e da expectativa de vida dos afetados. Os tratamentos odontológicos mais frequentes para a SAOS são os dispositivos de avanço mandibular (DAMs) e a cirurgia ortognática de avanço maxilomandibular (AMM) - essa última, possivelmente, é a única opção de tratamento com alta probabilidade de cura do problema. Objetivo: o presente artigo faz uma revisão narrativa da SAOS sob a perspectiva de 25 anos de experiência clínica no tratamento da doença. Conclusão: os DAMs são uma sólida opção de tratamento para o ronco primário e apneias leves ou moderadas. Apneias graves, em pacientes que não se adaptam ou se recusam a usar o CPAP, também podem ser tratadas com os DAMs. A cirurgia ortognática de AMM é uma alternativa segura e muito eficaz de solução da SAOS.

Dynamic comparison of pharyngeal stability during sleep in patients with obstructive sleep apnea syndrome treated with maxillomandibular advancement.

PURPOSE: To compare the dynamic differences occurring in the pharynx during sleep after maxillomandibular advancement (MMA) surgery for the treatment of patients with obstructive sleep apnea syndrome. METHODS: This was a prospective, cross-sectional study conducted on 20 patients (15 men and 5 women) with a polysomnography diagnosis of obstructive sleep apnea (OSA) submitted to surgical treatment with MMA. All patients were submitted to magnetic resonance (MR) during propofol-induced sleep before and 6 months after surgery. Thirty linear measurements (30 sections) were obtained over time in the retrolingual (RL) region to compare their variability before and after MMA. RESULTS: The mean linear anteroposterior increase of the pharynx during induced sleep after MMA was 66 % in the RL region (P < 0.01). The coefficient of variation of the linear measurements was 117.5 % before surgery, being reduced to 51 % after surgery. CONCLUSIONS: MMA promoted an important increase of the pharynx during induced sleep and a more significant change in the variability of its lumen. With a lower variation in the diameter of the organ during the respiratory movements, there is greater airway stability and a consequent maintenance of the pharyngeal lumen that reduces or even prevents pharyngeal collapse.

Effectiveness of Maxillomandibular advancement (MMA) surgery in sleep apnea treatment: Case report.

Obstructive sleep apnea (OSA) is characterized by episodes of pharyngeal collapse during sleep. Craniofacial alterations such as retrognathia are often found in OSA patients. Maxillomandibular advancement (MMA) surgeries increase the pharyngeal space and are a treatment option for OSA. The aim of this study was to present a successful case of MMA surgery in the treatment of OSA. A patient with moderate OSA (apnea-hypopnea index (AHI)=25.2) and mandibular retrognathism and Maxillomandibular asymmetry underwent MMA surgery. The apnea-hypopnea index (AHI) were considerably improved after six months (IAH =6.7) and one year of treatment (IAH=0.2).