Primary and secondary telegnathic maxillomandibular advancement, with or without adjunctive procedures, for obstructive sleep apnea in adults: a literature review and treatment recommendations.

PURPOSE: To further define the role, surgical principles, and therapeutic efficacy of primary and secondary maxillomandibular advancement (MMA), with and without intrapharyngeal or extrapharyngeal adjunctive procedures, for obstructive sleep apnea in adults. MATERIALS AND METHODS: A review of the literature, using mean percent reduction in apnea hypopnea index as the primary outcome measure of therapeutic efficacy for standardized comparison. Other occasionally reported MMA outcome parameters were sleep staging variables, lowest oxyhemoglobin saturation levels, Epworth scores, blood pressure changes, lateral cephalometric data, and complications. RESULTS: Mean percent reduction in apnea hypopnea index was 92.1% for primary MMA with extrapharyngeal procedures, 88.4% for primary MMA, 86.6% for secondary MMA, 79.4% for primary MMA with intrapharyngeal procedures, 53.0% for non-MMA multilevel surgery, 31.3% for uvulopalatopharyngoplasty, and 89.8% for nasal continuous positive airway pressure. Treatment recommendations for telegnathic MMA included surgical goals and guidelines, indications and staging protocols, surgical principles and techniques, and postoperative airway management. CONCLUSIONS: Primary and secondary MMA are highly therapeutic, and extrapharyngeal are more therapeutic than intrapharyngeal procedures when performed concomitantly with primary MMA. However, long-term success of obstructive sleep apnea treatment should be measured by a yet undefined comprehensive algorithm of standardized multiple weighted outcome parameters.

Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis.

A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.

Maxillomandibular Advancement (MMA) in a Site-Specific Treatment Approach for Obstructive Sleep Apnea: A Surgical Algorithm.

Maxillomandibular advancement (MMA) is the most successful acceptable surgical treatment, excluding tracheostomy, for obstructive sleep apnea syndrome (OSAS). Nevertheless, the indications for and staging of MMA, with respect to the many procedures available, are unsettled and often limited to severe OSAS, dentocraniofacial deformities, and when other surgeries have failed. An algorithm is presented that defines the indications for MMA in an expanded role, based on a site-specific approach, according to proposed principles that include general goals and guidelines for governing the surgical treatment of OSAS.

Maxillomandibular advancement surgery for obstructive sleep apnea syndrome.

BACKGROUND: Although maxillomandibular advancement, or MMA, surgery is highly successful, the indications for and staging of MMA in the treatment of obstructive sleep apnea syndrome, or OSAS, have not been settled upon. TYPES OF STUDIES REVIEWED: The author presents a retrospective review of several published case series with inclusion criteria of 20 or more patients who underwent MMA and received documented preoperative and postoperative diagnostic polysomnography. Protocols of MMA as a primary vs. secondary operation, with and without adjunctive procedures in a site-specific approach, are compared and discussed. RESULTS: As an extrapharyngeal operation that enlarges and stabilizes the entire veloorohypopharyngeal airway, MMA, which can be safely combined with adjunctive non-pharyngeal procedures, may circumvent the staging dilemmas associated with multiple, less successful, segmental, invasive, pharyngeal procedures. In accordance with current goals and guidelines governing OSAS surgery, MMA does not need to be limited to severe OSAS cases as a last resort after other procedures have failed but, rather, is also indicated as an initial operation for (velo-oro)hypopharyngeal narrowing. CONCLUSIONS: MMA is a highly successful and potentially definitive primary single-staged surgery that may result in a significant reduction in OSAS-related health risks, as well as financial savings for the health care system. CLINICAL IMPLICATIONS: The diagnosis and management of OSAS requires a multidisciplinary team approach, including a working relationship between the dentist and sleep physician. General dentists and dental specialists who participate in the management of snoring and OSAS cases should have some knowledge of basic sleep medicine.