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Management of sleep apnea by orthosurgery

The goal of this page is to present rational scientific reasons to consider a maxillomandibular advancement orthognathic surgery as the treatment of choice for patients suffering from obstructive sleep apnea syndrome.

We revised the use of mandibular advancement devices (MADs) and of continuous positive airway pressure (CPAP).

Mandibular advancement device

MADs are efficient in the treatment of simple snoring and in cases of light to moderate obstructive apnea, that is an AHI of 5 to 20. Using a MAD for a duration of 6 to 7 hours during the night (more precisely 6.6 to 6.8 hours) has an efficiency that can be compared with the use of CPAP for a duration of 4 hours (Lowe A, AJODO 2012;142:434-42).

Side effects caused by the long-term use of MADs are discomfort in temporomandibular joints, tooth pain, salivation, dry mouth, gingival irritation and change in occlusion.

Alteration of occlusion (movement of teeth) following a prolonged use (1 year, 2 years, 3 years and +) is well documented. Changes in occlusion are progressive in time and can go unnoticed at first until they become permanent afterwards. In a group of 70 individuals having used a MAD over a 7-year period, 44% of these individuals had had changes considered negative. This represents 31 individuals out of the 70 of the study (Almeida et al, AJODO 2006;129:205-13).

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Continuous positive airway pressure

The continuous positive airway pressure machine and its efficiency are previously discussed in detail (see following link). This machine is considered as the gold standard in the treatment of apnea. Let’s remember that it takes an average use of 7 hours during the night and adherence to therapy of more than 90% to reduce an AHI of 30 to 60 to an AHI in the range of 5. A recent study, Craniofacial Changes After 2 Years of Nasal Continuous Positive Airway Pressure Use in Patients With Obstructive Sleep Apnea (CHEST 2010; 138(4):870–874), shows that CPAP nasal mask can be associated with craniofacial changes and changes in the intermaxillary relationship. However, these side effects have little impact considering the great benefits caused by the reduction of the AHI and daytime sleepiness.

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Uvulopalatoplasty

Surgery of the soft palate was described for the first time in 1981 by Fujita et al (Otalaryngol Head Neck Surg 89:923, 1981). This kind of surgery is no longer recommended nowadays, because the success rate is very small (less than 25%). The main reason being that the airway obstruction area is not at the junction of the nasopharynx and the oropharynx. Changes caused to soft tissues are unpredictable and can even shrink pharyngeal airways. Patients having undergone this type of surgery mention that their experience was extremely painful on top of not solving their apnea problem at all.

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Nasal airways

Patient’s nasal septum deviation to the right (black dotted line) and widening of the lower left turbinate (white dotted line)

Any deformity of nasal internal structures can affect nasal air flow and the capacity of an individual to breathe through the nose. It goes without saying that if the nose is not functional for breathing, the individual must then breathe through the mouth. Yet, chronic mouth breathing is associated with a narrower and deeper palate. See the comment on mouth breathing and narrow palate (in French) for more details.

Deformities to consider:

  • Collapsed nostrils (alar cartilage)
  • Nasal septum deviation
  • Widening of turbinates
  • Narrow palate

The X-ray on the opposite side shows a nasal septum deviation (black dotted line) and widening of the lower left turbinate (within the white dotted line). This patient was consulting for an orthosurgery treatment to correct his sleep apnea. Although he knew that he could not breathe through the nose adequately, he did not know that he had such a nasal septum deviation and hypertrophy of the lower turbinate and that it was playing a role in his incapacity to breathe through the nose. He was referred to an ORL and he will undergo surgery to correct this problem.

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Maxillomandibular (bimaxillary) advancement (MMA)

The use of orthognathic surgery to treat sleep apnea started toward the end of the 1970s when it was reported that mandibular advancement had reduced apnea symptoms.

Mandibular advancement repositions several muscles anteriorly, such as the diagastric muscle (anterior belly), mylohyoid muscle, genioglossus and geniohyoid muscles. All these muscles pull the tongue forward and upward and take it away from the pharynx.

Maxillary advancement pulls on tissues of the soft palate upward and forward as well as the palatoglossus muscles, which increases tongue support.

These 2 movements of maxillary and mandibular advancement increase the space available for the tongue and improve the size of nasopharyngeal airways.

Class II division 2. Airway restriction of the oropharynx (white arrows). Backward shift of the lower jaw (yellow arrow). Upper incisor that is too vertical (red arrow).

Post orthosurgery treatment cephalogram. Red arrow: indicates the anterior movement of the symphysis using genioplasty. White arrow: indicates the plate that maintains the genial tubercles in advanced position. Green arrows: indicate the widening of the oropharynx which now measures 10.5 mm.

 

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Comparison of efficiency of a bimaxillary advancement surgery with the use of CPAP

A team of oral surgeons from Dalhousie University in Halifax, headed by Dr Reginald Goodday, published in February 2012 a study comparing subjective results obtained with a MMA surgery with those obtained with the use of CPAP.

A hundred and sixteen (116) individuals participated in the study. They were evaluated according to the Epworth sleepiness scale.

Before bimaxillary advancement surgery:

  • 114 out of the 116, that is 98% of patients snored
  • 109 out of the 116, that is 94% of patients had apnea episodes reported by the spouse
  • 102 out of the 116, that is 88% of patients were using CPAP
  • 72% of patients had a score greater than 10 (>10) on the Epworth scale, which means that they had great chances of falling asleep during various daytime activities (see Epworth questionnaire)

After bimaxillary advancement surgery:

  • 83% of patients no longer snored
  • 94% of patients no longer had apnea episodes reported by the spouse
  • Only 4 patients were using CPAP, which means a reduction of 96% of the use of CPAP after surgery
  • 90% of patients had a score lower than 10 (<10) on the Epworth scale, which means that they had not many chances of falling asleep during their daytime activities
  • 89% of patients said that the surgery was worth it
  • 95% of patients said they would recommend such surgery to other patients suffering from apnea

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Why look for an orthosurgery treatment for apnea?

Patients are looking for a surgical treatment because of daytime sleepiness symptoms, loud snoring and respiratory pauses or arrests observed during their sleep.

They also consult because they have a hard time with their mandibular advancement device or they no longer want to use continuous positive air pressure (CPAP).

Patients who consult me often tried everything.

Whether it be Émile, who underwent uvulopalatoplasty, who tried a MAD for a while, who uses CPAP but has more and more difficulties tolerating it.

Whether it be Claude, who is not able to get used to CPAP and who has been wearing a MAD for more than 3 years, but which MAD has caused so much dental movement that he bites with only 2 teeth.

Whether it be Denis, who underwent uvulopalatoplasty which causes him to have a dry mouth, who wears a MAD, but who developed tinnitus and who only bites with a few teeth. He has a hard time getting used to CPAP.

Whether it be Serge, who is only 40 years old and who uses CPAP successfully, but who does not see himself spending his life with a little compressor to lug around with him for all his trips including vacations down south.

These patients are looking for a potentially definitive treatment to their apnea problem. They want to improve their quality of life and reduce the risks of sleep apnea symptoms on their health.

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References

Lowe AA. Treating obstructive sleep apnea: The case for oral appliances. Am J Orthod Dentofacial Orthop. 2012, Oct;142(4):434-40

Jacobson RL, and Schendel SA. Treating obstructive sleep apnea: The case for surgery. Am J Orthod Dentofacial Orthop. 2012, Oct;142(4):435-42.

Goodday R. Diagnosis, treatment planning, and surgical correction of obstructive sleep apnea. J Oral Maxillofac Surg. 2009, Oct;67(10):2183-96.

Goodday R, and Bourque S. Subjective outcomes of maxillomandibular advancement surgery for treatment of obstructive sleep apnea syndrome. J Oral Maxillofac Surg. 2012, Feb;70(2):417-20.

Boyd SB, and Walters AS. Effectiveness of Treatment Apnea-Hypopnea Index: A Mathematical Estimate of the True Apnea-Hypopnea Index in the Home Setting [Internet]. J Oral Maxillofac Surg. 2012, Jul 5;Available from: http://linkinghub.elsevier.com/retrieve/pii/S0278239112006520?showall=true

Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, and Lowe AA. Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea. Chest. 2010, Oct;138(4):870-4.

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