Apnea” is the Greek word for “without breath.” Obstructive sleep apnea (OSA) was ( 1837) First Charles Dickens term “Pickwickian syndrome” described a similar presentation of a typical OSA patient; obese, somnolent, and with an excessive appetite.

1. DEPT OF ORTHODONTICS& DENTOFACIAL
ORTHOPAEDICS
PEOPLES DENTAL ACADEMY
BHOPAL(M.P)
Surgical Procedures for the Treatment of
OSA
Kok Weng Lye and Joseph R. Deatherage
Seminars in Orthodontics, Vol 15, No 2 (June), 2009: pp 94-98.
PRESENTED BY
DR BHAGWAT R.
KAPSE
PG II year STUDENT
1

2. Apnea” is the Greek word for “without
breath.”
 Obstructive sleep apnea (OSA) was
( 1837) First Charles Dickens term
“Pickwickian syndrome”
 described a similar presentation of a
typical OSA patient; obese, somnolent,
and with an excessive appetite.
2

3. In 1956 Sidney Burwell documented a
case of an OSA patient,
 rationalized the signs and symptoms,
 and made a distinction between this
disease and other illnesses.
The prevalence of the disease has been found to
be 8% in men and 2% of women (United
States).
 Carlson JT, Hedner JA, Ejnell H, et al: High prevalence of hypertension in sleep apnea patients
independent of obesity. Am J Respir Crit Care Med 150:72-77, 1994
3

4. This chronic condition has wide ranging
effects,from health problems to serious
social and financial consequences.
 The collapse and blockage of the airway leads to
1. Snoring,
2. Multiple arousals,
3. Sleep fragmentation,
4. Hypoxia, and
5. Reperfusion injuries.
4

5. Snoring
 The snoring is a result of the
vibration of the tissues of the
posterior airway caused by the
narrowing of the airway and air
turbulence.
 Thus reduced air flow causes
hypoxia and hypercapnia which
lead to arousals and sleep
fragmentation.
5

6. This chain of events results in excessive
daytime sleepiness (EDS) in 90% of OSA
patients.
 In turn, EDS affects concentration, cognition,
and ability to work effectively and may lead
to traffic accidents.
 Young T, Blustein J, Finn L, et al: Sleep-disordered breathing and motor vehicle accidents in
a population based sample of employed adults. Sleep 20:608-613, 1997
6

7. Physiologically, OSA may bring about Arrhythmias,
 Heart failure,
 Ischemic heart disease,
Systemic and pulmonary hypertension,
 Neurological complications reperfusion .
7

8.  In fact, it is a potential life-threatening
problem. If left untreated, has a mortality rate of 37%
in moderate-to-severe OSA during a period of
8 years.
 He J, Kryger MH, Zorick FJ, et al: Mortality and apnea index in obstructive sleep apnea:
Experience in 385 male patients. Chest 94:9-14, 1988
8

9. Diagnosis of OSA
It is made from a detailed physiological
examination during sleep called
polysomnography.
This is the required objective investigation for
the confirmation of the presence and severity
of the condition.
It is also able to pickup other sleep disorders
like narcolepsy, periodic limb movement
disorder and central sleep apnea.
9

10. The various parameters calculate the
amount of apneas
1. Cessation of air flow for more than 10 s
2. Hypopnea i.e decrease in air flow by 50%
with significant oxygen desaturation
3. Quality of sleep i.e amount of REM, stage 3
and stage 4 sleep.
10

11. Including an accurate medical history, physical
examination, airway analysis, and other
additional aids to identify the sites of
obstruction in the airway.
 Some medical conditions, i.e chronic
obstructive pulmonary disease, muscular
dystrophy, cardiac dysfunction, hypothyroidism,
and pituitary tumors.
 Davila DG: Medical considerations in surgery for sleep apnea, In Waite PD (ed). Oral and
Maxillofacial Treatment of Obstructive Sleep Apnea. Oral Maxillofac Surg Clin North Am 7:205219, 1995
11

12.  Physical examination
Weight and body mass index .
 A neck circumference > 43.2 cm is also a
positive risk factor for OSA.
 MathurR,DouglasNJ:Familystudiesinpatientswiththe sleep apnea-hypopnea syndrome. Ann
Intern Med 122: 174-178, 1995
12

13. Clinical examination
 Any nasal septal deviation, internal or
external valve collapse, turbinate
hypertrophy, nasal polyps, chronic sinusitis,
which leads to increased negative inspiratory
pressure and bring about collapse in the
posterior airway.
 Lavie P, Fischel N, Zomer J, et al: The effects of partial and complete mechanical occlusion
of the nasal passages on sleep structure and breathing in sleep. Acta Otolaryngol 95:161166, 1983
13

14. Clinical examination
nasopharynx, oral pharynx, and hypopharynx
are examined with the aid of a flexible
endoscope.
 The presence and size of any adenoid
hypertrophy in the nasopharynx may be of
significance and is noted.
14

15.  The focus of interest is in the retropalatal
and retroglossal openings.
It is examined during normal breathing. Its
shape and any constrictions in the
anteroposterior or lateral dimensions are
noted.
 Muller’s maneuver is also performed to to
correlate to the OSA severity.
Terris DJ, Hanasono MM, Liu YC: Reliability of the Muller maneuver and its association with
sleep-disordered breathing. Laryngoscope 110:1819-1823, 2000
15

16. Muller’s maneuver
• In this maneuver, the patient attempts to
inhale with his mouth closed and his nostrils
plugged, which leads to a collapse of the
airway.
• Introducing a flexible fiberoptic scope into
the hypopharynx to obtain a view, the
examiner may witness the collapse and
identify weakened sections of the airway.
16

17. Flexible fiberoptic scope
 A positive test
results means the
site of upper airway
obstruction is likely
below the level of
the soft palate, and
the patient will
probably not benefit
from a UPPP alone.
17

18. The retroglossal opening is the airway at the
tongue base level.
The dimension at this level is ascertained to
judge the contribution of any macroglossia or
retro positioning of the tongue and mandible
towards the OSA.

Kuna ST, Bedi DG, Ryckman C: Effect of nasal airway positive pressure on upper airway size
and configuration. Am Rev Respir Dis 138:969-975, 1988
18

19. • Presence of enlarged lingual tonsils is also a
contributory factor .
• The hypopharynx is checked for any
restrictions secondary to growths, laryngeal
changes and vocal cords abnormalities.
19

20. Oral examination
Should focus on
 Length of the soft palate,
 Size of the palatine tonsils,
Width of the palatal vault and dental arches.

20

21. • The Mallampati
scale is used to
evaluate the
oropharyngeal soft
tissues and the
potential for
airway obstruction.
21

22. • Mallampati Scoring:
• Class I: Soft palate,
uvula, fauces, pillars
visible.
• Class II: Soft palate,
uvula, fauces visible.
• Class III: Soft palate,
base of uvula visible.
• Class IV: Only hard
palate visible
22

23. The Friedman score has been developed to
assess the relationship between tongue
position,tonsil size, and body mass index and
the likely success of soft tissue surgical
procedures.
 Friedman M, Ibrahim H, Bass L: Clinical staging for sleep-disordered breathing. Otolaryngol
Head Neck Surg 127:13-21, 2002
23

24. Fujita et al categorized the upper airway
obstruction as either retropalatal or
retroglossal.
i. The retropalatal level involves the soft
palate, uvula, and palatine tonsils.
ii. The retroglossal level involves the tongue
base and supraglottic structures.
Fujita S: Obstructive sleep apnea syndrome: Pathophysiology, upper airway evaluation and
surgical treatment.Ear Nose Throat J 72:67-72, 75-76, 1993
24

25.  Type I obstruction is the presence of
restriction only at the retropalatal level.
 TypeII obstruction is the presence of
restriction only at the retroglossal level.
 Type III is the presence of both obstructions
at both levels.
25

26. Moore considered the airway
obstruction as a spectrum of disease,
Starting from primary snoring as the mildest
form,
Upper airway resistance syndrome (UARS)
And then to the different degrees of OSA;
1. mild,
2. moderate,
3. severe.
26

27. Treatment
 Colin Sullivan (1981 )that Continuous
positive airway pressure (CPAP) could
pneumatically splint open the collapsed
airway and eliminate apneas and hypopnea.
•
Sullivan CE, Issa FG, Berthon-Jones M, et al: Reversal of obstructive sleep apnoea by
continuous positive airway pressure applied through the nares. Lancet 1:862-865,1981
27

28.  CPAP has been the
gold standard in the
treatment of OSA.
There are only
minimal side effects
with this mode of
treatment.
28

29.  However, despite its high efficacy,patients
frequently cannot tolerate its usage every
night for life and thus long-term acceptance
has been found to below.
This has been consistent even with
advancement in mask and air pressure
delivery system technology.
•
Richard W, Venker J, den Herder C, et al: Acceptance and long-term compliance of nCPAP in
obstructive sleep apnea. Eur Arch Otorhinolaryngol 264:1081-1086, 2007
29

30. The dental fraternity fabricated the
mandibular advancement devices (MAD) for
these patients as another form of non
invasive therapy.
 Complications associated with long term
usage of the MADs,such as TMJ problems and
changes in the occlusion.
 Hoffstein V: Review of oral appliances for treatment of sleep-disordered breathing. Sleep
Breath 11:1-22, 2007
30

31.  When the nonsurgical therapies for OSA fail or are
unacceptable to the patients, surgical options are
considered.
 1964, Ikematsu started treating snoring with a soft
palate procedure known as
Uvulopalatopharyngoplasty (UPPP).
 The first surgical treatment for OSA was tracheotomy
in 1969 by Kuhol.


Ikematsu T: Study of snoring, forth report: Therapy. J Jpn Otorhinolaryngol 64:434-435, 1964
Kuhol W, Doll E, Franck MC: Erfolgreiche Behandlung eines pickwick syndrome Dutch eine duwertracheal
kanule. Dtsch Med Wochenschr 94:1286-1290, 1969
31

32.  The first surgical
treatment for OSA
was tracheotomy
in 1969 by Kuhol.

Kuhol W, Doll E, Franck MC: Erfolgreiche Behandlung
eines pickwick syndrome Dutch eine duwertracheal
kanule. Dtsch Med Wochenschr 94:1286-1290, 1969
32

33. 33

34. Moore’s concept,
Derived from Moore’s concept, two
principles of therapy.
1. First principle states that the entire upper
airway is affected, especially in moderate
and severe OSA.
2. The second states that the more severe the
disorder, the more aggressive the surgical
therapy has to be to achieve success.
34

35. Long-Term Results of Surgery to Treat
OSA
35

36. DefiningSurgicalCure/Success
Based mainly on objective measures.
 In 1981,Fujita et al stated that success is
achieved if there is a 50% reduction in the
postoperative apnea index.
 Waite et al set their success level at a final
RDI(respiratory distress index) less than 10
and no desaturations of less than 90%.

Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic abnormalities in obstructive sleep
apnea syndrome: Uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 89:923-934, 1981
36

37. • Currently, the commonly accepted definition
for surgical cure is RDI or apnea-hypopnea
index less than 20 with a reduction greater
than 50% and few desaturations less than
90% wit improvement of subjective
symptoms.
37

38. Surgical
MaxillomandibularAdvancement
Technique
Kok Weng Lye and Joseph R. Deatherag
.
Semin Orthod VOL 15 NO.2 JUNE 2009;15:99-104
38

39. Hard tissue surgery for obstructive sleep
apnea (OSA) treatment includes1. Genioglossus advancement (GGA)
2. Maxillomandibular advancement (MMA).
Troell RJ, Riley RW, Powell NB, et al: Surgical management of the hypopharyngeal airway in
sleep disordered breathing. Otolaryngol Clin North Am 31:979-1012,1998
39

40. Genioglossus advancement surgery
initially was
described as a
rectangular
osteotomy at the
chin, which contains
the genial tubercles.
40

41.  GGA has been a frequently performed
procedure, but not as an isolated one, to treat
OSA.
 GGA often is performed together with
uvulopharyngopalatoplasty, with an acceptable
success rate of 80% for moderate OSA
(respiratory distress index 21 to 40),
 64% for moderately severe OSA (RDI 41–60),
and only 15% for severe OSA (RDI 61).
•
Hendler BH, Costello BJ, Silverstein K, et al: A protocol for uvulopalatopharyngoplasty, mortised
genioplasty, and maxillomandibular advancement in patients with obstructive sleep apnea: an
analysis of 40 cases. J Oral Maxillofac Surg 59:892-897, 2001
41

42. Maxillomandibular advancement
surgery
• Kuo et al (1979) The
treatment involved the
advancement of the maxilla
and mandible via
traditional orthognathic
surgery, which was then
called MMA.
•
Kuo PC, West RA, Bloomquist DS, et al: The effect
of osteotomy in three patients with hypersomnia
sleep apnea.OralSurgOralMedOralPathol48:385
42

43. Skeletal attachment of the suprahyoid and
velopharyngeal muscles and tendons and an
increase in volume of the nasopharynx,
oropharynx, and hypopharynx.
 Together, this advancement leads to the
anterior movement of the soft palate,
tongue, and anterior pharyngeal tissues
•
Kuo PC, West RA, Bloomquist DS, et al: The effect of osteotomy in three patients with
hypersomnia sleep apnea.OralSurgOralMedOralPathol48:385
43

44. Subsequently, an enlargement of the
posterior airway and a decrease in laxity of
the pharyngeal tissues ensues and results in a
decrease in the obstruction of the posterior
airway space.
Since 1979,there have been several
publications that showed overall success
rates of 96%, 97%,98%, and 100%.
•
Prinsell JR: Maxillomandibular advancement surgery in a site-specific treatment
approach for obstructive sleep apnea in 50 consecutive patients. Chest 116:15191529,1999
44

45. Li et al showed a 90%success rate for a group of
40 patients with a mean follow-up period
exceeding 50 months.
 These results are further supported by a study
examining the surgical stability of MMA,
 which found that the large horizontal
advancement of the maxilla and mandible is
stable and without significant relapse.
•
•
Li KK, Powell NB, Riley RW, et al: Long-term results of maxillomandibular
advancement surgery. Sleep Breath 4:137-140, 20009. Nimkarn Y, Miles PG,
Waite PD: Maxillomandibular advancement surgery in obstructive sleep apnea
syndrome patients: Long-term surgical stability. J Oral Maxillofac Surg 53:14141418, 1995
45

46. 2 Philosophies regarding
the use of MMA.
Some groups believed in a 2-stage protocol
where MMA is the stage 2 procedure
if stage 1, which consists of
uvulopharyngopalatoplasty,GGA, and hyoid
suspension,fails.
•
Bettega G, Pepin JL, Veale D, et al: Obstructive sleep apnea syndrome. Fifty-one
consecutive patients treated by maxillofacial surgery. Am J Respir Crit Care Med 162:641649, 2000
46

47. Uvulopharyngopalatoplasty (UPPP)
47

48.  This latter protocol was developed to reduce the
use and complications of the more invasive
MMA procedure for patients who would have
responded to the first-stage procedures.
 In the landmark study from which this protocol
was developed, the authors found that the
success rate was 60% for stage 1 surgery and
97% for stage 2 surgery.
•
Riley RW, Powell NB, Guilleminault C, et al: Obstructive sleep apnea: A review of 306
consecutive treated patients. Otolaryngol Head Neck Surg 108:117-125,1993
48

49. For these reasons, other groups of clinicians
believe in using the most efficacious
technique from the start and proceeding
directly with MMA.
 Waiteetal,in a key study,evaluated patients
who had had MMA surgery together with
septoplasty and inferior turbinectomies.
•
•
Hochban W, Conradt R, Brandenburg U, et al: Surgical maxillofacial treatment of
obstructive sleep apnea. Plast Reconstr Surg 99:619-626, 1997
Waite PD, Wooten V, Lachner J, et al: Maxillomandibular advancement surgery in 23
patients with obstructive sleep apnea syndrome. J Oral Maxillofac Surg 47:12561261, 1989
49

50. They achieved a success rate of 96%.
 Based on the criteria of a 50% reduction in
the RDI and a final RDI of less than 20,
 Hochban et al and Prinsell also used MMA as
the primary procedure for 38 and 50 OSA
patients, achieving 97% and 100% success
rate, respectively.
•
Hochban W, Conradt R, Brandenburg U, et al: Surgical maxillofacial treatment of obstructive sleep
apnea. Plast Reconstr Surg 99:619-626, 1997
50

51. Indications and Contraindications
for MMA
To be a suitable patient for MMA treatment,
a few prerequisites are necessary.
 The patients’ apnea-hyponea index or RDI
must be greater than 15, with a lowest
desaturation 90% and subjective excessive
daytime sleepiness.
•
Prinsell JR: Maxillomandibular advancement surgery for obstructive sleep apnea syndrome.
J Am Dent Assoc 133:1489-1497, 2002
51

52. In addition, conservative treatments, such as weight loss,
mandibular repositioning devices,
 continuous positive airway pressure, must
have been unsuccessful or intolerable for the
patient.
The patient must also be medically fit to
undergothesurgery.
52

53. MMA should be the procedure of choice.
First, there should be obstruction at multiple
sites .
 Second, the patient should present with a
dentofacial skeletal deformity and
malocclusion, ( Class II relationship)
 MMA surgery should be able to provide an
opportunity to obtain multiple benefits.
53

54. Contraindications
for MMA
Patients who do not meet the criteria for the
MMA procedure .
who are unwilling and/or unable to undergo
MMA surgery should be excluded.
54

55. Surgical Planning and Technique
MMA is primarily orthognathic surgery in
which the maxilla and mandible are
advanced through osteotomies.
 Surgery requires all the relevant
preoperative records and planning, such as
facial examination, radiographs,
cephalometric analysis,
nasopharyngoscopy and model surgery.
55

56.  Preoperative orthodontic treatment should be
used to ensure a good postoperative occlusion
as well as correcting any pre-existing
malalignment of the teeth to enhance the
cosmetic appearance of the patients.
 Many OSA patients are older and are unwilling
to undergo the recommended orthodontic
phase of the treatment, or they may not wish to
delay the treatment of their OSA condition.
56

57. Some OSA patients may have multiple
missing teeth, active advanced periodontal
disease, or complex fixed prosthodontic
restorations,
which may complicate orthodontic
treatment.
 The patients’ problem is often a functional
one, and they may be less concerned with
the esthetic improvement of Rx.
57

58. Orthodontics
The objectives of presurgical
orthodontic treatment for MMA
patients is different from those of
routine orthognathic surgery for
patients who have dentofacial
deformities.
 For the MMA patients, the purpose
of the presurgical orthodontic
treatment is to assist in maximizing
the anterior positioning of the
maxilla and mandible while
attempting to obtain a reasonable
occlusion.
58

59. In Class II patients, it is advisable to retract
the lower incisor teeth and procline the
upper incisor teeth to maximize the amount
of mandibular advancement.
 This step will provide the greatest amount of
airway improvement.
59

60. lateral cephalogram is a standardized and
repeatable radiograph that presents the
profile view of the viscerocranium.
 It is a routine tool for the diagnostic workup
of all OSA patients.
 Cephalometric analysis helps to confirm the
clinical and nasopharyngoscopy findings.
60

61. The values of different parameters in the
analysis can be compared to normal values to
characterize the craniofacial relationship and
the posterior airway status.
Cephalometric analysis reveals the severity
of any craniofacial dysmorphy or
abnormalities.
61

62. Studies have referred to the retro-positioning of
the jaws,
 Short mandibular length,
 Long anterior face height,
Clockwise rotation of the facial structure,
Short cranial base,
Decreased craniofacial flexure angle as common
abnormalities found in OSA patients.
•
Steinberg B, Fraser B: The cranial base in obstructive sleep apnea. J Oral Maxillofac Surg 53:11501154,1995
62

63. In terms of treatment planning,
 It is an important tool to help identify the
patients who have severe craniofacial
deficiency (SNB angle75°),
They should be directly offered MMA
surgery instead of soft tissue procedures. 10
63

64. There are more advanced imaging techniques
to study the posterior airway,
 Cephalometric analysis still offers
considerable advantages,including Low cost,
Ease of use
Minimal radiation exposure.
64

65. Technique
The MMA is
achieved by use of
the standard
bilateral sagittal
split osteotomy
technique for the
mandible and the Le
Fort I level maxillary
osteotomy.
65

66.  The mandible is cut and
a sagittal split is carried
out bilaterally in the
posterior body, angle
and lower ramus
region.
 The proximal segments
with the condyles are
kept in the same
position while the
distal segment;
66

67. The body of mandible, alveolus and teeth,
are advanced according to the prefabricated
occlusal splint into a Class III relationship.
The occlusal splint is made during the
presurgical model surgery.
The inferior alveolar nerve is kept intact but
sustains some tension during the surgical
advancement procedure
67

68.  The distal segment is then fixated with
bicortical screws or titanium miniplates and
screws.
 Performing the mandibular advancement
first creates a more stable occlusal platform.
The advancement of the mandible pulls the
geniohyoid, genioglossus, mylohyoid and the
digastric muscles anteriorly.
68

69. This in turn brings the base of tongue and
hyoid bone forwards and upwards.
In addition, the advancement of the
mandible creates a larger volume for the
tongue and floor of mouth.
These two effects result in the enlargement
of the posterior airway space at the
retroglossal and hypopharyl and
hypopharyngeal region level.
69

70. The maxilla is then cut and mobilized at the
Le Fort I level.
The advancement is then achieved with the
aid of a final occlusal splint or a stable final
occlusion.
The maxilla is then fixated with 4 titanium
plates and screws.
70

71. • There are prebent OSA advancement plates
that are designed for this purpose and have
been shown to be more resistant to relapse.
•
Araujo MM, Waite PD, Lemons JE: Strength analysis of Le Fort I osteotomy fixation:
Titanium versus resorbable plates. J Oral Maxillofac Surg 59:1034-1039, 2001
71

72. Because there is very often a large gap and
minimal bony contact between the upper
and lower segments of the maxilla,
 Bone grafting is necessary to ensure good
bony healing, better stability, and the
minimization of relapse.
72

73. Nasal septal defects and enlarged inferior
turbinates can be treated via the Le Fort
approach after down-fracturing of the
maxilla .
The generally accepted magnitude of
advancement was 10 mm.
73

74. In patients with dysgnathia who undergo
orthodontic treatment the maxilla and
mandible will obviously not be advanced
equal amounts.
An additional procedure to complement the
MMA is the GGA.
•
Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea syndrome: a
surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac
Surg 51:742-747, 1993
74

75. • This could be done
via the rectangular
osteotomy technique
popularized by Riley
et al
• or an inferior
horizontal geniotomy;
the standard chin
osteotomy used in
orthognathic surgery.
75

76. • This technique
increases the
magnitude of
repositioning of the
genioglossus,
geniohyoid and
digastric muscles.
•
Riley RW, Powell NB, Guilleminault C:
Obstructive sleep apnea syndrome: a surgical
protocol for dynamic upper airway
reconstruction. J Oral Maxillofac Surg 51:742747, 1993
76

77. Simultaneous adjunctive soft-tissue procedures
can be considered during the MMA procedure.
 pharyngeal soft-tissue procedures performed
simultaneously with MMA may result in airway
compromise secondary to bleeding and swelling.
 These procedures include surgery to the soft
palate, tonsils, and the tongue. These cases may
need surgical tracheostomy,
 prolonged endotracheal intubation or
continuous positive airway pressure use for the
period of postoperative edema.
77

78. In addition, any tension on the soft-tissue
closure from the skeletal advancement may
lead to poor healing or even fibrosis and
scarring.
 Nonpharyngeal procedures, such as nasal
procedures, cervicofacial liposuction, or
lipectomy can be done simultaneously with
MMA .
•
Prinsell JR: Maxillomandibular advancement surgery in a site-specific treatment approach
for obstructive sleep apnea in 50 consecutive patients. Chest 116:1519-1529, 1999
78

79. Complications
• There are no major complications reported
for the MMA procedure. Various authors
have mentioned some minor complications.
• As the advancement of the mandible is often
10 mm or greater, the incidence of
permanent hypesthesia of the lower lip is
one of the commonest problems.
• Li KK, Troell RJ, Riley RW, et al: Uvulopalatopharyngoplasty,
• maxillomandibular advancement, and the velopharynx. Laryngoscope
111:1075-1078, 2001
79

80. • Studies have shown long term hypesthesia to
be in the range of 13% and 20%. If there is
no concurrent orthodontic treatment,
postoperative occlusal changes, such as
malocclusion and open bites, are relatively
common.1
• Li KK, Troell RJ, Riley RW, et al: Uvulopalatopharyngoplasty,
• maxillomandibular advancement, and the velopharynx. Laryngoscope
111:1075-1078, 2001
80

81. This could result in the need for reoperation,
postoperative orthodontic treatment, or
postoperative prosthodontic rehabilitation.
 When there has been previous or concurrent
soft palate surgery to stiffen or shorten the
palate, velopharyngeal insufficiency can occur.
Velopharyngeal insufficiency results in a lack of
palatal closure and allows air escape during
speech and swallowing difficulty.
•
•
Li KK, Troell RJ, Riley RW, et al: Uvulopalatopharyngoplasty,
maxillomandibular advancement, and the velopharynx. Laryngoscope
111:1075-1078, 2001
81

82. Another complication
• Temporo-mandibular disorder(TMD).
The TMD is caused by the alteration in the
condylar position and increased joint pressure
from the large mandibular advancement.
Pre-existing TMD is a risk factor that may
drastically increase the likelihood of
postoperative TMD.
Additional reported concerns that may arise are
limited range of motion, sinus dysfunction and
decreased bite force.
82

83. • These complications have been observed more
frequently in older patients.
• some other minor complications, such as local
infection, an oro nasal perforation that healed
spontaneously, and maxillary pseudo-union
resulting in instability and that required bone
grafting
83

84. • Minimal postoperative difficulties with a
mean hospital stay of 1.6 days, no significant
impairment from the hypesthesia, and good
patient acceptance of their facial changes.
• Waite et al also showed 95% patient
satisfaction despite the minor complaints.
• . Waite PD, Wooten V, Lachner J, et al: Maxillomandibular advancement surgery in 23
•
patients with obstructive sleep apnea syndrome. J Oral Maxillofac Surg 47:12561261,
1989
84

85. Advances in MMA
In the presence of modern
technology,researchers and clinicians have
started using computed tomography (CT) and
magnetic resonance (MR) scans to evaluate
the posterior airway 3-dimensionally.
This is superior to the widely used 2
dimensional cephalograms
85

86. Cephalometric analysis of the airway has
been well established and permits
measurements at key anatomical locations.
A CT and MR provide extremely accurate
distance and area measurements of the
airway in all dimensions, there
86

87. • In a recent study, 20 patients who underwent
MMA had CT scans preoperatively and
following surgery to analyze the morphologic
changes of the airway.
• The results demonstrated significant increase
in both the anteroposterior and lateral
airway dimensions after MMA surgery.
•
Solow B, Skov S, Ovesen J, et al: Airway dimension and head posture
in obstructive sleep apnoea. Eur J Orthod
• 18:571-579, 1996
87

88. Another area of interest is the emergence of the
“quality-of-life” dimension.
This represents the functional effect of an illness
and its consequent therapy upon a patient, as
perceived by the patient.
 It has been a neglected dimension as clinicians
have been treating patients based on results of
objective investigation.
•
•
Schipper H, Clinch JJ, Olweny CLM: Quality of life studies: Definitions and conceptual
issues, In Spilker B (ed): Quality of Life and Pharmacoeconomics in Clinical Trials (ed
2). Philadelphia, PA, Lippincott-Raven, 1996, pp 11-23
88

89. Nowadays,quality of life is increasingly valued as
an important aspect of patient care.
 There have been very few studies that
examined the changes in the quality of life after
surgical procedures for OSA. Lye recently
reported on MMA having equally high success in
achieving significant improvement in the area of
quality of life.
•
Lye KW, Waite PD, Meara D, et al: Quality of life evaluation of maxillomandibular
advancement surgery for treatment of obstructive sleep apnea. J Oral Maxillofac Surg
66:968-972, 2008
89

90. conclusion,
There is strong evidence to support MMA as
one of the most efficacious surgical
procedure for the treatment of OSA.
 It is a safe procedure and the more
commonly noted complications are relatively
minor as compared to the risk of
inadequately treated OSA.
90

91. There have been some modifications to the
technique and inclusion of some adjunctive
procedures over the years.
There is also essential research being done to
provide the latest information on this
treatment which will help in our
understanding and improve our management
of the OSA patient.
91

92. THANK YOU
92