Uvulopalatopharyngoplasty, maxillomandibular advancement, and the velopharynx

Non-sleep related outcomes of maxillomandibular advancement, a systematic review

Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.

An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea

Background

Obstructive Sleep Apnoea (OSA) is a common sleep disorder marked by partial or total obstruction of the upper airway while a person is asleep leading to breathing difficulty, reduced oxygenation and frequent awakenings. This condition affects the general health significantly compromising quality of life. The objective of this overview  is to thoroughly assess the systematic reviews on current surgical therapies for the management of OSA in terms of patient outcomes.

Methods

A thorough literature search was performed from inception till 31st December 2022 using PubMed, and Cochrane databases. Studies evaluating the effectiveness and safety of different surgical techniques for the management of OSA were considered. The quality of articles was assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and Glenny et al. checklist.

Results

Out of eighteen studies, only seven studies met the inclusion and exclusion criteria. Results showed that the majority of studies were in the pediatric age group except one systematic  review which assessed the adult age group.

Conclusion

None of the published articles had compared all surgical procedures based on the standard evaluating procedure nor followed all reporting guidelines in the primary studies. For better implementation, further multi center studies are warranted with unique reporting criteria and guidelines about pre- as well as post-operative phases. Future research should concentrate on contrasting strategies, combination therapies, and evaluating long-term effects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-023-02051-x.

Maxillomandibular Advancement and Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: A Systematic Review

This systematic review aimed to comparatively evaluate the efficacy and safety of maxillomandibular advancement (MMA) and upper airway stimulation (UAS) in obstructive sleep apnea (OSA) treatment. A MEDLINE and Embase database search of articles on MMA and/or UAS for OSA was conducted. Twenty-one MMA studies and nine UAS studies were included. All the MMA studies demonstrated a reduction in apnea hypopnea index (AHI) postoperatively, and success rates ranged from 41.1% to 100%. Ten MMA studies reported pre- and postoperative Epworth sleepiness scale (ESS), and all but one study demonstrated a reduction in ESS. In the UAS studies, all but one demonstrated a reduction in AHI, and success rates ranged from 26.7% to 77.8%. In the eight UAS studies reporting pre- and postoperative ESS, an ESS reduction was demonstrated. No studies reported any deaths related to MMA or UAS. The most common postoperative complications after MMA and UAS were facial paresthesia in the mandibular area and discomfort due to electrical stimulation, respectively. This systematic review suggests that both MMA and UAS are effective and generally safe therapies for OSA. However, due to the limitations of the included studies, there is no evidence yet to directly compare these two procedures in OSA treatment.

Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis

Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which target different levels of airway obstruction. The objective of this review was to comparatively evaluate the clinical efficacy and safety of MMA and MLS in the treatment of OSA. MEDLINE and Embase databases were searched for studies on MMA and/or MLS in OSA patients. Twenty MMA studies and 39 MLS studies were identified. OSA patients who underwent MMA showed significant improvements in AHI, LSAT, ODI, and ESS by -46.2/h, 13.5%, -30.3/h, and -8.5, respectively. The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%, respectively. Patients who underwent MLS showed significant improvements in AHI, LSAT, ODI, and ESS by -24.7/h, 8.7%, -19.1/h, and -5.8, respectively. The pooled surgical success and cure rates for MLS were 65.1% and 28.1%, respectively. The rates of major complication of MMA and MLS were 3.2% and 1.1%, respectively, and the rate of minor complication of MMA was higher than that of MLS. We conclude that both MMA and MLS are effective treatment options for OSA. Compared to MLS, MMA may be more effective in improving OSA. However, the complication rate of MMA is higher.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis

Objective

To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA).

Data Sources

The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE.

Review Methods

Three authors systematically reviewed the international literature through July 26, 2018.

Results

A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term.

Conclusion

The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Quality of Life Assessment After Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea

PURPOSE

Although maxillomandibular advancement (MMA) surgery is highly efficacious for the management of obstructive sleep apnea (OSA), little information exists regarding the subjective effect of this treatment modality. The present study was undertaken to investigate the effect of MMA on patient-perceived quality of life (QOL) in OSA.

PATIENTS AND METHODS

A retrospective cohort study of patients treated with MMA for OSA from May 2010 to April 2015 was performed. The primary outcome measure was a change in the QOL detected using the Ottawa Sleep Apnea Questionnaire (OSA-Q), which assesses the MMA-related changes in QOL with a 5-point Likert scale. The secondary outcome measure was a change in the apnea hypopnea index (AHI).

RESULTS

Twenty-two patients participated in the present study. The mean maxillary and mandibular advancement were 8.36 and 11.08 mm, respectively. The AHI decreased from 42.4 to 6.9 events per hour postoperatively (P < .001). The QOL improved significantly after MMA (OSA-Q score 3.98 ± 0.35; P < 001). The sleep quality (4.35 ± 0.63), daytime function (4.13 ± 0.46), physical health (4.19 ± 0.45), mental and emotional health (4.02 ± 0.55), and sexual health (3.78 ± 0.62) categories all improved postoperatively (P < .001). The MMA-related side effects did not adversely affect the QOL.

CONCLUSIONS

MMA for OSA significantly improves patient's subjective overall QOL, with few MMA-related side effects.

Maxillomandibular Advancement and Tracheostomy for Morbidly Obese Obstructive Sleep Apnea

Objective

The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m2) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes.

Data Sources

MEDLINE, Scopus, Web of Science, and the Cochrane Library.

Review Methods

A search was performed from inception through April 8, 2014, in each database.

Results

Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m2) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m2) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h ( P < .00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% ( P < .00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h ( P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h ( P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% ( P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy ( P = .0034).

Conclusion

Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea

PURPOSE

The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay.

MATERIALS AND METHODS

A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables.

RESULTS

Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression.

CONCLUSION

Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

[Surgical treatment of Obstructive Sleep Apnea Syndrome. Functional assessment]

INTRODUCTION

Obstructive Sleep Apnea Syndrome (OSAS), when associated with adverse skeletal dysmorphia, can be managed by curative surgery i.e. advanced maxillomandibular associated with genioplasty and uvulopalatoglossoplasty ("6 in 1"). The purpose of this study was to assess the functional impact of this procedure.

MATERIALS AND METHODS

This retrospective study was made on 27 patients with OSAS surgically treated between 1998 and 2009. The functional results were considered satisfactory when postoperative apnea/hypopnea index (AHI) was <15/h and/or at least decreased by 50%.

RESULTS

After surgical treatment, the AHI dropped below 15/h for 70.4%, and for 92.6% it was at least decreased by 50%, one year after surgery. A significant concomitant decrease of the body mass index (BMI) was also observed.

DISCUSSION

This "6 in 1" surgical management seemed to effectively treat OSAS in the selected cases.

Cephalometric analysis of modifications of the pharynx due to maxillo-mandibular advancement surgery in patients with obstructive sleep apnea

Cephalometry has been used to measure hard and soft facial tissues, as well as the pharyngeal air space for the diagnosis of obstructive sleep apnea (OSA). The changes occurring in the pharynx due to maxillo-mandibular advancement (MMA) have not been established or quantified. The objective of this study was to identify the anatomical changes of the pharynx and of hard tissues that occur in patients with OSA after MMA. 19 patients with a polysomnographic diagnosis of OSA were submitted to cephalometric analysis before and 6 months after surgery in order to evaluate the changes produced by MMA in the pharynx and soft tissues. Cephalometry was standardized in order to obtain descriptive measurements of the dimensions of the airways, the position of the hyoid bone, and maxilla-mandibular relations. The modifications of the pharynx due to MMA showed a significant relation obtained by cephalometry. For each millimeter of maxillary and mandibular bone advancement there was a 0.76mm increase in the retropalatal region and a 1.2mm increase in the pharynx in the retrolingual region. In addition, MMA promoted a significant repositioning of the hyoid bone in the cranial direction.

Effects of orthognathic surgery on oropharyngeal airway: a meta-analysis

Oropharyngeal changes caused by orthognathic surgery have been a concern because the sleep quality of patients may be enhanced or worsened by these changes. The purpose of this meta-analysis was to identify, review and compare scientific literature about changes in airway in adult patients undergoing orthognathic surgery to correct anteroposterior osseous discrepancies. An electronic search of four databases was carried out up to July 2010, with supplemental hand searching of the references of the retrieved articles. Quality assessment of the included articles was carried out. Data were extracted and a meta-analysis was performed. Heterogeneity was assessed amongst the studies and results were presented in forest plots. 49 studies met the inclusion criteria. Only studies with moderate or high methodological soundness were included in the review. Moderate evidence was found to support a significant decrease in the oropharyngeal airway in mandibular setback surgery, a milder decrease in bimaxillary surgery to correct Class III and an increase in maxillomandibular advancement surgery. Evidence is lacking on airway volume changes after orthognathic surgery.

Reoperative treatment of obstructive sleep apnea

Over the last several decades, various surgical treatments have been advocated and used to treat obstructive sleep apnea. Treatments ranging from aggressive procedures, such as tracheostomy, to the least-invasive procedures, such as radioablation, have not yielded satisfactory results. One of the major causes for surgical failures and lower success rates lies in the inadequate understanding and appreciation of the anatomic and pathophysiologic factors that contribute to upper airway obstruction. In some cases, combinations of various surgical techniques may help improve the conditions. This article reviews several major types of surgical procedures, their complications, and the recommended approaches for retreatments.

Complications of hyoid suspension in the treatment of obstructive sleep apnea syndrome

The objectives of the study are to assess adverse events and complications of hyoid suspension (HS) as a treatment of obstructive sleep apnea syndrome (OSAS). The study design was cohort. Thirty-nine patients with OSAS and obstruction at tongue base level, as assessed by sleep endoscopy, underwent HS. Information about adverse events and complications were obtained by reviewing charts and patient-completed questionnaires. The mean follow-up period from surgery to last control visit was 13.1 months (range 2-38). The charts demonstrated mainly adverse events. Minor complications occurred in six patients. No major complications were observed. The mean admission duration was 3.3 days (range 2-5). Twenty-six patients (67%) returned their questionnaires. No association was found between completing questionnaires and the success of the intervention (p = 0.73). The questionnaires were completed on average 25.9 months (range 3.5-51.5) after surgery. VAS scores showed a fast decline in complaints regarding taste, speech, swallowing and pain. No significant long-term differences were found, when comparing the postoperative VAS scores with the preoperative VAS scores. Of the 26 evaluable questionnaires, 20 patients (77%) would recommend HS to an acquaintance if they suffered from sleep apnea syndrome, when only taking side effects into consideration. The intention to give a positive recommendation did not seem to be related to the therapeutic success of the intervention. In conclusion, this study demonstrates that the complication rate of HS is low and that the discomfort is very acceptable.

Influence of UPPP surgery on tolerance to subsequent continuous positive airway pressure in patients with OSAHS

To investigate the effect of uvlopalatopharyngoplasty (UPPP) on post-surgery continuous positive airway pressure (CPAP) treatment during sleep in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Thirty-one OSAHS patients after UPPP surgery were recruited and studied on for more than 12 months after the procedure. Among them, 24 patients were treated with classical UPPP (cUPPP), which removes all of uvula and part of the soft palate. Seven had modified UPPP (mUPPP), keeping part of the uvula. The control group was 31 years in age, body mass index (BMI) and apnea-hypopnea index (AHI) matched, and newly diagnosed OSAHS patients without prior treatment. A manual titration of CPAP was performed during both (NREM) and non-rapid eye movement (NREM) sleep in all 62 patients. Patients were asked to keep a supine position while sleeping during the test. When significant mouth air leakage occurred and/or titration worsened with an increase of CPAP pressure, the pressure level was considered as the highest CPAP (hCPAP) a patient can tolerate in that sleep stage. The CPAP machine used for titration could produce highest pressure at 20 cm H2O. There were 74% (23/31) of UPPP patients who had less than 50% decrease in AHI, and 84% (26/31) of the 31 patients still had AHI>15 (range 16-110) during post-operation polysomnography (PSG) test. Most of them need further CPAP therapy. All of the untreated OSAHS patients could tolerate 17-20 cm H2O of CPAP during sleep. None had severe mouth air leak before an optimal pressure was reached. In contrast, four in the surgery group failed to respond to CPAP treatment during both NREM and REM sleep and one more during REM sleep. All of the seven patients who had a mUPPP could tolerate CPAP. One of the three tested both before and after surgery failed in the CPAP treatment after surgery during REM sleep. UPPP may compromise nasal CPAP therapy in OSAHS, especially in procedures with greater resection of the soft palate.

Changes in nasorespiratory function in association with maxillary distraction osteogenesis in subjects with cleft lip and palate

OBJECTIVE

The current study aimed to determine how nasorespiratory function changes in association with maxillary distraction osteogenesis (DO). Furthermore, with regard to impaired nasorespiratory function, the possibility of a relationship between the cleft side and laterality and any effect of maxillary distraction osteogenesis was investigated.

DESIGN

In this descriptive, prospective clinical report, subjective and objective data regarding nasorespiratory function before and after maxillary distraction osteogenesis were compared.

SUBJECTS

Data from 13 subjects with cleft lip and palate were used. Subjects had a severe maxillary deficiency and underwent distraction osteogenesis using a rigid external device system.

OUTCOME MEASURES

The subjective measure was the score on a questionnaire regarding nasorespiratory function using a visual analog scale. The objective measure was nasal resistance.

RESULTS

The visual analog scale score for two items significantly decreased just after distraction osteogenesis. Nasal resistance also significantly decreased 1 year after distraction osteogenesis. Moreover, nasal resistance on the cleft side was significantly greater than that on the noncleft side just before and 1 year after distraction osteogenesis. There was a significant positive correlation between changes in the visual analog scale score and nasal resistance.

CONCLUSIONS

These results suggest that nasorespiratory function changes in association with maxillary distraction osteogenesis in subjects with cleft lip and palate. Moreover, it appears that nasal obstruction on the cleft side does not change in subjects with unilateral cleft lip and palate.

The surgical treatment of obstructive sleep apnea

Obstructive sleep apnea is a highly prevalent disorder that significantly increases mortality when it is moderate to severe. Continuous positive airway pressure (CPAP) provides excellent relief to sleep apnea in the majority of patients. Unfortunately, many patients cannot tolerate CPAP and seek surgical alternatives. The reported surgical success rates range between 25 and 100% with most studies achieving a 50-70% success rate. The severity of the sleep apnea, as well as the patient's physical features influence the surgical success rate. Patients with mild sleep apnea should be treated if systematic. Treatment should be encouraged for patients with moderate to severe sleep apnea because of the decrease in life expectancy and other associated morbidities. Current surgical procedures include uvulopalatopharyngoplasty, genioglossus advancement, radiofrequency ablation to the base of tongue, tongue suspension, maxillomandibular advancement, and tracheostomy.

Evidence-based medicine in sleep apnea surgery

Since the first description of sleep apnea as a clinical entity, the understanding of it within the medical community has increased significantly. Much research has explored the causes, assessment, and treatment of this disease. This research has resulted in a variety of tools for assessment and approaches to treatment. As research progresses, new data have shed light on the strengths of traditional approaches and their limitations. This article gives background for current approaches and charts a potential future course for sleep apnea assessment and treatment.