Maxillomandibular advancement in obstructive sleep apnea syndrome patients: a restrospective study on the sagittal cephalometric variables

Combined orthodontic and surgical open bite correction

OBJECTIVES

To examine the stability of combined surgical and orthodontic bite correction with emphasis on open-bite closure. All study patients were treated with strict and consistent orthodontic and surgical protocols.

MATERIALS AND METHODS

Study inclusion required all patients to have anterior open bites, maxillary accentuated curve of Spee, 36-month minimum follow-up, and no temporomandibular joint pathology. Thirty patients met the inclusion/exclusion criteria. Importantly, segmental upper arch orthodontic preparation (performed by EG) was used. Surgery consisted of a multisegment Le Fort I (MSLFI) combined with a bilateral sagittal osteotomies (BSSO). Surgery was performed (by ADA and LT) at the Department of Dentistry and Maxillofacial Surgery of the University of Verona, Italy.

RESULTS

The long-term open bite and overjet relapse were not statistically significant. The mean transverse relapse of the upper and lower molars was statistically significant. Of great importance, the upper and lower arch widths narrowed together, maintaining intercuspation of the posterior dentition which prevented anterior open bites from developing.

CONCLUSIONS

This study revealed stability of three-dimensional occlusal correction including anterior open bite. Stable open bite closure was achieved by using rigid protocols for orthodontic preparation, surgical techniques, surgical follow-up, and orthodontic finishing.

Review the Impact of Mandibular Setback Surgery for the Correction of Class III Malocclusion on the Upper Airway Space

AIM: This study aimed to review the scientific evidence related to the effect of mandibular setback surgery for the correction of Class III malocclusion on the changes in volume and anatomical structures’ positions of the upper airway within at least 1 year follow-up. METHODS: An electronic research was conducted on PubMed, Google scholar, and Elsevier up to April 20, 2021, the inclusion criteria were prospective or retrospective studies aiming to compare the changes in upper airway space following isolated mandibular setback through at least 1 year of follow-up. RESULTS: A total of 84 studies were retrieved, only 12 studies met the eligibility criteria. Their methods of measurement were using lateral cephalometry, CT, or Cone-beam computed tomography. Most of them showed narrowing in the Pharyngeal airway space, with some variability within the follow-up periods. Impact on the possibility of obstructive sleep apnea (OSA) was discussed in most of the included studies. CONCLUSION: Narrowing of upper airway volume is associated with isolated mandibular setback surgeries within 1 year of follow-up. However, OSA was not necessarily a consequence. Any predisposing factors for OSA should be considered before isolated mandibular setback surgery.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI, and increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

Cephalometric measures correlate with polysomnography parameters in individuals with midface deficiency

To determine the association between cephalometric measurements and polysomnographic parameters in Brazilian patients with midface deficiency. This was a primary, clinical, observational, longitudinal, retrospective, analytical, and single-center study. Forty-eight patients with midface deficiency were divided into two groups as follows: those who underwent surgically assisted rapid palatal expansion (SARME) and those who received maxillary advancement (MA). Pre- and post-operative cephalometric and polysomnography measurements were obtained. Pearson's correlation was used to verify the presence of any significant associations between PSG scores and cephalometric measurements. Associations between BMI (Body Mass Index) and AHI (Apnea Hypopnea Index) as well as arousals were observed. In the SARME group, associations between AHI and SNA, UAS and MP-H, arousals and SNA, and Co-A and MP-H were noted. Associations between AHI and Co-A, PoOr-A and MP-H, arousals and UAS, and between minimum saturation of O2 and SNA, SNB, and Co-A were observed in the MA group. This study demonstrates the alterations in the middle third of the face that were related to sleep disturbance. In addition, it shows the associations between the polysomnographic parameters and the cephalometric representations corresponding to the analyzed deformities and transverse or anteroposterior maxillary deficiencies.

Maxillomandibular advancement effectively treats obstructive sleep apnea in adolescents at short-term follow-up

OBJECTIVE

To evaluate the efficacy of maxillomandibular advancement (MMA) surgery for the treatment of malocclusion and obstructive sleep apnea (OSA) in an adolescent population.

STUDY DESIGN

A retrospective cohort study was designed using electronic medical record chart review.

RESULTS

Fifteen patients aged 20 years or younger (range, 14-20) were included. All patients underwent MMA surgery for the primary correction of malocclusion and secondary treatment of OSA. Mean preoperative apnea-hypopnea index (AHI) was 28.9 ± 16.0 events/h (range, 7.1-54.7), and mean postoperative AHI was 5.7 ± 4.6 events/h (range, 1.5-18.4), reflecting a reduction of 23.2 events/h, an 80.6% reduction (P < .001). Fourteen patients (93.3%) experienced improvement in AHI. Mean minimal posterior airway space increased from 4.6 mm to 8.6 mm (P < .001). Mean posterior airway space at the level of the uvular tip increased from 6.7 mm to 11.5 mm (P < .001). Patients who underwent adjunct genioglossus advancement (GGA) had a mean decrease in AHI of 35.3 events/h (P = .004), which was not significantly different from the decrease in those who did not receive GGA.

CONCLUSIONS

MMA surgery with or without GGA is an effective treatment option for adolescents with a malocclusion and an AHI >5.0 events/h. In this population, it is shown to decrease AHI and increase posterior airway space. More research is required to determine the ideal adolescent candidate for MMA surgery.

Why most patients do not exhibit obstructive sleep apnea after mandibular setback surgery?

Maxillomandibular advancement (MMA) is effective for the treatment of obstructive sleep apnea (OSA). In previous studies, the airway was increased in the anteroposterior and transverse dimensions after MMA. However, the effect of the opposite of mandibular movement (mandibular setback) on the airway is still controversial. Mandibular setback surgery has been suggested to be one of the risk factors in the development of sleep apnea. Previous studies have found that mandibular setback surgery could reduce the total airway volume and posterior airway space significantly in both the one-jaw and two-jaw surgery groups. However, a direct cause-and-effect relationship between the mandibular setback and development of sleep apnea has not been clearly established. Moreover, there are only a few reported cases of postoperative OSA development after mandibular setback surgery.

These findings may be attributed to a fundamental difference in demographic variables such as age, sex, and body mass index (BMI) between patients with mandibular prognathism and patients with OSA. Another possibility is that the site of obstruction or pattern of obstruction may be different between the awake and sleep status in patients with OSA and mandibular prognathism. In a case-controlled study, information including the BMI and other presurgical conditions potentially related to OSA should be considered when evaluating the airway. In conclusion, the preoperative evaluation and management of co-morbid conditions would be essential for the prevention of OSA after mandibular setback surgery despite its low incidence.

Cephalometric analysis of the pharyngeal airway space after maxillary advancement surgery

This study evaluated the effect of maxillary advancement surgery on the size of the pharyngeal airway space (PAS). Lateral cephalometric radiographs were collected for 90 patients (29 men and 61 women; average age, 27.2 ± 8.1 years) before (T1) and 1 year after (T2) maxillary advancement surgery. Horizontal and vertical changes in the maxilla and PAS were measured and classified by distance. The maxilla was advanced horizontally by 2.9 ± 1.7 mm and vertically by 2.7 ± 1.4 mm. Upward maxillary movement of ≥4 mm significantly increased PAS (mean change in PAS, 2.6 mm), and upward maxillary movement significantly decreased the posterior nasal spine to the P-point. Only patients with vertical advancement ≥4 mm and horizontal advancement of 3 mm had significant increases in all three PAS parameters. Although forward maxillary movement is believed to have a large effect on PAS, it is suggest that upward vertical movement is more effective for improving PAS. Both the extent and direction of maxillar movement should be considered. Future studies should use cone-beam computed tomography to evaluate the effect of axial direction and differences in PAS.

Impact of surgical maxillomandibular advancement upon pharyngeal airway volume and the apnoea-hypopnoea index in the treatment of obstructive sleep apnoea: systematic review and meta-analysis

Background

A systematic review was carried out on the effect of surgical maxillomandibular advancement (MMA) on pharyngeal airway (PA) dimensions and the apnoea-hypopnoea index (AHI) in the treatment of obstructive sleep apnoea (OSA), with the aim of determining whether increased PA in the context of MMA is the main factor conditioning the subsequent decrease in AHI.

Methods

A search was made of the PubMed, Embase, Google Scholar and Cochrane databases. A total of 496 studies were identified. The inclusion criteria were a diagnosis of moderate to severe OSA, MMA success evaluated by polysomnography, reporting of the magnitude of MMA achieved, PA increase and a minimum follow-up of 6 months.

Results

Following application of the eligibility criteria, eight articles were included. Metaregression analysis showed MMA to significantly increase both pharyngeal airway volume (PAV) (mean 7.35 cm³ (range 5.35-9.34)) and pharyngeal airway space (mean 4.75 mm (range 3.15-6.35)) and ensure a final AHI score below the threshold of 20 (mean 12.9 events/hour).

Conclusions

Although subgroup analysis showed MMA to be effective in treating OSA, more randomised trials are needed to individualise the required magnitude and direction of surgical movements in each patient, and to standardise the measurements of linear and nonlinear PAV parameters.

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.

Impact of Bimaxillary Advancement Surgery on the Upper Airway and on Obstructive Sleep Apnea Syndrome: a Meta-Analysis

Upper airway changes following bimaxillary advancement surgery to treat obstructive sleep apnea syndrome remain controversial. The main objective of this systematic review and meta-analysis was to investigate the effects of bimaxillary advancement surgery on the upper airway (UA) of obstructive sleep apnea syndrome patients through examining changes three-dimensionally in vertical and supine position and through changes in oximetric variables (AHI, RDI, O2 Sat) and in the quality of life measured by the Epworth sleepiness scale (ESS). A thorough search of the PubMed, Scopus, Embase and Cochrane databases and a grey literature search (Opengrey) were conducted. No limit was placed on publication year or language. The inclusion criteria were: adult obstructive sleep apnea patients who had undergone bimaxillary advancement surgery, three-dimensional CBCT or CT and oximetric measurements and at least six weeks follow-up. Sample sizes of under 10 patients were excluded. Finally, 26 articles were included in the qualitative review and 23 in the meta-analysis. Bimaxillary advancement surgery has been shown to be beneficial in terms of increased upper airway size, improved oximetric indicators and the quality of life measured on the Epworth sleepiness scale.

"Silent" Sleep Apnea in Dentofacial Deformities and Prevalence of Daytime Sleepiness After Orthognathic and Intranasal Surgery

PURPOSE

The purposes of this study were to determine the occurrence of undiagnosed "silent" obstructive sleep apnea (OSA) in dentofacial deformity (DFD) patients at initial surgical presentation and to report on the level of daytime sleepiness in DFD patients with OSA and chronic obstructive nasal breathing (CONB) after undergoing bimaxillary, chin, and intranasal surgery.

MATERIALS AND METHODS

A retrospective cohort study of patients with a bimaxillary DFD and CONB was implemented. Patients were divided into those with no OSA (group I) and those with OSA (group II). Group II was further subdivided into patients referred with polysomnogram (PSG)-confirmed OSA (group IIa) and those with a diagnosis of OSA only after surgical consultation, airway evaluation, and a positive PSG (group IIb). Group II patients were analyzed at a minimum of 1 year after surgery (range, 1 to 10 years) for daytime sleepiness with the Epworth Sleepiness Scale. Patients with postoperative excessive daytime sleepiness were assessed for risk factors and continued need for OSA treatment. Patients in group II were studied to determine which DFD patterns were most associated with OSA. We compared the prevalence of OSA between our study population and the general population.

RESULTS

Two hundred sixty-two patients met the inclusion criteria. Of these, 23% (60 of 262) had PSG-confirmed OSA (group II). This rate was much higher than that found in the general population. Of the patients, 7% (19 of 262) were known to have OSA at initial surgical consultation (group IIa). An additional 16% (41 of 262) were later confirmed by PSG to have OSA (group IIb). Patients with primary mandibular deficiency and short face DFDs were most likely to have OSA (P < .001 and P = .001, respectively). In group II, 91% (55 of 60) rated their daytime sleepiness as "not sleepy" at a minimum of 1 year after surgery. A significant association was found between group II patients with postoperative excessive daytime sleepiness ("sleepy" or "very sleepy") and a preoperative body mass index category of overweight (P = .026).

CONCLUSIONS

Our study found silent OSA to be frequent in the DFD population. The prevalence of OSA in DFD patients exceeded that estimated in the general population, with retrusive jaw patterns most affected. In DFD patients also presenting with OSA and CONB, we confirmed low levels of daytime sleepiness long-term after simultaneous bimaxillary orthognathic, chin, and intranasal surgery.

Which cephalometric analysis for maxillo-mandibular surgery in patients with obstructive sleep apnoea syndrome?

Maxillo-mandibular advancement MMA is considered an efficacious treatment for patients affected by severe obstructive sleep apnoea syndrome (OSAS). Even though OSAS improvement is the main goal of MMA, excessive maxillo-mandibular protrusion should be avoided to guarantee pleasant postoperative facial aesthetics. In order to attain such a result, the amount of MMA should be planned preoperatively by both aesthetic and cephalometric analyses. Steiner and Delaire cephalometric analyses are commonly used in the preoperative planning of orthognatic surgery for dentofacial deformities, however controversies still exist about the basis and postoperative aesthetic results of such cephalometric analyses in OSAS patients candidate for MMA. Forty-eight patients affected by severe OSAS were submitted to MMA. Pre- and post-operative Steiner and Delaire cephalometric tracings were assessed in each subject. For Steiner analysis, the variation in the SNA and SNB angles was measured, while for Delaire tracings the variation in the C3/FM-CPA and C3/FM-Me angles was assessed. Mean MMA was 6.9 + 3.8 mm for the maxilla and 13.6 + 5 mm for the mandible. After surgery, an improvement of the apnoea-hypopnoea index was recorded (40.47 + 7.64 preoperative vs. 12.56 + 5.78 postoperative). In all patients, both cephalometric analyses showed presurgical bimaxillary retrusion. After surgery, the mean value of Steiner's SNA angle increased from 78.18° to 85.58° (p < 0.001), while mean Delaire's C3/FM-CPA angle increased from 81.19° to 89.71° (p < 0.001). The mean value of Steiner's SNB angle increased from 74.33° to 80.73° (p < 0.001), while Delaire's C3/FM-Me angle increased from 80.10° to 87.29° (p < 0.001). Postoperatively, both the maxilla and mandible were in a more protrusive position (p < 0.001) according to Steiner analysis compared with Delaire tracing. Basing MMA on Delaire cephalometric analysis leads to an increased advancement of the maxillo-mandibular complex than Steiner tracing. The consequences of this aspect on facial aesthetics should be considered during surgical planning and preoperative informed consent in OSAS patients candidate for MMA.

Obstructive sleep apnoea and the need for its introduction into dental curricula

Obstructive sleep apnoea (OSA) is a major health problem which causes blood oxygen desaturation that may initiate a cascade of events via inflammatory cytokines and adrenocorticotrophic hormone that may have impact upon quality of life and lead to potential life-threatening events. Even though OSA affects an increasing number of individuals, the role of dental practitioners in recognition, screening and management has not developed accordingly. The goal of this article was to provide updated information to dental practitioners on pathophysiology, consequences and treatment options of OSA with a focused discussion on oral appliance (OA) therapy, as this topic is not routinely included in current dental curricula of many dental schools. Additionally, we present a template dental curriculum for predoctoral and/or postdoctoral students in education regarding sleep disordered breathing.

Polysonographical evaluation in a case of moderate osas treated with mandibular advancement device

Background

The Obstructive Sleep Apnea Syndrome (OSAS) is a clinical picture characterized by partial or complete obstruction of the upper airway during sleep, associated with a reduction of oxygen saturation in the blood.The most common symptoms are: apnea sleep, snoring, headache, sleepiness, reduced concentration and memory, irritability, increased blood pressure and dry mouth.

Materials and methods

It was examinated a not-smoker man of 54 years that suffers of roncophaty. He did physical examination, rhinoscopyexam, faringoscopy, rhinofibrolaringoscopy, gnathological evaluation and polysomnographic examination performed with multichannel polygraphy (VitalNight). From the performed examinations, it has been diagnosed a moderate form of obstructive apnea sleep syndrome. He was treated with a mandibular advancement device and it was repeated the polysomnographic exam.

Results

Comparing the results of the polysonographic examination performed before and after the treatment, the patient's clinical picture clearly improved. It has shown a clear reduction of obstructive apneas, hypopneas and snoring.

Conclusions

The use of a mandibular advancement device is certainly a valuable aid in the treatment of moderate type OSAS. The quality of diurnal life is also improved as shown with Sleepness Epworth Scale.

Evaluation of an oral appliance in patients with mild to moderate obstructive sleep apnea syndrome intolerant to continuous positive airway pressure use: Preliminary results

Obstructive sleep apnea syndrome (OSAS) is a phenomenon of repeated, episodic reduction, or cessation of airflow (hypopnea/apnea) as a result of upper airways obstruction. First-line treatment in younger children is adenotonsillectomy, although other available treatment options in middle-aged adults include continuous positive airways pressure (CPAP) and airway adjuncts. Oral appliances (OA) are a viable treatment alternative in patients with OSAS.The objective of this study was to assess, in a 1-year follow-up study, an OA in OSAS patients. The participants were subjected to polysomnographic examination with a validated device (MicroMESAM). Eight participants were fitted with a Thornton Adjustable Positioner (TAP). The participants were asked to wear the test appliance for 7 nights, and in case of compliance, for 6 months. The selected patients record their usage of the appliance and any adverse effects in a treatment journal. The research focused on the following outcomes: sleep apnea (i.e. reduction in the apnea/hypopnea index) and the effect of oral appliances on daytime function.In conclusion, the results suggest that OA have a definite role in the treatment of snoring and sleep apnea.

Role of mandibular displacement and airway size in improving breathing after rapid maxillary expansion

BACKGROUND

Oral breathing and maxillary deficiency are often associated with steep mandibular plane angle, and retrognathic mandible compared with the faces of healthy controls. Some studies suggested that after rapid maxillary expansion, improvement in nasal breathing and repositioning of mandible with transitory increasing of facial height and, in some cases, spontaneous forward repositioning might occur. The above-mentioned mandibular effects could contribute to enlarge oropharynx volume with repositioning of tongue and soft palate with an improvement of upper airway volume after treatment. The aim of this study was to investigate by cone beam computed tomography the role of oropharyngeal volume and mandibular position changes after rapid maxillary expansion in patients showing improved breathing pattern confirmed by polysomnography exam.

METHODS

The final sample of this retrospective study comprised 14 Caucasian patients (mean age 7.6 years) who undergone rapid maxillary expansion with Haas-type expander banded on second deciduous upper molars. Cone beam computed tomography scans and polysomnography exams were collected before placing the appliance (T0) and after 12 months (T1). Mandibular landmarks localization and airway semiautomatic segmentation on cone beam computed tomography scans allowed airway volume computing and measurements.

RESULTS

No significant differences were found between oropharyngeal airway changes and mandibular displacement after rapid maxillary expansion in growing patients.

CONCLUSIONS

The suggested improvement in upper airway and breathing after rapid maxillary expansion should be further related to different compartments of airway such as rhinopharynx and nasal cavity.