Case Study: Sleep Apnea
Recently, I was asked to share my expertise on the treatment of Obstructive Sleep Apnea for the Northern Kentucky Medical Society Fall newsletter. Below is the article I contributed.
If you or a loved one are experiencing Obstructive Sleep Apnea, please reach out. We are always here to answer your questions!
THINKING OUTSIDE THE AIRWAY – TREATING OBSTRUCTIVE SLEEP APNEA WITH MAXILLOMANDIBULAR ADVANCEMENT SURGERY
Obstructive Sleep Apnea continues to be a major medical problem affecting all patient population groups whether male, female, young, old, obese, or even underweight. While more prevalent in males and those who are overweight, obstructive sleep apnea affects an alarming percentage of the population. One in fifteen adults in the United States has obstructive sleep apnea. 1 It is one of the top ten most costly healthcare issues we face.
Obstructive Sleep Apnea is estimated to occur in seventy percent of obese patients. Thirty-four percent of all National Football League linemen have Obstructive Sleep Apnea. According to the Journal of The American Medical Association, a major contributor to vehicular and work-related accidents is daytime sleepiness associated with Obstructive Sleep Apnea. The health ramifications of Obstructive Sleep Apnea are well-documented and include hypertension, cardiac arrhythmia, stroke, neurocognitive disorders and glucose intolerance. 2, 3, 4 Clearly on the rise, more articles have appeared in peer reviewed journals in the last eight years dedicated to Obstructive Sleep Apnea than appeared in peer reviewed journals in the prior twenty. In keeping with this, there are now nineteen different surgical procedures that can be performed for Obstructive Sleep Apnea in eight different intrapharyngeal and extrapharyngeal sites documented along the airway.
While CPAP remains the gold standard for conservative management of Obstructive Sleep Apnea and mandibular repositioning appliances are finding wider acceptance for conservative interventional therapy, these two modalities of treatment are not without their limitations. CPAP therapy has a high failure rate over time and compliance night to night is quite variable. (See Figure 1 and 2) Mandibular repositioning appliances also have non-compliance issues and worse, can lead to temporomandibular joint symptoms and changes in occlusion. Additionally, these appliances are not recognized as therapeutic for more moderately severe and severe cases of Obstructive Sleep Apnea and more disconcerting, they are rarely titrated to a known apnea hypopnea index.
Surgery for Obstructive Sleep Apnea spans all sites in the pharyngeal airway. Surgical procedures are best classified as either intrapharyngeal or extrapharyngeal. Intrapharyngeal surgeries, or surgeries inside the airway, include the removal of excess tissue in the soft palate and other palatal procedures. They also include tongue base surgeries as well as the removal of tonsils and adenoids in specific patients. Extrapharyngeal surgery includes advancement surgeries of the maxilla and mandible commonly known as maxillomandibular advancement surgery, as well as advancement procedures on the chin and genial tubercle. In essence, intrapharyngeal procedures remove tissue within the “tube” and extrapharyngeal procedures increase the size of the “tube” by expanding it through advancement of its anterior skeletal support – the maxilla and the mandible. Whereas intrapharnygeal procedures have been notoriously variable in their success rate, extrapharyngeal procedures have been very successful and very stable long-term when treatment is carefully planned to include the following:
- Orthodontic intervention to establish as large of a skeletal base discrepancy between the maxilla and mandible as possible.
- Midfacial advancement to its full esthetic extent.
- Counter-clockwise rotation of the midface.
- Mandibular advancement with counter-clockwise rotation.
- Genial tubercle advancement through the use of genioplasty or a pull-through genial tubercle window.
- Rigid skeletal fixation.
Treatment following this protocol has been reported to not only rival the success of continuous CPAP therapy as measured by percentage change in AHI but to surpass all other forms of surgical intervention for Obstructive Sleep Apnea. 5, 6, 7
Maxillomandibular advancement surgery results in increased airway volume, increased lateral wall tonicity, decreased airway length, and decreased airway turbulence, all of which contribute to the successful management of Obstructive Sleep Apnea.
In conclusion, although maxillomandibular advancement surgery appears painful, and more difficult for patients to tolerate, it is not. When done by experienced surgeons following the treatment protocol referenced earlier, patients experience only mild to moderate pain. Rigid fixation allows the patient to function immediately post-operatively. Maxillomandibular advancement requires only an overnight stay at the hospital. While numbness to the upper and lower lip can be problematic post-operatively, function is not affected and the neuro sensory deficit is well tolerated by patients. Long-term stability has been documented and when properly treatment planned, facial harmony of the lower face is maintained or improved.
Michael B. Lee, DDS
Cincinnati Center for Corrective Jaw Surgery
Dr. Lee practices oral and maxillofacial surgery in Cincinnati, Ohio. He is a diplomate of the American Board of Oral & Maxillofacial Surgeons. He practices with a special interest in and commitment to the management of OSA through maxillomandibular advancement surgery.
- Young, et al. Risk factors for obstructive sleep apnea in adults. JADA 2004; 2013 – 2016
- Peppard, P.E. et al. Prospective study of the association between sleep disordered breathing and hypertension. Eng J Med 2000; 342:1378-84
- Kim H, et al. Sleep disordered breathing and neurophysiological deficits. AmJ Crit Care Med 1997; 156:1813-9
- Punjabi, TM et al. Sleep disordered breathing on insulin resistance… AmJ Respir Crit Care Med 2002; 165:677-82
- Prinsell, J.R. A review of the literature using mean percent reduction in AHI as a measurement of therapeutic efficacy. Journal of Oral and Maxillofacial Surg 70: 2012; 1659-1677
- Li, KK Maxillomandibular advancement in obstructive sleep apnea Oral Maxillofacial Surg 69:2011; 607-694
- Caples, SM et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. SLEEP 2010; 33 (10): 1396-1407