Dental TraumaSurgery for obstructive sleep apnea

Background.—Obstructive sleep apnea (OSA) is a mul-tifactorial condition that requires an individualized ap-proach to diagnosis and multidisciplinary treatment. It isrelated to an anatomic obstruction of the upper airwaythat may respond to surgical or nonsurgical therapy. OSAoccurs during sleep as a result of an obstructed or partiallycollapsed upper airway and causes daytime tiredness orsleepiness, memory loss, irritability, depression, diminishedlibido, and headache. If not treated, OSA can cause diabe-tes, hypertension, heart disease, and sudden death duringsleep. When nonsurgical methods are not sufficient, sur-gery can be an effective option.

Diagnostic Evaluation.—Surgery is indicated for pa-tients who have OSA diagnosed by polysomnography, anapnea hypopnea index score over 5, a decrease in oxygensaturation to under 90%, poor sleep efficiency, and clinicalsymptoms. Often surgery can help patients who have un-dergone behavioral therapies (such as weight loss, posi-tional therapy, and avoidance of hypnotic agents oralcohol before sleeping) without success and those whocannot tolerate continuous positive airway pressure(CPAP) therapy or oral appliances or who simply preferthe surgical approach. It is important that patients be med-ically and psychologically able to tolerate surgery.

Routine orthodontic examination should include a com-prehensive medical history, a sleep history, and the Ep-worth sleepiness scale. Fiberoptic pharyngoscopy andovernight polysomnography are recommended, as isa cone-beam computed tomography airway analysis andthree-dimensional cephalometrics to identify and quantifythe site of obstruction and skeletal and dental relationships.

Surgery is done to permanently enlarge the airway andfocus on repositioning or removing the obstruction. Threeanatomic sections are targeted for evaluation and treat-ment: (1) the nose, (2) the retropalatal area and the lateralpharyngeal walls, and (3) the retroglossal area and tongue.The success of surgery depends on the health, age, and psy-chological condition of the patient; the surgeon’s skill andexperience; and the type of surgery performed. Body massindex and amount of skeletal advancement influence theresult.

Surgical Approaches.—Intrapharyngeal proceduresare done on the soft tissues of the velo-oro-hypo-pharyngeal airway. This includes the soft palate, velophar-ynx, hypertrophied tonsils, base of the tongue, or body of

the tongue in patients with macroglossia. Patients whohave any anatomic obstructions that are surgically correct-able undergo primary surgical treatment. Among the nasalprocedures performed are septoplasty, functional rhino-plasty, nasal valve surgery, turbinate reduction, and polypec-tomy. Although snoring symptoms may be ameliorated byuvulopalatopharyngoplasty, this procedure is rarely cura-tive for OSA. Skeletal surgery includes procedures involvingthe maxilla, mandible, chin, and hyoid bone and is designedtomove the jaws or chin forward where they better supportthe velo-oro-pharyngeal soft tissues.

Adults with severe OSA often have maxillomandibularadvancement of 10 mm, which is successful in 90% to100% of patients. Correction of the transverse dimensionis an important part of the maxillomandibular advance-ment. Since the soft tissues and tongue are attached tothe maxilla, mandible, and hyoid bone, advancing the max-illa, mandible, and chin pulls the soft palate and tongue for-ward and enlarges the entire velo-oro-hypopharyngealairway while enhancing the tone of the pharyngeal dilatedmuscles. Orthodontic treatment combined with surgerycan improve the functional occlusion and achieve optimalskeletal facial and dental esthetics.

The health advantages obtained by normalizing theairway and improving oxygen saturation during sleepdrives the use of an accelerated presurgical phase oftreatment. A three-dimensional diagnostic surgical treat-ment animation allows the clinician to superimposea cone-beam computed tomography image on soft tissueimaging. The orthodontist benefits from the use ofa three-dimensional orthodontic diagnostic setup,whether virtual or on an articulator. This permits an eval-uation of the final occlusion for presurgical equilibrationand allows customizing of the bracket-based prescrip-tion, with torque, angulation, and offset determined indi-vidually. To fabricate intermediate and final surgicalsplints, an accurate bite registration is obtained on an ad-justable hinge-access articulator.

Among the complications associated with surgical ap-proaches are neurosensory deficit, infection, bleeding,the need to remove hardware, skeletal instability, and TMJproblems. Patient satisfaction, however, is as high as 95%.Maxillomandibular advancement can be accomplishedwithin 3 hours by skilled, experienced surgeons, whichmakes for an easier, shorter recovery time of 2 to 3 days.Long-term stability and function are good.

Volume 59 � Issue 1 � 2014 e13

Pediatric OAS.—Children who suffer sleep apnea canexperience irreversible changes in facial growth and devel-opment as well as other complications if the condition isnot diagnosed and treated appropriately. Up to 21% of chil-dren with noninfectious respiratory complaints may haveOSA; among children with cleft palate, the incidence is30%. OSA can result from mandibular micrognathia associ-ated with congenital malformations such as Pierre Robin,Treacher Collins, and Nager’s syndromes or hemifacial mi-crosomia. The obstruction in these children is usuallycaused by the tongue. Mandibular distraction can safelyand effectively manage airway obstruction associated withmicrognathia.

Craniofacial photographs have been useful in predictingOSA, achieving 76% accuracy. Children with OSA tend tohave a dolichocephalic skeletal pattern with mandibularretrognathia, and 60% have adenoid and tonsillar hypertro-phy. All sites of obstruction, including skeletal malocclu-sions, should be identified. Symptoms may develop byage 5 years. Orthodontists can improve the skeletal anddental relationships by using interception therapy as wellas coincident medical management, specifically, CPAP, max-illomandibular advancement, and soft tissue surgery. Maxil-lomandibular advancement is usually delayed until fullmaturity.

Discussion.—Surgery may be the treatment of choicefor patients with OSA, even mild or moderate cases.

e14 Dental Abstracts

Maxillomandibular advancement may provide definitive,single-stage treatment for OSA and potentially will signifi-cantly improve patients’ quality of life and OSA health�re-lated risk status. Soft tissue surgery can also treat theproblem or be used as an adjunctive technique to assistCPAP.

Clinical Significance.—Surgery to addressOAS must be based on a thorough understand-ing of the principles and practices of sleep med-icine and knowledge of the soft tissue and hardtissue structures and surgical approaches. Or-thodontists trained in sleep medicine serve animportant role alongside surgeons and help toachieve better short-term and long-term results.Combining treatments such as CPAP with sur-gery may improve patients’ health status andpermit financial savings for both the healthcare system and individual patients.

Jacobson RL, Schendel SA: Treating obstructive sleep apnea: Thecase for surgery. Am J Orthod Dentofacial Orthop 142, 434-442, 2012

Reprints available from RL Jacobson, UCLA School of Dentistry, Deptof Orthodontics, 881 Alma Real Dr, Suite 200, Pacific Palisades, CA90272; e-mail: doctorrichardjacobson@yahoo.com