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Orthognathic Surgical Considerations forObstructive Sleep Apnea
319
21
. Fig. 21.13 Setback surgery involving both the maxilla and the mandible (reduction in total volume: 2.2cc, reduction in minimum area:
53mm)
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Orthognathic Surgical Considerations forObstructive Sleep Apnea
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323
Individualized Treatment
Planning forAsian Adult
Patients withObstructive Sleep
Apnea Syndrome toObtain
Improvement ofRespiratory
Function andFacial Esthetics:
Conventional
Maxillomandibular
22
Advancement (MMA) Versus
Modied MMA withSegmental
Osteotomy
SungOkHong, Seung-HakBaek, andJin-YoungChoi
Contents
22.1 Introduction – 325
22.2 Material andMethods – 326
22.2.1 The Subjects Used inThis Study – 326
22.2.2 Demographic Description oftheTwo Groups – 326
22.2.3 Evaluation oftheOSAS andCephalometric Parameters Before
andAfter Surgery – 326
22.3 Results – 326
22.3.1 Success Rate – 326
22.3.2 Comparison oftheOSAS Parameter Measurements Between
theT1 andT2 Stages intheCon-MMA andSeg-MMA Groups
Table22.3) – 326
(.
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_22
22.3.3 Comparison oftheAmounts ofChange intheOSAS Parameter
Measurements Between theCon-MMA andSeg-MMA Groups During
T1–T2 Stages (.
Table22.3) – 328
22.3.4 Comparison oftheCephalometric Measurements Between T1 andT2
Stages intheCon-MMA andSeg-MMA Groups (.
Table22.3) – 328
22.3.5 Comparison oftheAmounts ofChange intheCephalometric
Measurements Between theCon-MMA andSeg-MMA Groups During
T1–T2 Stages (.
Table22.3) – 328
22.4 Cases – 331
22.4.1 Case 1 (Patient #2): Con-MMA Procedure withCounterclockwise
Rotation andGA – 331
22.4.2 Case 2 (Patient #5): Seg-MMA Procedure – 332
22.4.3 Case 3 (Patient #7): Seg-MMA Procedure withCounterclockwise
Rotation – 332
22.5 Discussion – 333
22.5.1 Worsening oftheSymptoms ofOSAS During Preoperative
Orthodontic Treatment – 336
22.5.2 Proposition forIncreasing theSuccess Rate – 336
22.6 Conclusion – 336
References – 336
Individualized Treatment Planning for OSAS
325
22
22.1 Introduction
Obstructive sleep apnea syndrome (OSAS) is a sleep
disorder with repetitive episodes of hypopnea and apnea
induced by the upper airway collapse during inspiration
[1–4].
According to age, symptoms, degree, and level of airway obstruction, several treatment modalities have been
used for OSAS patients including change in life style,
nasal continuous positive airway pressure (nCPAP), oral
appliances, miniscrew-assisted rapid palatal expansion
appliance, soft tissue procedures, conventional and
modied maxillomandibular advancement (MMA)
(. Fig.22.1) [2–8].
Among these treatment options, nCPAP is considered as the rst line of treatment to overcome the negative pressure during inspiration. However, its
compliance rate is less than 50%, especially in moderate-to-severe OSAS cases [4, 9]. Second, soft tissue surgical procedures such as uvulopalatopharyngoplasty
(UPPP), tonsillectomy, hyoid suspension, and genioglossus advancement (GA) cannot fully correct narrowing of the pharyngeal airway and their success rates
are known to be approximately 40–60% [4, 10]. Third,
the MMA procedure with or without counterclockwise
rotation can enlarge the facial skeletal framework and
upper airway space, resulting in less airway collapse [4,
11–16]. The range of success rate is known to be
75–100% [4, 11–16]. In Caucasian patients, 9–12mm of
MMA has been recommended to achieve maximum
expansion of the upper airway [17, 18]. However, since
Asians have more protrusive lips and smaller nose compared to Caucasians, these amounts of MMA would be
esthetically unfavorable for Asian OSAS patients [2–4,
19–23]. Therefore, several previous studies have pro-
posed modications of MMA with segmental osteotomy for obtaining improvement of the sleep function
and facial esthetics for Asian OSAS patients [2–4, 16,
21–23]. The authors reported the concept of modied
MMA surgery, which consists of MMA and segmental
osteotomy with or without counterclockwise rotation
(seg-MMA; Le Fort I osteotomy and advancement of
the posterior segment of the maxilla, and anterior segmental osteotomy and total advancement of the mandible) [2–4].
However, according to the authors’ knowledge, there
have been a few studies that meticulously described how
to plan the amount of advancement or how to set up
differential treatment plan for either con-MMA or segMMA in Asian OSAS patients [16]. Therefore, the purpose of this study was to compare the effect of seg-MMA
with or without counterclockwise rotation on improvement of the respiratory function and facial esthetics in
adult OSAS patients with con-MMA procedure.
Treatment Modalities for Adult OSAS Patients
First Option Change in Life Style (Exercise, Diet etc.)
•
unsuccessful
intolerable
Second Option Identication of Degree / Level of Airway Obstruction
Pharyngeal
Level
Soft Tissue
Procedure
Uvulo-palato-
•
pharyngoplasty
•
Tonsillectomy
with or without Mniscrew-assisted RPE with or without counterclockwise rotation
. Fig. 22.1 The owchart of treatment options for obstructive
sleep apnea syndrome (OSAS). BMI body mass index, AHI apnea–
hypopnea index, nCPAP nasal continuous positive airway pressure,
Young adult
Mild symptom / OSAS parameters
•
Mild to moderate
degree
Hypopharyngeal
(Tongue Base) Level
Intraoral Appl.
Mandibular
•
advancement
•
in case with
Healthy TMJ
Soft / Hard Tissue
Procedure
Genioglossus
•
advancement
•
Tongue base
reduction
+
nCPAP
Cont-MMA
9 -12 mm
•
advancement of both
maxilla and mandible
One-piece Le Fort I
•
osteotomy / BSSRO
Middle or old age / Obese type
•
moderate to severe symptom / OSAS parameters
•
unclear obstruction site
•
Poor general condition for surgery
•
Severe degree
Pharyngeal and /or
Hypopharyngeal Levels
Seg-MMA
Normal or protrusive maxilla
•
Acute nasolabial angle / Low nose projection
•
Protrusive lip / Labioversed max. incisors
•
Seg. osteotomy / Forward movement of the
•
post. seg. for space closure combined with
Le Fort I osteotomy
ASO and total advancement of the mandible
•
Con-MMA conventional maxillomandibular advancement, SegMMA modied MMA with segmental osteotomy, TMJ temporomandibular joint, BSSRO bilateral sagittal split ramus osteotomy
326
S. O. Hong et al.
22.2 Material andMethods
22.2.1 The Subjects Used inThis Study
The subjects consisted of eight Korean adult OSAS
patients (7 males and 1 female; mean age, 26-yearold), who underwent con-MMA or seg-MMA surgery
at Seoul National University Dental Hospital from
January 2009 to July 2015 by a single oral and maxillofacial surgeon (Choi JY). Two patients had previous
surgery history such as septoplasty and UPPP, and
other two patients became candidates of con-MMA
or seg-MMA treatment due to nCPAP failure.
Exclusion criteria were as follows: patients with
genetic syndromes, psychological disease, or patients
who were unable to comply with the scheduled follow-ups. This study was reviewed and approved by the
Institutional Review Board of Seoul National
University School of Dentistry (IRB Number
S-D20150028).
22.2.2 Demographic Description oftheTwo
Groups
The subjects were divided into two groups: con-MMA
group [Le Fort I osteotomy in the maxilla, bilateral sagittal split ramus osteotomy (BSSRO) and genioglossus
advancement (GA) in the mandible; n = 4] and segMMA group [Le Fort I osteotomy, segmental osteotomy
and advancement of the posterior segment of the maxilla, and anterior segmental osteotomy (ASO), posterior
movement of the anterior segment, and total advancement of the mandible, without GA; n=4] (. Table22.1).
During surgical procedures, both groups were treated
with or without counterclockwise rotation of the maxillomandibular complex according to cephalometric analysis and treatment planning.
The GA procedure was performed only in patients
belonged to the con-MMA group, not in patients of the
seg-MMA group. The reason was to avoid unfavorable
fracture of the mandible during simultaneous ASO and
GA.In both groups, computer-aided design/computeraided manufacturing (CAD/CAM)-made condylar jigs
(Orapix Co, Ltd., Seoul, South Korea) were used to stabilize the condyle in the centric relation (CR) position
during surgery [24].
22.2.3 Evaluation oftheOSAS
andCephalometric Parameters
Before andAfter Surgery
Four OSAS parameters from nocturnal polysomnogram
[PSG; Body mass index (BMI, kg/m2), apnea–hypopnea
index (AHI, events/hour), respiratory disturbance index
(RDI, events/hour), and lowest saturation rate
(LSAT,%)] and ve cephalometric measurements (SNA,
SNB, FMA, U1 to FH, and nasolabial angle;
. Fig.22.2) were investigated before (T1) and 6months
after surgery (T2) (. Table22.2).
The lateral cephalograms were taken at the T1 and
T2 stages in the natural head position without any swallowing movement. These lateral cephalograms were
traced and analyzed by a single operator (Hong SO)
using the V-Ceph program (Version 5.5, CyberMed,
Seoul, Korea).
All variables of eight patients were retraced and reassessed by the same operator (Hong SO) at a two-week
interval. Since there were no signicant differences
between the rst and second measurements, the rst set
of measurements was used. The Wilcoxon signed ranks
test and Mann-Whitney U test were performed for statistical analysis.
22.3 Results
22.3.1 Success Rate
According to the success criteria for OSAS treatment by
Sher etal. [25] (postoperative AHI <20 events/hour and
>50% reduction compared with the preoperative AHI),
overall success rate was 87.5%. (con-MMA group,
n=4/4 and seg-MMA group, n=3/4, . Table22.2).
22.3.2 Comparison oftheOSAS Parameter
Measurements Between theT1
andT2 Stages intheCon-MMA
andSeg-MMA Groups (
There was the same trend of change in the OSAS parameter measurements from the T1 to T2 stages in the two
groups as follows: Both groups showed decrease in AHI
. Table22.3)
22
Individualized Treatment Planning for OSAS
(Adv 5mm)
Operation
Preoperative
orthodontic
treatment
(month)
GA (4mm)
3mm) and Mn (Adv 8mm)
GA (5mm)
mm) and Mn (Adv 10mm)
GA (4mm)
1mm) and Mn (Adv 6mm)
GA (6mm)
segment Adv- 6mm) and Mn (Adv
4.5mm)
segment Adv- 5mm) and Mn (Adv
11.5mm)
2mm; post. Imp, 1.5mm; posterior
segment Adv 9mm) and Mn (Adv
10.5mm)
segment Adv 5mm) and Mn (Adv
327
5mm)
22
Nasolabial
U1 to
FMA
Maxillary
Overjet
SNB
SNA
Age
angle(°)
FH (°)
(°)
incisor
showing
(mm)
(°)
(°)
/sex
(mm)
. Table 22.1 Demographic data for obstructive sleep apnea (OSAS) patients and their individualized surgical treatment plan
Group Patient
number
7 21Y/M 78.5 73.6 3.5 2.0 32.8 117.2 94.0 0.5 Modied MMA: Mx (Ant Imp,
(modied
6 27Y/M 85.1 79.3 3.5 3.0 23.6 99.9 87.8 10 Modied MMA: Mx (posterior
MMA)
3 26Y/M 78.0 73.7 3.0 0 42.7 109.0 90.8 None MMA: Mx (Total Elong 2mm; Adv7
(conventional
2 23Y/M 75.6 69.9 3.5 3.0 42.1 101.6 105.4 None MMA: Mx (Adv 7mm; Ant Imp
MMA)
1 22Y/F 83.6 72.7 4.5 8.0 46.7 98.5 105.3 4 MMA: Mx (Total Imp 4mm) and Mn
Group 1
4 28Y/M 76.8 71.2 5.0 2.0 22.9 102.3 109.0 None MMA: Mx (Adv5 mm; Ant Imp
5 40Y/M 85.7 82.1 2.5 1.0 27.7 111.6 98.8 3 Modied MMA: Mx (posterior
Group 2
8 20Y/M 74.7 71.6 5.0 4.0 36.1 113.4 80.0 5 Modied MMA: Mx (posterior
MMA maxillomandibular advancement, CCR counterclockwise rotation, Adv advancement, Imp impaction, Elong elongation, Ant anterior, Mx maxilla, Mn mandibular, GA genioglos-
sus advancement, SNA angle from sella to nasion to subspinale, SNB angle from sella to nasion to supramentale
22
328
S. O. Hong et al.
. Fig. 22.2 Cephalometric parameters. SNA angle from Sella to
nasion to point A, SNB angle from sella to nasion to point B, Nasolabial angle, angle formed by the columellar (Cm)–subnasale (Sn)labial superioris (Ls), U1 to FH angle between the maxillary incisor
and Frankfort horizontal plane, FMA, Frankfort horizontal plane
to mandibular plane angle, Overjet sagittal distance between the
maxillary incisor tip and the mandibular incisor tip, and overbite
vertical distance between the maxillary incisor tip and the mandibular incisor tip
and RDI (AHI, 44.9 to 7.6in the con-MMA group and
35.8 to 5.7in the seg-MMA group; RDI, 50.7 to 11.0in
the con-MMA group and 41.6 to 10.8in the seg-MMA
group, . Table22.3) and increase in LAST (84.5% to
88.2% in the con-MMA group and 86.8% to 91.5% in the
seg- MMA group, . Table22.3). However, both groups
did not exhibit signicant change in BMI (21.3 to 21.3kg/
m2 in the con-MMA group and 21.9 to 21.6kg/m2 in the
seg- MMA group, . Table22.3).
22.3.3 Comparison oftheAmounts
ofChange intheOSAS Parameter
Measurements Between
theCon-MMA andSeg-MMA Groups
During T1–T2 Stages (
In terms of BMI, AHI, RDI, and LAST, there was no
signicant difference in the amounts of change between
the two groups (all P>0.05, . Table22.3).
. Table22.3)
22.3.4 Comparison oftheCephalometric
Measurements Between T1 andT2
Stages intheCon-MMA
andSeg-MMA Groups (
There were some differences in the trend of change in
the cephalometric measurements from the T1 to T2
stages between the two groups as follows: The conMMA group showed a forward positioning of the maxilla and mandible (SNA, 78.5 to 82.5°; SNB, 71.9 to
76.4°, . Table22.3) and decrease in obtuse nasolabial
angle (NLA, 102.6 to 98.9°, . Table22.3). However, the
seg- MMA group exhibited that due to a forward movement of the posterior segment of the maxilla, and the
anterior segmental osteotomy and total advancement of
the mandible, there were no signicant changes in the
sagittal position of the maxilla and mandible (SNA,
81.0 to 80.8°; SNB, 76.7 to 77.6°, .
exaggeration of the acuteness in nasolabial angle (NLA,
90.2 to 88.2°, . Table22.3). However, there was upright-
ing of the labioversed maxillary incisor in the seg-MMA
group (U1 to FH, 110.5 to 104.4°, . Table22.3). Both
groups showed some decrease in FMA (38.6 to 36.5° in
the con-MMA group; 30.1 to 28.8° in the seg-MMA
group, . Table22.3).
22.3.5 Comparison oftheAmounts
. Table22.3)
Table22.3) and no
ofChange intheCephalometric
Measurements Between
theCon-MMA andSeg-MMA Groups
During T1–T2 Stages (
Although FMA, U1 to FH, and nasolabial angle did
not show signicant difference in the amounts of change
between the two groups (all P > 0.05, . Table 22.3),
ΔSNA exhibited a marginal difference between the two
groups (4.0° in the conv-MMA group vs. 0.2° in the segMMA group, P = 0.057, .
MMA group, there was no signicant change in the
sagittal position of the maxilla (SNA, 81.0 to 80.8°,
. Table22.3) due to a forward movement of the poste-
rior segment of the maxilla.
ΔSNB exhibited signicant difference between the
two groups (4.5° in the con-MMA group vs. 0.9° in the
seg- MMA group, P<0.05, . Table22.3). This differ-
ence occurred because the seg-MMA group had anterior segmental osteotomy and total advancement of
the mandible, resulting in no signicant change in the
. Table22.3)
Table 22.3). In the seg-
Individualized Treatment Planning for OSAS
FMA (°) U1 to FH (°) Nasolabial
Maxillary
angle(°)
incisor
showing
(mm)
T2
329
, NA not available
2
22
Cephalometric measurements
) AHI (n/h) RDI (n/h) LSAT (%) SNA (°) SNB (°) Overjet
2
(mm)
T2 T1 T2 T1 T2 T1 T2 T1 T2 T1 T2 T1 T2 T1 T2 T1 T2 T1 T2 T1
PSG results
Patient
. Table 22.2 Changes in the OSAS parameters and cephalometric measurements before (T1) and 6months after conventional MMA or modied MMA surgery (T2)
Group
BMI (kg/m
number
T1
1 18.8 17.3 39.8 2.1 53.3 2.6 82 91 83.6 84.5 72.7 75.8 4.5 1.8 8.0 2.5 46.7 43.9 98.5 99.0 105.3 116.4
Group 1
(conventional
2 23.7 22.5 42.9 5.5 42.9 16.6 90 91 75.6 81.1 69.9 76.4 3.5 3.5 3.0 3.0 42.1 39.9 101.6 105.0 105.4 98.2
MMA)
3 21.5 21.6 53.5 7.6 55.8 13.9 87 91 78.0 85.5 73.7 79.9 3 3 0 3.0 42.7 42.9 109.0 104.8 90.8 85.4
4 21.2 23.8 43.2 15.2 NA 79 80 76.8 78.9 71.2 73.6 5 5 2.0 3.0 22.9 19.2 102.3 107.7 109.0 95.6
5 18.9 19.9 60 6 61 11 80 92 85.7 84.7 82.1 82.9 2.5 1.7 1.0 1.5 27.7 29.6 111.6 112.3 98.8 99.0
Group 2
6 22.9 22 61 6 64.5 16.9 89 92 85.1 83.5 79.3 79.2 3.5 2.8 3.0 3.0 23.6 23.3 99.9 93.8 87.8 82.7
(modied
7 21.1 21.9 14.2 7.9 28.9 8.3 87 90 78.5 79.2 73.6 75.3 3.5 2 2.0 2.0 32.8 27.2 117.2 107.1 94.0 92.9
MMA)
8 24.7 22.7 7.9 2.7 11.9 6.8 91 92 74.7 75.8 71.6 73.1 5 3 4.0 3.5 36.1 35.2 113.4 104.2 80.0 78.1
MMA maxillomandibular advancement, BMI body mass index, AHI apnea–hypopnea index, RDI respiratory disturbance index, LSAT lowest saturation rate of O