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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4538_Библиотеки_им_академика_М_И_Перельмана
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2. OSA patients usually display chronic intermittent hypoxemia, which raises cir-
culant inammatory cytokines levels, contributing to the pathogenesis of multiple comorbidities presented with OSA.
These inammatory cytokines have also been reported in TMD.Therefore,
OSA might contribute to the pathogenesis of TMD by enhancing systemic
inammation. Therefore, it is not surprising that OSA patients have higher TMD
incidence [122, 123].
3. Malocclusion and other craniofacial abnormalities may induce the upper airway
collapse during sleep. This is the reason why mandibular advancement appliances are suggested to treat OSA.In fact, accompanying OSA, there might be
diverse craniofacial structure anomalies and/or muscle dysfunction predisposing
to TMD development [124].
Also, the co-occurrence of TMD and UARS has led investigators to postulate
a TMD/UARS phenotype that develops during growth in response to disordered
breathing during wakefulness [124].
However, paradoxically mandibular-advancement intraoral appliances to
treat or manage OSA may also cause TMD or increase its risk.
4. TMD and sleep bruxism may concomitantly present in OSA patients. Bruxism
episodes index (BEI) positively correlated with the AHI in patients with mild-to
moderate OSA, whereas patients with severe OSA had lower BMI than those
with mild-to-moderate OSA [125–130].
This relationship between OSA and bruxism has been previously discussed in
this chapter.
Patients referred for OSA treatment also present to the clinic with signs and
symptoms of TMD.This is a solid clinical feature for deciding what problem should
be addressed rst or if we can treat both simultaneously [131].
Cunali etal. reported a group of patients diagnosed with mild to moderate OSA
referred for oral appliance therapy. Nearly 52% of the patients presented TMD, with
a high prevalence of pain in OSA patients [132].
Since the development of TMD has also been reported after the treatment of
OSA with oral appliance therapy, it is crucial to detect the presence of previous
TMD in the patients referred for OSA treatment [131].
As with other forms of treatment, the use of MADs is not exempt from side effects.
While relatively common, most of the side effects associated with MADs tend to be
relatively minor and transient and do not usually prohibit the use of the appliances.
These have been mentioned above [132, 133].
It has been hypothesized that by inducing forward and downward position of the
mandible, MAD can impact clinical signs of TMD and objective perception of them
[132–134].
The most common temporomandibular joint-related side effects are:
• Transient morning jaw pain.
• Persistent temporomandibular joint pain.
• Tenderness in muscles of mastication.
• Joint sounds.
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Transient jaw pain includes pain or discomfort occurring in the morning upon
oral appliance removal that disappears spontaneously during the day. Usually is
mild, originating in muscles of mastication, and unlikely to cause OAT
abandonment.
Persistent TMD pain is less frequent and usually occurs in OSA patients with
previous TMD disorders, especially those or arthrogenic origin. However, the
advancement effect of the MAD on the TMJ capsule and lateral pterygoid can
aggravate this problem over time and can lead the patient to abandon the treatment.
Palliative care with NSAIDs, isometric contraction and passive jaw stretching exercises, verifying, or correcting the midline position, decreasing the titration rate,
decreasing the total amount of advancement, and conducting a comprehensive TMD
evaluation and management are mandatory [132, 134–136].
Advancement of the mandibular position wearing the appliance may contribute
to tenderness of mastication muscles. Management should be as in the previous
scenario. However, symptoms persist a modication in the design of the appliance,
physical therapy measures, or wearing a daytime appliance should be necessary
[137, 138].
Lastly, the patient may develop joint sounds after treatment with MAD.These
are usually transient and resolve with time. First-line treatment is watchful waiting. If the joint sounds are accompanied by persistent TMJ pain, temporary or
permanent discontinuation of the oral appliance is needed. However, a precise
diagnosis of the TMJ disorder should be made before taking that clinical decision [138, 139].
In summary, TMD can be a transient adverse effect associated with the use of
MADs, particularly during the initial phases of treatment. Patients with prior signs
and symptoms of TMD may experience a worsening of symptoms. For this reason,
patients with OSA should be screened for TMD before the initiation of MAD therapy and during the subsequent follow-up appointments to prevent the discontinuation [140].
L. D. AneybaLópez et al.
12.7 Highlights
• The odds of TMD are signicantly greater in individuals at high risk for SDB
supporting the idea of coexistence.
• Studies employing PSG for SDB and RDC-TMD nd an increased prevalence of
OSA or UARs in subjects with TMD supporting the idea of co-existence.
• OSA often precedes the rst onset of TMD in initially TMD-free adults, support-
ing a relation of causality.
• Multiple hypotheses can explain an association between OSA and TMD, and
how OSA might lead to TMD in susceptible individuals or might exacerbate the
severity of previously existing TMD.
• All patients referred for OSA treatment should be screened for the pres-
ence of TMD.
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• Patients with TMD should be screened for SDB and treated if present, of this
life-threatening condition.
• Treatment of SDB is anecdotally reported to improve TMD in some patients.
• However, no clinical trials or controlled clinical studies have been conducted to
determine whether treatment of SDB alters the natural course of existing TMD
or its rst occurrence in TMD-free patients.
• Prior treatment of TMD symptoms is often required before the initiation of OSA
treatment to prevent TMD aggravation.
• TMD side effects from oral appliances are often transient and don’t produce
discontinuation of the treatment.
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12.8 Orthognathic Surgery inPatients withOSA
Treatment for patients with obstructive sleep apnea (OSA) aims to prevent the collapse of the pharynx during sleep. There are several alternatives as a treatment.
These range from noninvasive therapy with the use of CPAP (continuous positive air
pressure device) to invasive surgical procedures that can modify the facial pattern of
patients [141].
The goal of CPAP is to create a pneumatic stent in the airway during sleep to
prevent obstruction and the resulting episodes of apnea and hypoxia; although it is
the most reliable method to correct the collapse of the airways, it is far from being
the most comfortable and ergonomic device during sleep, so the adherence to the
use of these devices is very variable and decreases over the time, therefore the morbidity and mortality in those patients who do not adapt to its use is higher [141].
Patients who do not adapt to CPAP therapy have an absolute increase of 10% in the
risk of mortality at 5 years, for which various surgical techniques have been
described in an attempt to resolve the condition permanently [142].
Advances in surgical therapy have improved signicantly since the description
and understanding of the syndrome. The rst invasive treatment described was the
tracheotomy performed by Kuhlo for the treatment of upper airway obstruction in
the “Pickwickian” subject [143].
Soft tissue surgical procedures to increase airway volume and/or space in patients
who cannot tolerate CPAP have sometimes improved subjectively or just with a
decrease in snoring during sleep, however, the actual rate of success for these procedures is relatively low and ranges from 40% to 60%, so patient acceptance of
these results is highly questionable [144–146].
One of the soft tissue interventions for the treatment of upper airway obstruction
in patients with sleep apnea described by Ikematsu and later popularized by Fujita
is uvulopalatopharyngoplasty (UPPP) [147, 148]. There are several hypotheses for
which there is a limited effectiveness of surgical interventions in soft tissues, it is
due to the fact that there may be multiple anomalies in the entire extension of the
pharynx which is not limited to one area, so it is essential to take into account the
dimensions of the pharynx in terms of its average length that is 12–15cm (14cm in
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Fig. 12.21 Linear and volumetric airway measurement in cone bean tomography
Fig. 12.22 Digital
planning of orthognathic
surgery, having the airway
as reference
L. D. AneybaLópez et al.
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men and 13cm in women), diameter in the transverse direction of 4–5cm and in the
anteroposterior direction of 2–3cm, with a vertical extension from the base of the
skull to the C6 level (corresponding to the cricoid cartilage), where it continues with
the esophagus [149–151].
It is essential to remember the muscles involved in the permeability of the airway, one of the main ones is the genioglossus muscle, which is shaped like a triangle whose vertex is located behind the mental symphysis and its convex base
corresponds to the dorsal aspect of the tongue this muscle contraction helps in stabilizing and lengthening the upper section of the tongue, maintaining its anterior
location, thus allowing the patency of the airway to be maintained. During sleep,
muscle bers relaxes, causing posterior displacement of the tongue and obstruction
in susceptible patients [152].
Advancement mentoplasty has been proposed as an alternative treatment. The
intervention is based on an osteotomy of the mental symphysis to bring the genioglossus and geniohyoid muscles forward, causing an advancement of the tongue,
avoiding obstruction of the upper airways in the hypopharynx during sleep [153].
The rst publication of an intervention in the jaws for OSA treatment was made
in 1984 by R.Riley, te. Guilleminault, *N.Powell, and tS.Derman. They described
a 24-year-old male patient with OSA, daytime sleepiness, and nocturnal arrhythmias who had undergone palatopharyngoplasty surgery without signicant improvement. A new surgical procedure was proposed combining an advance of the hyoid
bone and a mandibular horizontal sliding osteotomy; Later, the same authors published a more extensive series of cases through the treatment of Maxillomandibular
Advancement (MMA) in patients with severe OSA.They described a combined
maxillary, mandibular, and hyoid advancement. They observed an objective
improvement through PSG after 4–18months of surgery t [154].
Maxillomandibular Advancement (MMA) described a surgical intervention has
shown signicant surgical success in OSA treatment. A preoperative surgical assessment should be performed when considering Maxillomandibular advancement surgery. It should include x-ray studies, orthopantomography, and lateral cephalometry
to study craniofacial alterations, the facial biotype, and the probable site of airway
obstruction. Obtaining a volumetric tomography may improve information, which
we can navigate within the airways (Fig.12.21). In addition, it is possible through
computer programs to carry out preoperative surgical planning, providing a helpful
guide and an accurate reconstruction of the bone structures so we can predict and
plan the aesthetic and soft tissue changes obtained through the movements of the
bone structures (Fig.12.22).
This customization improves prediction and accuracy, allowing visible and precise relationships between the different soft tissue and bone structures.
We consider it crucial to obtain CAD-CAM models (Computer-Aided DesignComputer- Aided Manufacturing) to carry out the bone movements objectively and,
if necessary, to conrm the plates or select the correct length of the screws to be
placed (Fig.12.23) [155, 156].
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Fig. 12.23 Orthognathic
surgery planning in
stereolithography
L. D. AneybaLópez et al.
The selection criteria for patients who are candidates for MMA are the following:
• Diagnosis of OSA by polysomnography.
• Site of obstruction determined by Mallampati classication, cephalometry,
tomography, or ideally by drug-induced sedation endoscopy (DISE).
• Body mass index (BMI) less than 30kg/m2 (we consider it essential to reduce the
BMI as much as possible to obtain stable long-term results since we must remem-
ber that the redundant soft tissue of the upper respiratory tract becomes lax over
time due to natural aging).
• Age between 18 and 65years.
• Adequate health status to undergo a surgical procedure.
• Intolerance to CPAP after a trial period of at least 3months.
Maxillomandibular Advancement (MMA) should not be performed if patients
have a systemic condition for which they cannot tolerate surgery or if there is an
obstruction site at the level of the nasopharynx or hypopharynx [156].
For many physicians who work in OSA, the MMA is considered a very invasive
procedure, and therefore, they indicate it as a last resort. We believe that patients
who present dentofacial alterations such as mandibular retrognathia, maxillary
hypoplasia, microgenia, or a combination of the above should be candidates for
orthognathic surgery as the rst choice [157].
Many patients with OSA present bone alterations that can be corrected using
orthognathic surgery [157].
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it is known that a poor development, mainly of the jaw, is associated with a lower
volume of the airways [158].
On the other hand, Grauer etal. evaluated the shape and volume of the airway in
subjects with different facial patterns and concluded that the volume and shape vary
in patients with different anteroposterior relationships; however, when it comes to
vertical relationships, only the shape varies. The class II pattern had the lowest oropharyngeal volume (VO) in this study, while class I and class III had similar values [159].
The goal of MMA is to increase posterior airway space (PAS) to decrease airway
resistance and eliminate sites of airway collapse. In addition, MMA has decreased
retropalatal air velocity and improved lateral pharyngeal wall collapse [160].
High success rates are reported [141, 143, 146, 154]. Most studies show a surgical success rate of approximately 80% and a cure rate of 30%–40% [161], with
equivalent improvements in sleep quality to CPAP therapy.
The mechanism behind the improvement of OSA symptoms after MMA is complex and based on many factors, the primary means being the modication of the
dimensions of the posterior airways [162–164].
Changes in preoperative and postoperative polysomnography measure the success of MMA in OSA. Surgical “cure” is dened as an apnea–hypopnea index
(AHI) or Respiratory Impairment Index (RDI) of less than 5. In contrast, “success”
is dened as a combined AHI/RDI of less than 10–20 and a decrease in IAH/RDI of
50% or more. The denition of surgical success varies between publications.
However, the therapeutic success denition prevails [146].The success or cure, is
ultimately achieved by advancing the bony structure of the face to change the associated soft tissues and airway dimensions [165–167] A large neck circumference
has been suggested as negative factor for MMA success in patients with OSA [164].
Zaghi etal. [168] have described the preoperative severity of OSA to be the most
reliable predictor of outcome. More specically, the more severe cases of OSA tend
to benet more after MMA by lowering the AHI, but the cure rate was only 20%
among patients with a preoperative AHI of >90 events/h. Patients with a preoperative AHI of <30 events/h showed cure in 56% and therefore showed a higher probability of success.
There seems to be a more important effect on the pharyngeal airway produced by
mandibular advancement than at maxilla, due to the role played by the advancement
of the skeletal insertions of the suprahyoid musculature. But, there is some disagreement on this issue of preponderance of an area [169].
A hot topic of controversy in OSA with MMA is the amount of surgical advancement required to achieve the desired effect in the posterior airway space. It has been
suggested by Riley etal. that a 10mm advancement showed a statistically signicant improvement in the postoperative with conrmation by subsequent studies
[168, 170].
However, there is still some disagreement, as some studies have not found statistically signicant correlation between the amount of advancement and improvement in polysomnography results. A minimum advancement of 10mm has not yet
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L. D. AneybaLópez et al.
been studied exclusively in patients with normal or class I malocclusion (neutroclusion) [171].
Regarding the amount of advancement, there is no specic amount in the literature necessary to obtain better results, Boyd etal. [172] in their study reported an
advancement of 7±2.3in the maxilla and 9.2±3.3in the mandible, Vignono etal.
reported 10.4±4.3in the maxilla and 12.9±4.2in the mandible, and Li etal. [173]
a maxillomandibular advancement of 10.8±2.7. This is close to the commonly
accepted standard in most studies of achieving advances of approximately 10mm.
Buttereld etal. [174] reported that maxillary, but not mandibular, advancement
was signicantly correlated with changes in IAH and SBP, while others reported a
negative correlation between the magnitude of Le Fort advancement and changes in
IAH [175].
Mareque etal. [176] proposed a protocol for surgical action in patients with an
associated facial deformity, following a sequential pattern, depending on the location of the defect and the response to initial treatment as follows:
1. Class I patients with bimaxillary hypoplasia: Bimaxillary advancement.
2. Patients in class II and mandibular hypoplasia:
(a) Accept orthodontic treatment. Mandibular advancement.
(b) Not acceptance of orthodontic treatment:
• No aesthetic compromise: Geniohyoid advancement through anterior
mandibular osteotomy.
• Aesthetic compromise: This study shows that jaw advancement surgery,
particularly in the maxilla, does not continuously increase airway volume. There is essentially a plateau effect in maxillary advancement up to
7mm; in all three regions, the airway increased in volume with maxillary
advancement up to 7mm of maxillary advancement. Beyond 7mm of
promotion, airway volume (whole airway or segmented airway regions)
decreased despite further advancement. The most signicant percentage
change was seen in the nasopharynx but showed the most signicant
standard deviation [177].
In a cohort study of 62 patients who underwent maxillary advancement, two
variables were associated with a successful or unsuccessful outcome: the rst was
age, which was higher in unsuccessful patients, and the second was circumference
of the neck, which was greater in patients with treatment failure. Regarding age, a
possible explanation for this could be the degeneration of muscle bers in the pharyngeal airways, which gives greater relaxation and softness. The mechanism
behind MMA is to widen the pharyngeal airway by gently stretching tissues, but
with increasing age of the tissues, this mechanical effect maybe more susceptible to
failure, associated with signicant gravity and neck circumference [164].
Comparison of results of the procedures through different imaging studies is
found. Orthognathic surgery offers great variability of treatment possibilities for the
same problem. It is challenging for different surgeons to repeat the same surgical
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procedure accurately. On the other hand, it is impossible to carry out an identical
movement in different patients since each one has a very individual diagnosis and
facial characteristics, requiring highly individualized treatment. Finally, there are
inherent difculties with volumetric measurements of the airway. Postural changes
signicantly modify pharyngeal dimensions. The natural position of the head is the
standardized method proposed for performing cone-beam tomography; however, it
is difcult to reproduce precisely. The control of breathing and the tongue’s position
during the examination is challenging to achieve, and not all researchers consider
these variables [169]. Maxillomandibular advancement (MMA) is considered a safe
and well-tolerated procedure by patients; Boyd etal. [172] reported as main adverse
events that 40% of the patients presented long-standing paresthesia in the chin
region and 13.8% of the patients perceived an unfavorable change in their facial
aesthetics after treatment. No patient reported serious adverse events.
Camacho etal. [178] 2019 published a meta-analysis on the long-term results of
MMA as a treatment for OSA. They analyzed 120 patients and concluded that
patients maintained an improvement in AHI, sleepiness, and oxygen saturation.
However, the average AHI may increase in the long term with some reports studying
longer term effects (≥8years). These have concluded excellent immediate results
with an increase of AHI that varies between 11.3 and 40.6 events [179, 180]. Some
factors that might inuence this include redundant upper airway tissue that might
become laxer over time, skeletal recurrence, and normal patient aging.
Zhou etal. (2020) [181], published a systematic review and meta-analysis comparing the efcacy of different surgical treatments based on MMA in adults with
OSA, including 227 patients and eight other treatments. The treatments studied were:
• Traditional maxillomandibular advancement (MMA).
• Modied maxillary advancement (MMA and advancement mentoplasty).
• Maxillomandibular advancement with counterclockwise movement (MMACM).
• Maxillomandibular advancement and drug-induced sedation endoscopy
(MMA+DISE).
• Maxillomandibular advancement and trans oral robotic surgery (MMA+TORS).
• Maxillomandibular advancement and uvulopalatopharyngoplasty
(MMA+UPPP).
• Maxillomandibular advancement and uvulopalatopharyngoplasty with uvula
preservation (MMA+UPFPUP).
Of these treatments, the one that offered the most signicant improvement in
terms of AHI, Oxygen Saturation, and Epworth Scale was maxillomandibular
advancement with uvulopalatopharyngoplasty with uvula preservation
(MMA + UPPPUP); however, analyzing isolated procedures, good results were
seen in maxillomandibular advancement (MMMA) with counterclockwise maxillomandibular advancement (MMACM), offering benet for patients with moderate
to severe OSA [181].
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These data contrast Camacho etal. [178] report that did not nd improvement for
performing a maxillomandibular advancement alone or combined with
uvulopalatopharyngoplasty.
Whether or not to perform procedures on the soft palate (either UPPP or
UPFPCPU) depends on the site of obstruction.
When the obstruction is in the hypopharyngeal area, the advantages of this procedure are limited, Bettega etal. [182] report that the success rates of these procedures are 40.8% in general and are reduced to 5% when there is a narrowing in the
retrolingual space. Therefore, drug-induced sedation endoscopy (DISE) has become
popular today since it allows for the establishment of the sites of obstruction with
greater precision and, in this way, to plan the treatments that can offer the best
results. However, the systematic review carried out by Zhou etal. [181] did not nd
a signicant improvement in the therapeutic success of performing an MMA alone
or previously with DISE, which is why it is considered a diagnostic tool rather than
therapeutic success tool.
L. D. AneybaLópez et al.
12.9 Conclusions
• Whenever the patient presents a skeletal discrepancy, MMA treatment should be
considered as the rst treatment option.
• The main criteria for a patient to be a candidate for orthognathic surgery are
diagnosis of OSA by polysomnography, identication of the site of obstruction,
(by tomography or DISE), and a BMI of less than 30.
• The goal of MMA is to increase posterior airway space while decreasing airway
resistance and eliminating sites of collapse.
• Although considered by some health professionals to be an invasive treatment,
MMA is a safe and effective alternative for the treatment of moderate to severe
obstructive sleep apnea.
• The success rate of MMA in OSA treatment has been reported to be approxi-
mately 80% and a cure rate of 30%–40%.
• Within the different modalities of this procedure, the best results are the MMA
with advancement mentoplasty and MMA with counterclockwise rotation.
• In some cases, MMA and uvulopalatopharyngoplasty with uvula preservation
can offer superior results to MMA alone.
• Mainly when DISE previously veries the site or sites of obstruction.
• More methodologically well-designed studies are required to verify the success
of these treatments in the longer term to verify their stability over time.
• The dentist specializing in oral and maxillofacial surgery must be a part of the
multidisciplinary teams that care for patients with OSA’s and participate in the
initial evaluation of patients and in maxillofacial surgical treatments when these
are indicated.
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