Three-Dimensional Computed Tomographic Airway Analysis of Patients With Obstructive Sleep Apnea Treated by Maxillomandibular Advancement

doi:10.1016/j.joms.2010.11.037

Journal of Oral and Maxillofacial Surgery

Volume 69, Issue 3, March 2011, Pages 677-686

This manuscript was presented in part at the American Association of Oral and Maxillofacial Surgeons Annual Meeting, Toronto, Ontario, Canada, October 16, 2009.

https://doi.org/10.1016/j.joms.2010.11.037 Get rights and content

Purpose

To evaluate changes in airway size and shape in patients with obstructive sleep apnea (OSA) after maxillomandibular advancement (MMA) and genial tubercle advancement (GTA).

Materials and Methods

This was a retrospective cohort study, enrolling a sample of adults with polysomnography-confirmed OSA who underwent MMA + GTA. All subjects who had preoperative and postoperative 3-dimensional computed tomography (CT) scans to evaluate changes in airway size and shape after MMA + GTA were included. Preoperative and postoperative sleep- and breathing-related symptoms were recorded. Descriptive and bivariate statistics were computed. For all analyses, P < .05 was considered statistically significant.

Results

During the study period, 13 patients underwent MMA + GTA, of whom 11 (84.6%) met the inclusion criteria. There were 9 men and 2 women with a mean age of 39 years. The mean body mass index was 26.3; mean respiratory disturbance index (RDI), 48.8; and mean lowest oxygen saturation, 80.5%. After MMA + GTA, there were significant increases in lateral and anteroposterior airway diameters (P < .01), volume (P = .02), surface area (P < .01), and cross-sectional areas at multiple sites (P < .04). Airway length decreased (P < .01) and airway shape (P = .04) became more uniform. The mean change in RDI was –60%.

Conclusions

Results of this preliminary study indicate that MMA + GTA appears to produce significant changes in airway size and shape that correlate with a decrease in RDI.

Section snippets

Patients and Study Design

This was a retrospective cohort study of patients with OSA treated by MMA + GTA at the Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital (Boston, MA), over a 29-month period (August 2007 to December 2009). This study was approved by the Partners Institutional Review Board (Protocol #2006P00811). Subjects were included if 1) the diagnosis of OSA was confirmed by overnight polysomnogram and 2) there were pretreatment and post-treatment 3D CT scans from the hard palate

Results

From 2004 through 2009, 112 patients were evaluated for OSA. Twenty-eight patients were treated with MMA + GTA. On the basis of preliminary investigations using 3D CT imaging to aid the diagnosis and management of OSA,18, 19, 20, 22 we began obtaining preoperative and postoperative maxillofacial CT scans for all adults with OSA in August of 2007.

From August 2007 through December 2009, 13 patients underwent MMA for treatment of OSA, of which 11 (84.6%) met the inclusion criteria for the study.

Discussion

Although certain upper airway parameters have been shown to correlate with the presence and severity of OSA,4, 5, 6, 7, 8, 9, 10, 20 the changes in these parameters after MMA and correlation with relief of symptoms have not been well established.11, 12, 13, 14 In the sagittal plane, posterior airway space and airway length have been shown to improve after MMA and are associated with improvement in symptoms.2, 15, 16, 22, 26 MMA, however, alters airway anatomy in multiple planes of space.

Acknowledgments

The authors acknowledge Dr Thomas Dodson for his input regarding study design and statistical analysis.

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Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis
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To evaluate the effectiveness of maxillomandibular advancement surgery in the treatment of Obstructive Sleep Apnea by comparing the pre- and postoperative Apnea and Hypopnea Index, in addition to classifying the degree of evidence and risk of intervention bias.
A systematic review of the literature was carried out in the PUBMED, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE and COCHRANE platforms, including cohort studies with polysomnographic follow-up, without other associated pharyngeal or nasal surgical procedures. The risk of study bias was assessed using the Modified Delphi technique. Pre- and postoperative Apnea and Hypopnea Index data were plotted for meta-analysis, and the quality of evidence was assessed using the GRADE system.
Of 1882 references, 32 articles were selected for full-text reading, of which four studies were included, totaling 83 adults with obstructive sleep apnea who underwent maxillomandibular advancement. The meta-analysis was in favor of the intervention (DM = −33.36, 95% CI −41.43 to −25.29, p < 0.00001), with a mean percentage reduction in the Apnea and Hypopnea Index of 79.5% after surgery, even though the level of evidence was classified as very low quality by the GRADE system.
The meta-analysis was in favor of the intervention, characterizing maxillomandibular advancement surgery as an effective treatment for obstructive sleep apnea in adults.
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Surgical intervention is a durable solution for patients with sleep pathology. Operative techniques are vast, ranging from office injections to maxillary mandibular bony osteotomies. Recent innovations trend toward minimally invasive procedures. Novel concepts such as endoscopic surgery, robotic surgery, and nerve stimulation have improved recovery and outcomes. Thorough diagnostic algorithms can identify the source of obstruction. Resulting treatments are tailored toward the involved anatomy.
Comparison of airway changes after maxillomandibular advancement with or without genial tubercle advancement in obstructive sleep apnea using cone-beam computed tomography
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This study compared the airway changes of patients with obstructive sleep apnea (OSA) after maxillomandibular advancement (MMA) with or without genial tubercle advancement (GTA) using cone-beam computed tomography.
The authors retrospectively studied 26 patients with moderate to severe OSA who underwent MMA with or without GTA. Airway changes were determined from preoperative and postoperative 3-dimensional reconstructed cone-beam computed tomography images. The Wilcoxon signed rank test, Mann-Whitney U tests, and Spearman correlation coefficients were used in data analysis.
Airway was changed in all dimensions significantly after MMA with or without GTA. There was no significant difference in horizontal surgical changes between MMA and MMA with the GTA group. The mean increase in total airway volume was 66.8% for MMA alone and 74.7% for MMA with GTA (P = 0.39). Patients who underwent MMA had a larger percentage change of segmented upper airway volume than patients with MMA and GTA (106.6% vs 85.3%; P = 0.65). The group with MMA and GTA had a greater percentage change of segmented lower airway volume than the MMA alone group (80.1% vs 56.3%; P = 0.42).
Differences in airway changes between MMA alone and MMA with GTA were not statistically significant. Performing the GTA concomitantly with MMA may not cause greater improvement in the pharyngeal airway in patients with OSA compared with MMA alone.
The correlation of maxillomandibular advancement and airway volume change in obstructive sleep apnea using cone beam computed tomography
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Citation Excerpt :
Veys et al.10 found that the increase in TAV was strongly correlated with the decrease in AHI. Similarly, Abramson et al.15 showed a significant correlation and advocated normalization of the airway parameters as an assessment rather than only PSG. Additionally, an increase in TAV ≥ 70% achieved no further reduction in AHI, so some suggest using the prediction of TAV change for treatment planning rather than a standard of 10 mm advancement16.
The purpose of this retrospective study was to evaluate the correlation of maxillomandibular advancement (MMA) and airway volume changes in patients with obstructive sleep apnea (OSA), and to determine the surgical skeletal movements necessary to achieve an increase in total airway volume (TAV) of ≥70%. Thirty patients with OSA treated by MMA were evaluated. Pre- and postoperative cone beam computed tomography images were used to determine the horizontal distance and angular changes in surgical parameters and linear, area, and volumetric airway parameters. Postoperatively, the horizontal distance of surgical parameters (A-point, UI, B-point, pogonion, and menton) and craniofacial angulation (SNA and SNB) increased significantly, similar to total surface area, TAV, and minimum cross-sectional area of the airway (p < 0.0001). The total airway length decreased significantly (p < 0.0001). The mean increase in TAV was 67.2%. There were positive correlations between linear surgical changes and the percentage change in TAV. All surgical parameters were predictive of a change in TAV ≥70%. The optimal surgical change was 6 mm for A-point, 7.9 mm for UI, 7.6 mm for B-point, 11.2 mm for pogonion, and 10 mm for menton. In conclusion, maxillary advancement of less than 10 mm was adequate in this study to obtain an increase in the TAV of at least 70%.
The relationship between bimaxillary orthognathic surgery and the extent of posterior airway space in class II and III patients – A retrospective three-dimensional cohort analysis
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To assess the relationship between bimaxillary orthognathic surgery in class II and III patients, the three-dimensional extent of the posterior airway space (PAS) using cone-beam computed tomography (CBCT).
A retrospective evaluation of a cohort of Class II and III patients, who had undergone orthognathic surgery (Le Fort I osteotomy, bilateral sagittal split osteotomy), between December 2011 and July 2014, was performed. In each case, CBCT scans were performed one week prior (T1) to and 6 months (T2) after surgery, followed by analysis of several airway parameters (volume, mean cross-sectional area, and diameter) and the three-dimensional extent of mandibular movement.
In Class II patients significant postoperative volumetric increases in the middle and lower PAS segment as well as in all diametric and spherical variables (p ≤ 0.001) could be seen. In Class III patients there were only significant postoperative increases in the volumetric, and partially in diametric and spherical, variables (p < 0.05) of the upper PAS segment. There was also a significant linear relation between forward displacement of the maxilla and mandible and some airway parameters (p < 0.05).
These results reveal that bignathic surgery in Class II patients provokes an increase in most dimensions of the PAS. This intervention can be assumed to reduce airway resistance and might therefore be a suitable treatment option for patients suffering from OSAS. For bignathic surgery in Class III patients, a positive effect could be seen, especially at the nasopharynx.

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: This study was supported by the Hanson Foundation, the AO/Synthes Research Fellowship in Pediatric Oral and Maxillofacial Surgery (Z.A., M.L.), the Oral and Maxillofacial Surgery Foundation Fellowship in Clinical Investigation (S.M.S.), and the Massachusetts General Hospital Department of Oral and Maxillofacial Surgery Education and Research Fund (Z.R.A., S.M.S., M.L.) and Center for Applied Clinical Investigation (S.M.S.).

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A paradigm shift in orthognathic surgery: A special series part IIThree-Dimensional Computed Tomographic Airway Analysis of Patients With Obstructive Sleep Apnea Treated by Maxillomandibular Advancement

Purpose

Materials and Methods

Results

Conclusions

Section snippets

Patients and Study Design

Results

Discussion

Acknowledgments

Chest

Otolaryngol Head Neck Surg

Chest

Use of 3-dimensional computed tomography scan to evaluate upper airway patency for patients undergoing sleep disordered breathing surgery

Auris Nasus Larynx

J Biomech

Respir Physiol

Chest

Oral Maxillofac Surg Clin North Am

J Oral Maxillofac Surg

Chest

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

A paradigm shift in orthognathic surgery: A special series part II
Three-Dimensional Computed Tomographic Airway Analysis of Patients With Obstructive Sleep Apnea Treated by Maxillomandibular Advancement