Trends in skeletal surgeries for OSA.pptx

This presentation highlights the recent evidence and trends in skeletal surgeries for management of obstructive sleep apnoea.

1. Dr. Kishor Bhandari Senior Consultant Oral and Maxillofacial Surgeon Bir Hospital, NAMS Fellowship in Craniofacial Surgery (Taiwan) Fellowship in Cranio-maxillofacial Surgery (Germany) Trends in Skeletal Surgeries for OSA

2. No conflict of interest. Photographs of patients presented are with written consent.

3. Contents Treatment concepts and surgical indications in OSA Scope of surgical treatment for OSA Surgical Decision making Maxillomandibular Advancement (MMA) What does evidence say? Maxillomandibular Advancement (MMA)- planning and execution Conclusion

4. 1. Treatment concepts and surgical indications in OSA Management of patients with OSA targets to restore an adequate respiratory function and oxygen saturation during sleep Increase the quantity of air flow Improve the regularity of breathing Enlarge the airway dimensions by Removal of anatomical obstruction within the upper airway Moving the anatomical boundary forward

5. Specific anatomic abnormality causing OSA Failure or rejection of non-invasive medical therapy (e.g. CPAP or MAD) Desire for a permanent cure Medically fit for surgery American Academy of Sleep Medicine (AASM) recommendations Surgical indications

6. Developmental mandibular hypoplasia Crouzon’s syndrome-midface hypoplasia Bilateral TMJ ankylosis Specific maxillofacial anatomy causing OSA Apert’s syndrome- Bicoronal craniosynostosis

7. 2. Scope of Surgical Treatment for OSA

8. Cheng-Hui Lin C, Wang PF, Ray Han Loh S, Lau HT, Sheng-Ping Hsu S. Maxillomandibular Rotational Advancement: Airway, Aesthetics, and Angle’s Considerations. Sleep Med Clin. 2019 Mar;14(1):83–9.

9. Types of skeletal surgeries for OSA Hyoid advancement Genioplasty/genioglossus advancement Maxillary expansion Maxillomandibular expansion Mandibular distraction Maxillomandibular advancement Awad M, Gouveia C, Zaghi S, Camacho M, Liu SYC. Changing practice: Trends in skeletal surgery for obstructive sleep apnea. J Cranio-Maxillo-fac Surg Off Publ Eur Assoc Cranio-Maxillo-fac Surg. 2019 Aug;47(8):1185–9. Maxillomandibular advancement remains the cornerstone of skeletal surgical therapy, with impressive results and emerging literature on long-term complications, outcomes, and surgical modifications.

10. 3. Surgical decision making

11. Original Stanford Protocol

12. Lateral Cephalogram Software based 2D Lateral Cephalogram tracing Software based 3D Cephalometric tracing

13. The morphological structure and compliance of the upper airways can be observed intuitively. The degree and location of upper airway stenosis can be accurately assessed, and the measurement indicators and related parameters can be combined. The correlation can optimize the clinical treatment options for adult male patients with OSA.

14. Phase I and II created to target multilevel obstruction while avoiding unnecessary surgery. Rationale: ‘’Start with less invasive option, then go to MMA as last resort’’ Out of 239 patients, 60 % achieved surgical cure with phase I with overall response rates ranging from 42% to 75%. (Patients who were incompletely treated by phase I surgery found to have persistent hypopharyngeal obstruction that classically involved complete collapse of the lateral pharyngeal walls.) 24 patients went for phase II with success rate of 100 %. Eg: a patient with severe OSA, minimal soft tissue hypertrophy, severe maxillomandibular deficiency- poor response to less invasive soft tissue surgery (Li 2010, Prinsell 2012) Pitfall

15. Revised Stanford Protocol Liu SYC, Awad M, Riley R, Capasso R. The Role of the Revised Stanford Protocol in Today’s Precision Medicine. Sleep Med Clin. 2019 Mar;14(1):99–107. Update: Phase II Preceding Phase I Surgery Two categories of patients can benefit from proceeding to Phase II (MMA) without first undergoing phase I surgery. Patients with OSA and concurrent dentofacial deformity Patients with moderate to severe OSA without dentofacial deformity with a. Complete lateral pharyngeal wall collapse on DISE, b. Low hyoid position and obtuse cervicomental angle, and c. High inclination of the occlusal plane.

16. 4. Maxillomandibular Advancement (MMA) Introduction Maxillomandibular advancement (MMA) or orthognathic surgery , also sometimes called bimaxillary advancement (Bi-Max) , or maxillomandibular osteotomy (MMO) , is a surgical procedure which moves the maxilla and the mandible forward. The procedure has popularly been in use for correction of facial deformities.

17. How does MMA work for OSA? Enlargement of facial skeletal framework leads to enlargement of pharyngeal and hypo pharyngeal airway (Li 2002) Expands anteroposterior and lateral dimensions (more predominantly) of upper airway from level of hard palate to hyoid bone (Fairburn 2007, using CT scan) Reduced collapsibility, especially at the lateral pharyngeal wall region (Li 2002, using force meter to ensure same inspiration force, and assessed on Mueller’s manoeuvre)

18. Fairburn SC, Waite PD, Vilos G, et al. Three-dimensional changes in upper airways of patients with obstructive sleep apnea following maxillomandibular advancement. J Oral Maxillofac Surg 2007; 65(1):6–12 . MMA advancement of 10 mm AP dimension increases: 5.6 mm (56%) of the advancement amount at the velopharynx 4.5 mm (45%) at the retro-uvula, 4.9 mm (49%) at the oropharynx, and 5.8 mm (58%) at the retroglossal airway Surprisingly, the LAT dimension increases 7.1 mm (71% of advancement amount) at the velopharynx, 5.7 mm (57%) at the retro-uvula, 13.2 mm (132%) at the oropharynx, and 6.6 mm (66%) at the retroglossalairway. Skeletal advancement can dilate the LAT dimension of the pharyngeal airway more than twice that of the AP expansion

19. What does evidence say?

20. N= 627 The mean apnea–hypopnea index (AHI) decreased from 63.9/h to 9.5/h (p < 0.001) following surgery. Surgical success in MMA for OSA 86 %. The major and minor complication rates were 1.0% and 3.1%, respectively. Most subjects reported satisfaction after MMA with improvements in quality of life measures and most OSA symptomatology. Conclusion: MMA is a safe and highly effective treatment for OSA. 2010 *Surgical success for OSA= 50% reduction of AHI or AHI less than 20/hr *Cure= AHI less than 5/hr

21. Mean percent reduction in apnea hypopnea index 92.1% for primary MMA with extrapharyngeal procedures 88.4% for primary MMA 86.6% for secondary MMA 79.4% for primary MMA with intrapharyngeal procedures 53.0% for non-MMA multilevel surgery 31.3% for uvulopalatopharyngoplasty, and 89.8% for nasal continuous positive airway pressure. 2012 ` `

22. N=518 Surgical success in MMA for OSA= 85.5% Cure rate= 38.5% MMA is an effective treatment for OSA Most patients with high residual AHI and RDI after other unsuccessful surgical procedures are likely to benefit from MMA. *Surgical success for OSA= 50% reduction of AHI or AHI less than 20/hr *Cure= AHI less than 5/hr 2016

23. 414 studies A steady increase in the publication of articles pertaining to maxillary expansion and maxillomandibular advancement was identi fi ed. Research interest in hyoid advancement and genioplasty/genioglossus advancement has declined in the past decade. Conclusions: MMA is the most widely studied and ef fi cacious multi-level surgery for OSA today. 2018 `

24. Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea, which target different levels of airway obstruction. 2021 `

25. Planning and execution

26. Majority of patients visit maxillofacial surgery OPD or Orthodontics OPD with complain of facial deformity, OSA will be a secondary finding Referrals from Sleep physicians, pulmonologists, ENT surgeons, general physicians Patients referrals for MMA

27. Typical patients’ journey towards MMA/Orthognathic Surgery/Bimax Surgery

28. Head Orientation Pre-correction

29. Head Orientation Post-correction

30. Composite Skull Model

31. Simulated Osteotomies Le Fort I Osteotomy Bilateral Sagittal Ramus Split Osteotomy (BSSRO) Genioplasty

32. Surgery

33. Inferior alveolar nerve

34. Case Illustration

35. Before MMA After MMA Maxilla advanced by 4 mm Mandible advanced by 8

36. Before After

37. 5.Conclusion Strongly backed up by results and evidence, maxillomandibular advancement (MMA) can be considered a viable surgical option for indicated patients of obstructive sleep apnoea.

38. THANK YOU 9851183191 [email protected]

39. Dr. Kishor Bhandari Senior Consultant Oral and Maxillofacial Surgeon Bir Hospital, NAMS Fellowship in Craniofacial Surgery (Taiwan) Fellowship in Cranio-maxillofacial Surgery (Germany) Trends in Skeletal Surgeries for OSA