Long Term Clinical Effectiveness of Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea: A Multicenter Study

Long Term Clinical Effectiveness of Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea: A Multicenter Study

Scott B. Boyd, DDS, PhD; Arthur S. Walters, MD; Peter D. Waite, MPH, DDS; MD, Susan M. Harding, MD

Statement of the Problem: Several short-term observational studies indicate that maxillomandibular advancement surgery (MMA) may be an effective alternative therapy for patients with obstructive sleep apnea (OSA) who are unable to adhere to CPAP therapy.  However, little is known about the long-term effectiveness of MMA—although it is clinically important to know long-term outcomes, as OSA is considered a chronic disease that may require lifelong treatment.  The purpose of this study was to determine the long-term clinical effectiveness of MMA, as measured by changes in the apnea-hypopnea index (AHI), sleepiness, sleep architecture and health related-quality of life (HR-QOL). 

 Materials and Methods:  We performed a multicenter observational cohort study consisting of 31 patients who underwent MMA for treatment of OSA at either Vanderbilt Medical Center between 1997 and 2007 (n=22) or the University of Alabama at Birmingham between 2006 and 2010 (n=9).  The study group was composed primarily of middle age (mean age = 50.9 ±9.7), obese (mean baseline BMI = 29.1 ± 4.1) males (77%) with severe OSA (baseline AHI = 49.4 ± 23.7).  No patient in the study group was adherent to CPAP therapy, and all individuals subsequently underwent MMA.  Each patient had polysomnography performed at baseline pre-operatively, 3-6 months following MMA, and >2 years after surgery (mean follow-up 6.5 ± 2.9 years).  Patients also completed the Epworth Sleepiness Scale (ESS), and either the Sleep Apnea Quality of Life Index (SAQLI), or Functional Outcomes of Sleep Questionnaire (FOSQ) at the long-term evaluation.

Methods of Data Analysis:  Descriptive statistical analysis was performed for all continuous variables and reported as mean ± SD.  The Wilcoxon signed rank test was used to assess changes in: BMI, AHI, % REM sleep, ESS and FOSQ scores at the short-term and long-term time intervals following MMA.  For all analyses, a p-value of <0.05 was considered statistically significant.

Results: Surgical treatment resulted in a significant short term reduction in AHI (49.4 ± 23.7 to 8.9 ± 7.9, P <0.001) that was maintained on a long term basis (8.9 ± 7.9 to 9.7 ± 13.1 p = 0.459). These changes in AHI occurred despite a significant increase in weight from baseline (BMI: 29.1 ±4.1 to 30.8 ±4.2, p<0.001).  Surgical treatment also resulted in an increase in % REM sleep (11.2 ± 10.2 to16.6 ±10.0, p = 0.0082) that was maintained on a long-term basis (16.6 ± 10.0 to 15.3 ± 5.3, p = 0.6277). The patients also demonstrated a significant reduction in sleepiness from baseline (ESS: 12.1 ± 4.9 to 6.5 ± 3.2, p = 0.0059).  HR-QOL improved as measured from the FOSQ on a short-term basis (10.9±1.5 to 17.2 ± 2.9, p = 0.0625), and these changes were maintained on a long-term basis (17.2±2.9 to 17.3 ±2.6, p = 0.625).  SAQLI results showed a large improvement in quality of life (9.0 ± 1.2), with few treatment related symptoms (1.4 ±2.3).  

Conclusion:  The results of this study indicate that MMA is a clinically effective long-term treatment for patients with moderate to severe OSA, as measured by changes in AHI, sleepiness, sleep architecture and health-related quality of life.

   References

Holty J-E, Guilleminault C.  Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis.  Sleep Medicine Reviews 2010; 14: 287-297.    

Caples SM, Rowley JA, Prinsell JR, et al.  Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis.  Sleep 2010; 33: 1396-1407.