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.