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Indicates sessions with recordings available for purchase.Materials/Methods: This study involved a retrospective medical record review of all OSA patients treated at Boston University Medical Center by a single surgeon between 2000-2010 with phase I treatment procedures. Each patient underwent a comprehensive preoperative (T1) evaluation including clinical and radiographic examination, subjective assessment using the Epworth Sleepiness Scale (ESS), and objective evaluation with a polysomnogram (PSG). Criteria for inclusion included: 1) Patients with a diagnosis of moderate OSA (AHI between 15 -30), who were intolerant to CPAP therapy, 2) Identifiable clinical obstruction at the soft palate and tongue base levels, 3) Mandibular retrognathism and an inferiorly positioned hyoid bone verified by clinical exam and measurements on cephalometric radiographs, 4) Surgical management with a combination of three procedures: UPPP, HMS and GBAT, and, 4) Minimum of 12 months follow-up. All patients had postoperative subjective and objective examinations performed at the 12 or more months (T2) interval to evaluate and compare short- and long-term success of surgery. For study purposes, all patients were classified on the basis the ADI/RDI values seen at T2 into the following categories: 1) Successful: 50% or more reduction, 2) Modest improvement: 26-49 % reduction, and, 3) Failure: less than 25 % improvement.
Results: Twenty-two patients (18 males, 4 females) were included in the study. At T1, the average AHI was 22.4 (R 17-28) and ESS score was 8 (R 5-11). The average preoperative BMI of the patient sample was 28.6 (R 23 to 32.4). At T2, all patients (100%) subjectively reported decreased or absent snoring and 20 patients (86%) reported statistically significant improvement in the subjective ESS score (average= 4); however, PSG results showed success in only 5 patients (23%), modest improvement in 10 patients (45%) and failure in 7 patients (32%). The average BMI at T2 was 27.9 (R 23 to 31). Average baseline oxygen saturation was 92 % at T1 and T2, while oxygen saturation nadir at T1 and T2 was 81% and 83% respectively. 8 of the 22 patients have since undergone MMA with complete elimination of OSA in each patient with an average postsurgical AHI of 1.1 (R 0-2).
Discussion: Long-term clinical outcomes for phase 1 surgical therapy for treatment of patients with a diagnosis of moderate OSA were found to be poor. Although patients subjectively felt improved, PSG evaluations clearly demonstrated that the surgery was not successful in eliminating OSA in any patient at the one-year postoperative interval. MMA appears to be a highly successful alternative in failed patients, and in our opinion, should be considered as first choice in the management of OSA patients with mandibular retrognathism.
[1] Riley RW, (1993). Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway rconstruction, Journal of Oral and Maxillofacial Surgery. 51(7): 742-747
[2] Kasey K. Li, (2011). Maxillomandibular Advancement for Obstructive Sleep Apnea, Journal of Oral and Maxillofacial Surgery. 69 (3): 687-694