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Orthognathic Surgery for Obstructive Sleep Apnea

Joseph E. Cillo Jr. DMD, MPH, PhD, FACS Associate Professor and Program Director ,
David J. Dattilo DDS Associate Professor and Division Director

PII: S1073-8746(19)30041-6
DOI: https://doi.org/10.1053/j.sodo.2019.08.003
Reference: YSODO 577

To appear in: Seminars in Orthodontics

Please cite this article as: Joseph E. Cillo Jr. DMD, MPH, PhD, FACS Associate Professor and Program Director ,
David J. Dattilo DDS Associate Professor and Division Director , Orthognathic Surgery for Obstruc-
tive Sleep Apnea, Seminars in Orthodontics (2019), doi: https://doi.org/10.1053/j.sodo.2019.08.003

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 Orthognathic Surgery for Obstructive Sleep Apnea

Joseph E. Cillo Jr., DMD, MPH, PhD, FACS*

David J. Dattilo, DDS**

*Associate Professor and Program Director

**Associate Professor and Division Director

Division of Oral and Maxillofacial Surgery

320 East North Avenue, Suite 6100 South Tower

Allegheny General Hospital

Allegheny Health Network

Pittsburgh, PA 15212

Corresponding Authors email: [email protected]

Abstract

As the importance in the management of obstructive sleep apnea and other obstructive upper

airway disease continues to increase, the effect of orthognathic surgery on the upper airway in

correction of both dentofacial deformities and obstructive sleep apnea has become a prominent

component of treatment planning in recent decades. Applied correctly, orthognathic surgery can

have a dramatic and life-changing effect on decreasing nocturnal obstructions through expansion

of the upper airway. Large advancements of the maxillomandibular complex allows for three-

dimensional upper airway expansion to nocturnal obstruction that diminish the deleterious

effects of obstructive sleep apnea. This paper will discuss the orthognathic surgical techniques

that are essential in the treatment planning to achieve the desired results of relief of nocturnal

upper airway obstructions.

Introduction

Obstructive sleep apnea (OSA) is serious medical condition characterized by repeated collapse of

the upper airway during sleep which leads to airway resistance and obstruction, snoring, fatigue,

and daytime sleepiness1. This condition may have a significant impact on cognitive behavior,

occupational disability, and worsen medical comorbidities, such as cerebrovascular and

cardiovascular disease.2 Prior to 1985, OSA was a disease researched and treated exclusively by

the medical specialties of otolaryngology and pulmonary medicine. Each passing year its

prevalence grew alarmingly swift as more patients were diagnosed and the effect of this

obstructive airway disease on the cardiovascular system, social issues associated with chronic

daytime sleepiness, increased mortality rates, such as nocturnal sudden death, made it a public
health threat that demanded immediate attention. At the time, through nocturnal and awake

endoscopic studies the airway collapse was known to occur at multiple areas along the upper

respiratory pathway. Continuous positive airway pressure (CPAP) is the recommended solution 1

but compliance has been a significant issue. Tracheostomy was the only procedure available and

was designed to bypass the entire upper airway but had its obvious social and physiologic

problems. The uvulopalatopharyngoplasty2 (UPPP) showed initial promise, but was eventually

found to have no more than a 40% successful and this only in mild obstructive cases. 3

Robert Riley and Nelson Powell, both dual otolaryngologists and oral and maxillofacial

surgeons from Stanford University, began using orthognathic surgical procedures designed for

the correction of craniofacial deformities for the treatment of OSA. 4 The mandible and its

attached anatomy, such as the genial tubercle attachment of the genioglossus muscle, were

advanced forward to help relieve base of the tongue obstruction from the posterior pharyngeal

wall. Along with Christian Guilleminault of the Stanford Sleep Disorders Clinic, these three

men developed a two-phase plan for the surgical treatment of OSA. 5 Phase 1 surgery consisted

of multiple procedures to address obstructive areas all along the upper respiratory tract; nasal and

palatal procedures for the nasopharynx, genioglossus advancement procedures for oropharynx ,

and hyoid suspension procedures for hypopharynx and Phase 2 surgery was maxillomandibular

advancement and became known as the Stanford Protocol of Surgical Management of OSA.

According to the Stanford Protocol, Phase I surgery was completed first and the patient re-

evaluated 6 months later. In the situation of an insufficient response to Phase 1 surgery as

determined as an AHI/RDI reduction by 50% or less than 5, Phase 2 surgery would then be

recommended. Early clinical papers using reduction in the apnea-hypopnea index (AHI) or

respiratory disturbance index (RDI) and nadir (lowest) oxygen saturation (nO2) levels from
overnight sleep studies revealed a stunning success in the phase 2 with a greater than 90%

success 6,7,8. This was a game changing event that eventually resulted in maxillofacial surgeons,

orthodontist and the entire profession of dentistry becoming primary movers for the surgical

treatment of OSA.

It was apparent from the beginning that orthognathic surgery for dentofacial deformities and

OSA had only the technical procedures in common. Many of the earlier OSA surgical patients

reported in the literature had no orthodontic input at all for their surgery due to the urgency of the

situation and patient refusal to undergo such a time consuming and expensive procedure.

Maxillomandibular advancement (MMA) for these patients had no real guidelines except to

advance the maxillofacial complex as far forward as the enveloping musculature would permit

with a simple goal of returning the patient to his or her original functional occlusion as long as

the airway expansion was accomplished.

Orthodontists who got involved with OSA patients found the following differences from

conventional orthognathic surgery:

1. The extreme advancement of the lower facial skeleton (maxilla and mandible) tend to

experience more instability. This may be due to increase soft tissue stretch of the face

and mandibular musculature or the reduced boney interface for stability.

2. The importance of planning the final esthetic facial outcome becomes far less important

than the functional requirements of OSA correction.

3. These patients not only represent a different age group on the average, but also tend to

have more missing teeth and periodontal problems. Therefore, coordination with
 surgeons, periodontists, and restorative dentists is essential to successful treatment in

these patients.9

4. Due to the poor medical condition of these patients and the urgency of correction, surgery

first to advance and align the arches followed by post-surgical occlusal adjustment or

formal banding may be the best option.

The orthodontist and the surgeon must understand that ideal treatment plans and esthetic

considerations that are a major part of conventional orthognathic surgery may have to take a

back seat to the medical needs of these very compromised patients.

The soft tissue reaction to conventional orthognathic surgery, while very important and

predictable, remains secondary to the intended correction of the functional goals of occlusal and

hard tissue balance. In orthognathic surgery for the OSA the soft tissue reaction of the oro-

pharyngeal complex is the primary goal of all orthognathic movements.

The following report will discuss the advances in technique, the long-term stability and the

present-day state of the art that have resulted from the last twenty years of applying these

orthognathic principles to the treatment of OSA.

Upper Airway and Craniofacial Anatomy in OSA

Various dynamic and static methods have been used to determine the single or multi-level source

of upper airway in OSA. The primary challenge with radiograph interpretation of the upper

airway is that it is accomplished on awake patients and occasionally in a sitting or standing

upright position. While providing important anatomical visualization and information, these

challenges are generally seen in static methods of upper airway radiographic interpretation such

as cone beam CT (CBCT) digital or conventional panoramic and lateral cephalometric

radiographs. Dynamic methods of evaluation of the upper airway may be better visualized with

such techniques as dynamic sleep magnetic resonance imaging (MRI) and drug-induced sleep

endoscopy (DISE). Sleep MRI allows for simultaneous evaluation of upper airway obstruction

and respiratory events in real time during natural sleep. This allows for respiratory and

desaturation events to be directly correlated with polysomnogram results and anatomic site of

obstruction. DISE is a combined endoscopic and anesthetic procedure that attempts to mimic

natural sleep through deepening of general anesthesia until a patient begins to obstruct in order to

observe the upper airway on flexible endoscopy.

Evaluation of the anatomical levels of upper airway sleep obstruction have been shown by

dynamic sleep MRI to be positively correlated with OSA severity. Specifically, severe OSA

patients have significantly more lateral pharyngeal wall collapse as compared to BMI-matched

mild OSA patients 10, 11. Airway obstructions visualized on sleep MRI during natural sleep

ranged from isolated retropalatal and retroglossal obstruction to multi-level combined

obstruction 12. DISE showed that obstruction may be observed in three dimensions:

anteroposterior, transverse and circumferential 13. DISE is able to visualize various anatomical

structures that can induce obstruction during sleep such as the retrovelar area (includes the soft

palate, mucosal velum, and uvula); the oropharyngeal area (includes the palatine tonsils and

pharyngeal walls); the hypopharyngeal area (includes the tongue base, lingual tonsils and lateral

pharyngeal walls); and the laryngeal area (includes the epiglottis and arytenoids). DISE findings

tend to indicate multiple levels of upper airway obstruction particularly in the retropalatal and

lateral pharyngeal walls. While individual anatomical obstruction during sleep will vary, findings

from dynamic upper airway observation in real time indicate that majority of nocturnal
obstruction are multilevel and occur primarily in the lateral pharyngeal wall, retropalatal and

retroglossal areas.

Static imaging of the upper airway such as static MRI, three-dimensional computed tomography

(3D-CT), and lateral cephalometry is a valuable screening tool for OSA. OSA patients,

compared to non-OSA patients, tend to have compromised three-dimensional upper airway to

include compromised total airway volume and minimum cross-sectional area 14. Upper airway

length has been shown to have a positive correlation and predictor to the OSA severity 11, 12,

while lateral/retroglossal anteroposterior dimension ratio shows an inverse correlation with the

OSA severity 15. These radiographic measures may be a good screening tool that will allow for

further advanced techniques to determine the location of obstruction. Cephalometric evaluation,

compared to the non-OSA population, reveals significant deviations in the OSA population that

may one or more of the following: shorter dimension of cranial base; shorter maxillary length;

maxillo-mandibular retrognathia related to Nasion perpendicular plane (N perpendicular FH)

despite normal angles of prognathism; mandibular retrognathia; increased anterior lower facial

height and mandibular plane angle; reduced size of bony pharynx; inferiorly positioned hyoid

bone at C4-C6 level 17.

Effect of Orthognathic Surgery for Dentofacial Deformities on the Upper Airway

Correction of dentofacial deformities (DFD), such as skeletal Class III malocclusion, have now

taken on a different perspective with consideration of upper airway obstruction. Corrective

mandibular surgery affects the hyoid bone and tongue position which may influence pharyngeal

airway dimensions 9. A decrease in pharyngeal airway from this movement may cause the

development or worsening of OSA and must be taken into consideration in treatment planning 17.
Skeletal Class III dentofacial deformity generally may be treated with mandibular setback

procedures alone to correct the malocclusion without any consideration for the potential

deleterious effects on the upper airway. Single-jaw mandibular setback osteotomies have been

shown to reduce pharyngeal airway dimensions significantly due to posterior positioning of the

hyoid bone and decreased posterior airway space 18, 19. Compared to mandibular setback surgery

alone for the correction of skeletal Class III deformities, bimaxillary surgery to treat this

condition produces a less compromised post-surgical pharyngeal airway with significantly less
20 - 22
decreased cross-sectional area of the upper airway . However, while mandibular setback

procedures have been shown reduce pharyngeal airway dimensions, a possible predisposing

factor in the development of OSA, patients tend to adapt quickly and, while there are some initial

reduced respiratory parameters with some surgeries, there has not been much significant
23 - 25
evidence to confirm post-surgical OSA development . These studies, however, have been

performed on young and healthy adolescents and the effect of aging and changes in body habitus

are not taken into consideration. Many decades later the alteration in posterior airway may

contribute any alteration of the posterior airway space due to orthognathic surgery should be

considered during orthodontic and presurgical treatment planning. Therefore, contemporary

orthognathic surgery treatment planning for correction of DFD should also seek to expand the

facial skeleton and thus the upper airway to alleviate, prevent, or decrease the risk of future

development of OSA.

Correction of skeletal Class II malocclusions with mandibular advancement surgery alone and

without genioplasty provides significant enlargement of the upper airway at the level of
26
oropharynx . The improvement is achieved through repositioning of the hyoid bone and

vallecula into a more superior and anterior position which has shown long term stability 27.
Maxillary only orthognathic surgery may also effect the upper airway and OSA. These tend to be

most effective when correcting maxillary hypoplasia through advancement and/or expansion in
28
individuals requiring this procedure to correct and existing DFD . However, correction of

vertical deficiencies does not appear to be as effective as correction of vertical maxillary excess

does not show a significant change in upper airway volume or subjective patient excessive

daytime sleepiness 29.

Maxillomandibular advancement (Figures1-7)

Maxillomandibular advancement (MMA) utilizes the principles of orthognathic surgery to

simultaneously advance both the upper and lower jaws specifically to treat OSA through

advancement and expansion of the facial skeleton. MMA has been successfully performed for

several decades and, other than tracheotomy, is the most effective and predictable surgical

procedure in the management of adult OSA 5, 7, 31 - 34. MMA advances the maxillomandibular

complex with a LeFort I maxillary and bilateral sagittal split mandibular ramus osteotomies, with

or without genioglossus advancement, and application of rigid internal fixation. Through the

subsequent expansion of the facial skeleton, the resultant increase in upper airway pharyngeal

volume is intended to decrease the risk of pharyngeal collapse from negative pressure inspiration

due to obstruction during sleep to ostensibly relieve or decrease the severity of OSA. In a multi-

center prospective study to comprehensively determine the effectiveness and safety of MMA for

the treatment of OSA, Boyd et al 35 found MMA to be a highly effective and safe treatment with

predictable improvements in sleepiness, quality of life, sleep-disordered breathing, and

neurocognitive performance, and a reduction in cardiovascular risk as measured by decrease in

blood pressure. MMA is the only surgical procedure, outside the tracheotomy, that can

effectively treat severe OSA.

Effect of MMA on Upper Airway Anatomy

The purpose of MMA in the treatment of OSA is to relieve nocturnal obstruction and the

negative pressure effect that results. Decreasing the deleterious effects of the negative pressure

effect will decrease the breathing workload and improve the condition of OSA. The effect of

MMA on decreasing nocturnal breathing workload is an important consideration in the success

of this procedure. Numerous clinical and radiographic evaluations have been utilized to evaluate

the effect of orthognathic surgery and MMA on the upper airway. Two- and three-dimensional

evaluation of upper airway length, anterior-posterior multilevel width, vertical and horizontal

position of the hyoid bone, cephalometric measurements, upper airway volume, and minimum

axial area have shown an association with occurrence of OSA 36.

Three-dimensional post-operative upper airway changes after MMA show significant

improvements that are comparable to unoperated non-OSA patients 37. Post-operative MMA

changes result in significant decrease in laminar and turbulent air flow at every level of the upper

airway, specifically at the soft palate and base of tongue 38. This is due to expansion of the upper

airway in not only the anterior-posterior and lateral dimensions but also elevates the hyoid bone
39
. This all has an effect of decreasing the upper airway length as well 40.

Treatment planning for MMA is complex and more complicated than simply advancement of the

maxillomandibular complex as the occlusal plane and chin position need to be evaluated and

treated. Rotation of the occlusal plane, particularly counterclockwise (CCW) ration the of the

maxillomandibular complex. The purpose of CCW is to both improve esthetics as well as open

the upper airway. CCW rotation of the occlusal plane in MMA produces a significant increase in

minimal axial area and volume of the pharyngeal airway through increase in the volume and

minimum axial area. Retrogenic individuals may tend to have a significantly decrease posterior
airway space and may be more predisposed to OSA. Genioglossus advancement (GGA) is

intended to provide additional expansion of the upper airway at the hypopharyngeal level 41.

While MMA results in an increased overall anteroposterior posterior airway space, the addition

of GGA produces even greater expansion at the hypopharynx level and may further improve the

upper airway 42.

Effectiveness of MMA in Treatment of OSA

Evaluation methods in the effectiveness of MMA for OSA have included both subjective and

objective analyses 43, 44. Pre-operative OSA severity significantly influences outcome of MMA

with a strong positive correlation between pre-operative AHI/RDI and post-operative percent

change 45. In individuals with extremely severe OSA with an extremely high AHI of higher than

100, MMA an extremely highly successful one-stage surgery that eliminates positive pressure

treatment, improves subjective and objective outcomes 44. Traditionally, as described by Holty

and Guilleminault 5, objective surgical success is defined as a post-operative AHI of less than 20

and a 50% reduction in AHI with a „„cure rate‟‟ as a postoperative AHI less than 5. The success

rate commonly seen in the literature for MMA has consistently been greater than other OSA
46
surgical procedures and averages around 90% with a range between 71% and 100% 45, 47. The

surgical cure rates (AHI less than 5) range from 38% 47, 48 to 43% 5. Preoperative AHI of fewer

than 60 events per hour is strongly associated with the highest incidence of surgical cure.

Numerous meta-analyses of the effectiveness of MMA are clear that this procedure is highly

effective in the treatment of OSA 5, 8, 39, 45. The ubiquitous results from all of these studies have

shown that MMA significantly improves AHI/RDI between 64 to 80%. Improvements in nadir

oxygen saturation were between 70 to 87% and for up to 77% improvement in excessive daytime

sleepiness.
Timing of MMA

Traditionally, MMA was indicated for treatment of only severe OSA in patients who are

intolerant, recalcitrant, or incapable to undergo conservative treatments such as positive airway

pressure or oral appliances 49. Additionally, as the Stanford Protocol advocates, MMA (Phase 2

surgery) should be performed once Phase 1 surgery has been proven to be ineffective in the

management of OSA. Recently, rather than subjecting a patient to numerous unsuccessful

surgeries prior to having MMA, it has been advocated that MMA should be considered as a first-

line surgical therapy for moderate to severe OSA. Boyd et al 50 suggested that MMA should be

the initial surgical treatment choice for eligible patients who are recalcitrant to conservative

therapies for moderate to severe OSA. Their comparisons between three surgical groups, MMA

alone, UPPP followed by MMA, and UPPP alone, and after adjusting for differences in baseline

AHI, the mean post-operative change in AHI was significantly larger and more effective for

MMA alone compared with both UPPP and UPPP followed by MMA.

Skeletal Stability of MMA

Skeletal stability of MMA in the treatment of OSA is an important aspect of long-term success.

Advancement of 8 to 12 millimeters of the maxillomandibular complex is generally required to

obtain this intended result 5. This large amount of movement may result in craniofacial skeletal

instability with relapse and the undesirable possible recurrence or worsening of OSA. The large

advancements involved in MMA raise concerns for skeletal stability and relapse. Fortunately,

with the proper use of rigid fixation, short, medium, and long-term skeletal stability in MMA is

achievable. Clinically significant loss of skeletal stability, as described by Proffit et al, is a post-

operative change of 2 or more degrees or millimeters. Nimkarn et al 51 previously reported that

medium (1 to 4 years) and long-term (greater than 4 years) MMA demonstrated minimal and
clinically insignificant skeletal relapse. Similarly, Lee 52 showed minor clinically insignificant

cephalometric skeletal changes with no development of malocclusion 2 years after MMA. Cillo

and Dattilo 53 showed that MMA in the treatment of severe OSA was a highly skeletally stable

long-term with no clinically significant loss of skeletal stability as far out as 8 to 13 years after

surgery independent of gender, age at the time of surgery, time to follow-up, and amount of

surgical movement.

Esthetic Effects of MMA

The soft tissue response of orthognathic surgery is predictable and stable. Soft tissue responses to

orthognathic surgery for correction of DFD are generally intended to change to esthetic aspects

of the face. OSA patients may or may not have an acquired or congenital deformity that requires

surgical treatment. Soft tissue movements produced by MMA have a direct effect mostly on the

upper and lower lips, and chin in an almost one-to-one hard-tissue-to-soft-tissue ratio 54. The

extremes of advancement performed in MMA for OSA may be thought of causing an

unacceptable change in the esthetic aspects of the face. However, most of these individuals are

bi-maxillary retrusion and evaluation of patient perception of facial appearance after MMA

suggests that moderate changes are noticed by most patients but are met with a 90% positive or

neutral response 54.

Safety of MMA

Orthognathic surgery for DFD is considered a safe and effective procedure that is generally

performed on adolescent or young adults 55. The usually healthy DFD population tend to have

significantly fewer post-operative complications compared to OSA patients that undergo MMA

who are on average, older and have more comorbidities. OSA population tends to be morbidly
obese compared with the relatively healthier DFD population, the significantly less healthy OSA

population have a three times as great incidence of minor and major complications with no

mortality. However, despite this disparity the complication rate in MMA for OSA is no different

than other surgical procedures at between 1.0% to 3.1% 5. The overall frequency of early major

medical post-operative complications, defined as admission to the intensive care unit or death, is

low 56. Being that the rate of all complications in MMA is low and similar to other procedures

with similar level of risk with no impact on quality of life issues and it may be considered a safe

procedure.

Orthodontics in MMA

The main purpose to perform MMA is to correct a serious disease, OSA, and not to correct DFD.

Therefore, the use of orthodontics is not an absolute necessity. The advancement of the

maxillomandibular complex maintains the pre-surgical occlusion and, for the most part, does not

intentionally change the occlusion. There may be situations were a relative malocclusion may be

corrected without the need for orthodontics. Several studies that have evaluated MMA for OSA

have had a mix of patient that did and did not have pre- and post-operative orthodontic treatment
34, 35
. The utilization of orthodontic therapy certainly is advantageous in MMA surgery. The pre-

surgical orthodontic set-up for OSA is generally no different than in the treatment of DFD. It will

involve the same general needs to level and align the arches, remove dental compensations, place

teeth of basal bone, and coordinate the arches to position teeth into the appropriate post-operative

occlusion. In individuals who previously may have had orthodontic therapy and have no dental

compensations or other issues, the need for a pre-operative set up may be unnecessary. However,

individuals who have not previously had successful orthodontic therapy or have considerable

orthodontic issues would certainly benefit, but not absolutely require, pre-operative orthodontic
therapy. Pre-surgical orthodontic therapy in these situations will allow for an optimal surgical set

up and post-operative occlusal results. The need for pre-surgical orthodontic therapy is a decision

best made between the surgeon, orthodontist and patient to determine which would most benefit

the patient in the treatment of this perilous disease.

Conclusion

In conclusion, MMA for the treatment of OSA has been established as a highly successful

procedure on many fronts. It is a highly skeletally stable long-term procedure that significantly

expands the upper airway and relieves nocturnal obstruction. It improves subjective outcomes of

OSA through decrease in excessive daytime sleepiness and improvement in quality of life issues.

Most importantly, MMA pointedly improves sleep-disordered breathing through a significant

decrease in post-operative AHI/RDI, improvement in neurocognitive performance, and decrease

in cardiovascular risk through a decrease in blood pressure. Given the high success that the

MMA achieves, it is a procedure that should not be considered as a “salvage” or “operation of

last resort” in the treatment of OSA but as a first line surgical option in individuals with

moderate, severe, very severe, and extremely severe OSA and recalcitrant to conservative

treatments.
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Illustrations

Figure 1.

A. Pre-operative facial view of male with severe obstructive sleep apnea syndrome (AHI =

97, ESS = 21), pre-operative profile view, pre-operative lateral cephalometric radiograph

and pre-operative occlusion (no orthodontic therapy)

B. Post-operative facial view, post-operative profile view, post-operative lateral

cephalometric radiograph and post-operative occlusion (no orthodontic therapy)

Figure 2. Virtual Surgical Planning of maxillomandibular advancement.
Figure 3.

A. Pre-operative facial view of individual with severe OSA (AHI = 66, ESS = 18), pre-

operative profile view, pre-operative lateral cephalometric radiograph and pre-operative

occlusion with orthodontic therapy.

B. Post-operative facial view, post-operative profile view, post-operative lateral

cephalometric radiograph and post-operative occlusion with orthodontic therapy.

Figure 4. Virtual surgical planning of maxillomandibular advancement.
Figure 5. Volumetric upper airway assessment before and after maxillomandibular advancement

surgery.
Figure6. Model representation of the maxillomandibular advancement and genioglossus

advancement procedures.
Figure 7. Cephalometric evaluation before and after maxillomandibular advancement for

obstructive sleep apnea.