MMA Surgery for refractory OSA conference... · 2019. 9. 13. · Ron Aronovich, DMD University of...

$: MMA Surgery for refractory OSA conference... · 2019. 9. 13. · Ron Aronovich, DMD University of Michigan Oral and Maxillofacial Surgery MICHIGAN ACADEMY OF SLEEP MEDICINE 2019 ANNUAL$
Ron Aronovich, DMD

University of Michigan

Oral and Maxillofacial Surgery

MICHIGAN ACADEMY OF SLEEP MEDICINE

2019 ANNUAL MEETING

MMA Surgery

for refractory OSA

Type of Potential Conflict

Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

X

Accreditation StatementThis activity has been planned and implemented in

accordance with the accreditation requirements and

policies of the Accreditation Council for Continuing

Medical Education (ACCME) through the joint

providership of The American Academy of Sleep

Medicine and The Michigan Academy of Sleep

Medicine. The American Academy of Sleep Medicine

is accredited by the ACCME to provide continuing

medical education for physicians.

Multifactorial etiology of OSA

Upper airway

obstruction

Anatomical airway narrowing

Neuromuscular tone and pattern of

pharyngeal collapse

Medication use: Sedative/hypnotics

Opioids

Anxiolytics

Age

Genes/Hereditary factors

Obesity- Fat deposition pattern

Dietary factors

Physical exam

THYROMENTAL DISTANCE

HYOID POSITION

NECK CIRCUMFERENCE

FACIAL PROFILE/PROJECTION

Profileoplasty line – Nasion Perpendicular

Patient Profile Evaluation

Exam• MACROGLOSSIA

• ELONGATED UVULA

• ENLARGED TONSILS

• DENTAL CROSSBITES

• MEDIALIZED TONSILLAR

PILLARS

Evaluation of the upper airway

anatomy and physiology

Direct oral exam

Nasoendoscopy fiberoptic visualization – DISE

Cephalometrics

CBCT or CT scan

Fluoroscopy

MRI

Upper airway pressure and resistance

Acoustic reflection

Guileminault C, Riley R, and Powell N.

Chest 1984

2D Cephalometric

associated with OSA:

1. Retrusive mandible

and maxilla

2. Low hyoid

3. Narrow posterior

airway space < 9mm

4. Long & thick soft

palate

3D Airway Analysis

AHI 38.5/hr

Min SpO2 66%

Exam

Findings

MHx

Motivation

S&S

PAP

Compliance

What are surgical options for OSA?

Tonsillectomy

Nasal Sx

Palatal Sx

HS

Tongue reduction

MMA

MME

GGA

Bariatric surgery

Inspire

Maxillomandibular

Advancement

Orthognathic Surgery

Mandibular BSSO Advancement

Terminology

Orthognathic surgery

“Orthos”: To straighten the jaw

“Gnathic”: Of the jaw or related to the jaw

Telegnathic surgery

“Tele”: Distant

“Gnathic”: of the jaw or related to the jaw

A patient with polyarticular JIA

Post-operative panoramic radiograph

Pre-op Immediate

Post-op

Pre-op Post-op

Inverted-L osteotomy

Distraction Osteogenesis

Airway Changes

3D changes in 13 OSA pts with MMA.

Abramson et al. JOMS 2011- N = 13

VOL: 12.8 → 20.6 mm3

CSA: 168 → 286.0 mm2

Length: 74.8 → 70.7 mm

Kasey L et al. JOMS 2002

MMA decreases lateral pharyngeal

wall collapsibility on NPG

Meet A.B.

AHI 35.9 &SpO2 nadir

91

AHI supine NR: 41.6

BMI 31.9

PAS: 1.7

Airway length: 79

VOL: 8.6 & Min Ax Area:

31.1

Lateral Cephalometric change

Preop Postop

What we don’t want to change: the occlusion

AHI 35.9 → 5.8

SpO2 nadir 91 → 93%

BMI 31.9 → 26.3

PAS: 1.7 →8.2

Airway length: 79.3 →67.2

VOL: 8.6 → 26.6

Min Ax Area: 31.1→209

Makovey I et al. Maxillomandibular advancement surgery for Obstructive

Sleep Apnea: Are there predictors of success? J Oral Maxillofac Surg.

2017;75:363-370.

Cephalometric Data PreOp PostOp

SNA 80.9 90.0

SNB 77.8 83.8

PAS 3.3 +/- 1.7 10.2

PNS-P 39.6 +/- 6.9 34.3

CBCT data PreOp PostOp

Min CSA (mm2) 63.1 +/- 27.1 278.1 - 4.5 fold

Airway Volume (mL) 11.65 +/- 3.68 25.61 – 2.2 fold

Location of Min CSA Level 1 – 10%

Level 2 – 85%

Level 3 – 5%

Level 1 – 20%

Level 2 – 35%

Level 3 – 40%

Airway length (mm) 69.7 64.6

Surgical Success AHI < 20 and/or at least a 50% reduction in AHI

from baseline

Oxygen saturation ≥ 90%

Normalization of sleep architecture

Resolution of EDS

Equivalent to CPAP titration night

50 Consecutive MMA cases for site-specific

treatment of OSA. Jeffery Prinsell. Chest 1999.

N=50 who did not tolerate nCPAP

MMA and GGA

Mean advancement of 14.4 mm at the genial tubercle

F/U mean 5.2 months.

Mean Age: 42.7 (19-66)

Mean BMI: 30.7

Prinsell JR. MMA in site-specific treatment approach for OSA in

50 consecutive patients. Chest 1999: MMA is equivalent to CPAP

nCPAP MMA

Pre min SpO2

72.7% 72.7%

Post min SpO2

88.6% 88.6%

nCPAP MMA

Pre AHI 59.2 59.2

Post AHI 5.4 4.7

SBP DBP

Pre MMA 138.8

(15.6)

89.8 (12.3)

Post MMA 123.9

(13.8)

80.2 (11.1)

MMA surgery in 23 patients with OSA.

Waite et al. JOMS 1989

N = 23 with AHI > 20, retrognathism, and CPAP intolerance

MMA of 8-12mm performed

Mean AHI change: 65 → 15

Success of 65% based on success set at AHI < 10

74% success based on common criteria

No difference in extent of advancement, PAS, hyoid position, or weight change between the responders and non-responders.

Author N F/U(months)

AHI pre AHI post Success rate (%)

Waite 1989 23 1.5 62.8 15.2 65.2

Riley 1990 30 6 72 8.8 96.7

Hochban

1997

38 2 44.4 2.5 97.4

Prinsell

1999

50 5.2 59.2 4.7 100

Li 2000 40 50.7 69.6 8.9 90

Bettega

2000

20 6 59.3 11.1 75

Goh 2003 11 7.7 70.7 11.4 81.8

Dattilo

2004

15 1.5 76.2 12.6 86.7

Mean 234 12.4 54.4 7.7 89.9

Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD. Surgical modification of the upper airway in sleep apnea. SLEEP 2010

Long term outcomes

Study N MMA PreopAHI

Shortterm AHI

Longterm AHI

Length of follow up (years)

Riley et al.

2000

40 Staged 71.2 9.3 7.6 (90%

of pts)

4.2

Conradt et al.

1997

15 Primary 51.4 5.0 8.5 2

21 Patients Identified

Follow up PSG at 6.3 months postop

16 Males 4 Females

20 with sufficient data

Demographics: Makovey I et al. Maxillomandibular advancement surgery for

Obstructive Sleep Apnea: Are there predictors of success? J Oral Maxillofac

Surg. 2017;75:363-370.

❖ Mean Age: 48.8 +/- 12.3 (range 18-61y.o.)

❖ BMI: 32.03 +/- 5.13 kg/m2

❖ NC: 16.2 +/- 1.3 inches

❖ AHI: 49.4 +/- 20.0

❖ Minimal SpO2: 78.1%

❖ Macroglossia: 15/20 (75%)

❖ Nasopharyngoscopy:

❖75% Severe retro-palatal collapse on inspiration

❖50% Severe BOT collapse on inspiration

❖25% moderate BOT collapse on inspiration

Results: Makovey I et al. Maxillomandibular advancement surgery for


Surg. 2017;75:363-370.

PSG Data PreOp PostOp

AHI 49.4 +/- 20.0 15.6 (68% reduction)

Minimal Oxygen

Saturation (% Min SpO2)

78.1 85.1

% Time spent with

SpO2<88%

14.6 1.29

Central Apnea Index

(CAI)

3.17 +/- 4.45 10.33

%REM Sleep 12.91 15.58

Results: Makovey I et al. Maxillomandibular advancement surgery for


Surg. 2017;75:363-370.

0

10

20

30

40

50

60

70

80

90

Preop AHI Postop AHI

Series1

Series2

Series3

Series4

Series5

Series6

Series7

Series8

Series9

Series10

Series11

Series12

Series13

Series14

Series15

Based on AHI < 15Makovey I et al. Maxillomandibular advancement surgery for Obstructive Sleep Apnea: Are there predictors of success? J Oral

Maxillofac Surg. 2017;75:363-370.

Success rate 55% Failure rate 45%

0

20

40

60

80

100

120

Preop AHI Postop AHI

Series1

Series2

Series3

Series4

Series5

Series6

Series7

Series8

Series9

Series10

Series11

Series12

Series13

Series14

Series15

Note: Based on criteria for surgical success in the literature (AHI < 20 and

at least 50% Reduction in AHI), our comparative success rate is 75%

Results: Are there predictors of success? Makovey I et al. JOMS 2017

Predictor variable Success Group Failure Group P Value

CAI pre-op 0.63 5.7 0.0053**

CAI > 5 post-op 0 4 (44%)

- 1 with central events

only

Age 45.7 +/- 4.5 52.4 +/- 2.3 0.117

Gender 2F : 9M 2F : 7M 0.822

AHI pre-op 41.8 +/- 5.5 58.7 +/- 6.4 0.028**

BMI pre-op 31.4 +/- 1.6 32.8 +/- 1.8 0.273

Macroglossia 67% 77.8% 0.435

NC 16.1 +/- 0.5 16.4 +/- 0.4 0.308

PAS pre-op 2.9 +/- 0.5 3.8 +/- 0.6 0.123

Airway Vol Pre-op (cm3) 12.0 +/- 0.9 11.3 +/- 1.6 0.659

Min CSA Pre-op (mm2) 60.9 +/- 5.9 65.8 +/- 11.8 0.348

Soft palate length (mm) 37.4 +/- 1.4 42.3 +/- 2.8 0.0585

Mandibular length

C3 – Pog Pre-op (mm)

84.6 +/- 2.1 92.5 +/- 2.4 0.011**

Predictor variable Success Group Failure Group P Value

BMI postop (kg/m2) 29.1 +/- 1.8 30.6 +/- 1.5 0.263

Max Inc adv (mm) 11.5 +/- 0.5 12 +/- 0.7 0.249

Max A pt adv (mm) 9.6 +/- 0.4 11.0 +/- 0.6 0.0554

Max imp (mm) 3.5 +/- 0.4 3.25 +/- 0.3 0.697

Mand B pt adv (mm) 13.6 +/- 0.8 13.3 +/- 1.0 0.585

Mand Pog adv (mm) 16.5 +/- 1.6 15.5 +/- 1.4 0.672

Occlusal plane

rotation

7 3 0.178

Soft palate post (mm) 30.0 +/- 3.0 39.1 +/- 3.2 0.027**


Predictor variablePre – Post (Δ)

SuccessGroup

Failure Group P Value

Δ AHI 35.2 +/- 5.4 32.2 +/- 7.3 0.631

Δ min SpO2 7.9 +/- 1.7 6 +/- 3.1 0.291

Δ %tm

SpO2<88%

14.4 +/- 8.4 13.6 +/- 6.5 0.529

Δ %REM sleep 2.5 +/- 2.4 1.1 +/- 4.2 0.382

Δ PAS 5.7 +/- 0.8 8.1 +/- 1.7 0.898

Δ Airway Vol 13.5 +/- 1.8 14.5 +/- 2.6 0.619

Δ Min CSA 222.5 +/- 25.0 205.6 +/- 27.6 0.327

Δ Soft pal

length

7.14 +/- 3.8 3.2 +/- 2.8 0.787


Quality of life evaluation of MMA for OSA using

the FOSQ. Lye, Waite, Meara et al. JOMS 2008.

Functional outcomes of sleep questionnaire

N = 15 with 6 months follow-up

BMI: 32.1 → 31.5

AHI: 69.12 → 13.87

LSAT: 76.5% → 84.9%

Success rate: 86.7% (13/15)

Successful QOL change: 93.3%

FOSQ score ≥ 18

Improved general productivity

Improved social outcome

Improved activity level

Improvement in vigilance

Positive change on intimacy and sex

Improved total score

P Value

.0003

.002

.0008

<.0001

.0039

.0002

Restrospective study of patients with severe OSA

27/51 completed OSA-Q with min 5 yr follow-up

Average Age: 59 +/-11.7

Average follow-up: 12.7 +/- 3.8

SS improvement in overall QOL, personal

satisfaction, sleep quality, and functional outcomes.

Conclusion: MMA for OSA produces significant

long-term subjective QOL improvements

MMA for OSA is associated with very long-term

overall sleep-related QOL improvement. Cillo JE et

al. JOMS 2019

MMA: Does the extent of advancement matter?

University of Michigan experience

Based on a strict criteria of AHI ≤ 5

BMI > 32, AHI > 70: 60% success

BMI < 32, AHI < 70: 93% success

Patients with very severe OSA and high BMI have less improvement

MMA limited 10 – 14 mm

Can these treatment failures be overcome with larger advancements?

MMA with DO

Tracheostomy

Maxillary and mandibular osteotomies

5-7 day latency period

Distraction osteogenesis > 22 mm shows a reliable

cure in super-severe OSA cases

Risk:

- Additional procedures needed

- Device malfunction

- Malocclusion

- Non-union

- Midface esthetics a concern

Right

Lateral

Front

Smile

AHI 77.7

Airway vol: 9.4 cubic mm

PAS: 7.9 mm

Min Ax area: 69 mm2

BMI 38.7

Nocturnal hypoxemia SpO2< 88%: 8%

Co-starring role on….

3D VSP

Surgical changes

Panoramic Radiograph

Lateral Cephalogram

AHI 77.7 → 18 His AHI decreased by 77%

His Airway vol: 9.4 →29.7

PAS: 7.9 → 18.9

Min Ax area: 69 → 372

BMI 38.7 → 37

Nocturnal hypoxemia SpO2< 88%: 8% to < 1%

At risk patients

Baseline maxillary protrusion SNA >84 degrees

Skinny patients with thin soft tissues

Females more likely to rate changes unfavorably

Body dysmorphic disorder/syndrome

Younger patients with responsive facial soft tissue

Effects of Age

Thinning epidermis

Thinning dermis

Loss of skin elasticity

Rhytids, wrinkles, and

laxity of the skin

Redistribution of fat

with malar fat ptosis

accentuating the

nasolabial folds and

marionette lines

How can we improve on this?

Less skeletal maxillary advancement while maintaining the occlusion = less negative facial changes

More mandibular advancement = Greater tongue base advancement and increase in retroglossal and hypopharyngeal airway dimensions

Avoidance of morbidity associated with maxillomandibular DO and tracheostomy

Occlusal plane rotation

AHI: 42.8 → 6.6

LSAT: 84% → 88%

Supine NR AHI: 100.7 → 2.2

BMI: 34.4 → 32.9

OJ: 3

OB: 4

T-L: 0

Mx: 0

Mn: 0

Chin: 0

AHI 89 BMI 35.9

Surgical changes

Preop Postop

Morbidity and MMA Significant blood loss

Elevated sympathetic tone

BP control or hypotension difficult to achieve

Age is a significant factor

Non-union

Age is a significant risk factor

Facial numbness and dysesthesia

Age is a significant risk factor

Malocclusions: minor changes in the bite

Magnitude of surgical move correlates with relapse

Likely reduced with peri-operative orthodontics

Untoward esthetic changes

Complications

OSA DFD

Postoperative

complications

28 19

Dysesthesia 6 (common early) 0

Infection 18 (25 instances) 6

Hardware removal 11 (14 instances) 0

Nonunion 2 0

Reoperation 9 (10 instances) 0

Total number of

postop

complications

(POC)

108 33

Absolute risk of

POC

3.86 1.27

RR of POC in OSA

vs DFD

3.04

Passeri LA et al. Morbidity and mortality rates after MMA for the treatment of OSA. JOMS. 2016.

Stefanuto PM and Doucet Do miniplates with

monocortical screws fail at an unacceptably high rate in

bilateral sagittal osteotomies?

A retrospective chart review of cases with BSSO and miniplates and screws fixation from 2004-12.

2313 BSSO were preformed

1870 for mandibular advancement

443 for mandibular setback

A total of 11 failures were noted in 7 patients

5/7 had MMA for OSA and 5/7 had nocturnal bruxism

All in BSSO advancement cases with mean of 9 mm

No failures in setback cases

No failures recorded in cases with less than 7 mm of advancement

MMA UPPP LAUP

RFA Upper airway stimulation (Inspire)

BOT Red -TORS

Tracheostomy

Studies 9 15 2 8 2 5 4

N 234 950 34 175 69 68 159

%

reduction

in AHI

Success

87% (80

– 92)

89%

33%

(23 to

42)

Low

18%

Low

34

%

Low

68%

66%

50%

50%

(25 –

80%)

Most studies

lacked mean

AHI data

%96.2

AHI

change

(events/h

r)

54.4 to

7.7

40.3

to

29.8

18.6

to

14.7

23.

4 to

14.

2

29.3 → 9.0 59.4 →

29.6

NA

MMA improved multiple Health-Related and Functional

Outcomes in patients with OSA: A multicenter study.

Boyd et al. JOMS 2018

PSG parameters (AHI)

CV Risk

C-reactive protein

Office BP check

Quality of life

ESS, FOSQ, SF-36

Neurocognitive function

psychomotor vigilance task, Health-related outcomes

N = 30

Median follow-up 6.7 months

MMA 6-14 mm with N=11 undergoing GGA (36.7%)

SS QOL improvements on SF-36




Pre-MMA Post-MMA

ESS 13.3 4.9 SS

FOSW 14.1 18.3 SS

AHI (N=27/30) 39.6±26.5 7.9±7.5 SS

PVT 2.52 2.77 SS

SBP 131±19 127±16 NS

DBP 83±10 79.7±9.1 SS

CRP 2.6 mg/L 2.3 mg/L NS

Mean AHI decreased by 81.3%

55.6% of patients reached an AHI lower than 5

74.1% of patients reached an AHI of 15 or fewer with

resolution of hypersomnolence (ESS<10)

Improvement in QOL seen at all domains examined by

the FOSQ and SF-36

For patients who experience hypersomnolence despite

effective CPAP use and patient compliance, can surgery

improve symptoms?

In this study, 14/30 subjects used CPAP prior to surgery.

After MMA, both groups saw significant improvements in

the ESS: -7.6±5.5 (CPAP) and -9.2±6.0 (No CPAP)

THE FOSQ: 3.9±2.7 (CPAP) and 4.4±2.9 (No CPAP)

PVT

Mean 1/RT: 0.53±0.51 (CPAP) and -0.01±0.33 (No CPAP)

Mean slowest 10% 1/RT: 0.45±0.40 (CPAP) and -0.01±0.52 (No CPAP)




Adverse Events

EBL: 355±210.9 mL

Duration of Sx: 261.8±113 minutes

1 return to OR for malocclusion

3 Readmissions for removal of hardware (10%)

16.7% (N=5) had mandibular wound infections

Facial Appearance

- Favorable 62.5%

- Neutral 29.2%

- Unfavorable 8.3%

Occlusal changes in 70%

- Favorable 55%

- Neutral 30%

- Unfavorable 15%

On exam 56.7% had stable occlusion (unchanged)

36.7% had correction of malocclusion

Can we

improve

patient

selection?

Can the RCMP study predict

outcomes of MMA surgery

Inclusion Criteria

AHI ≥ 15

Age ≥ 18

BMI <40

Baseline PSG within 1 year

Exclusion Criteria

Mild OSA

CSA

Chronic opioid use

Other sleep disorders

Psychoactive medication use

Active TMJ disorders

Fibromylagia with facial pain

Mandibular protrusion < 5mm

Dental disorders including loose

teeth

Uncontrolled psychiatric disorders

Inability to follow-up after surgery

Medical conditions that preclude

MMA

M-ROSA TRIAL

What are the characteristics of an ideal candidate for

MMA Surgery?

Moderate to Severe OSA

Retrognatic maxilla and mandible

Narrow airway

Patients with BMI < 35 - Lower is better

No significant central sleep apnea (CSA is present if there are 5 or more central events per hour).

Minimal to no bodily pain issues such as fibromylagia(FM)

Non-smoker

Stable dentition and occlusion or malocclusion in need of jaw corrective surgery and willing to have orthodontics

Associated symptoms and negative impact on HRQoL

Conclusions:

MMA is highly effective in carefully selected patients but has a significantly higher risk of complications (compared to DFD cohort)

MMA involves larger advancements

MMA requires more rigid fixation and bone grafting - structural blocks in critical gaps i.e. buttresses

An individual’s tolerance for esthetically displeasing facial changes must be carefully evaluated

Alternative treatments should always be considered

Set realistic expectations

THANK YOU!!

MMA Surgery for refractory OSA conference... · 2019. 9. 13. · Ron Aronovich, DMD University of...

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