MAXILLOMANDIBULAR ADVANCEMENT: Primary Treatment for OSA ??? - PowerPoint PPT Presentation

MAXILLOMANDIBULAR ADVANCEMENT: Primary Treatment for OSA ??? Sampeter L Odera DMD, MD Assistant Professor OMFS February 17 th 2018 UCSF Oral and Maxillofacial Surgery

CLINICAL INDICATIONS u Significant OSA AHI >20 n +/- Hypertension, Stroke, arrhythmias, CHF u Failure of CPAP due to nonadherance or nonacceptance u Craniofacial Anomalies u Ability to withstand surgery

CLINICAL EVALUATION u Clinical Evaluation to determine severity and inspection for potential sites of obstruction u Temporomandibular Joint evaluation, tooth mobility, neurosensory function, status of dentition facial esthetics u Dental Casts and impressions Cephalometrics

CEPHALOMETRIC ANALYSIS

Volumetric Versus 2-Dimensional Airway Analysis

u Lower mean Age u Lower preoperative AHI Multivariate predictors of success u Lower preoperative BMI u Larger maxillomandibular advancements Meta-analysis by Holty et al

u MMA is an effective treatment for OSA u 67 % of patients had Phase I soft tissue treatment u Short Term Follow-up of about 5 months u Pre MMA AHI – 64 u Final AHI 9.5 (Mild-moderate OSA)

Meta- Analysis of 22 studies Success Tx AHI <20 or >50 % reduction AHI Cure OSA AHI < 5

HIERACHY OF STABILITY More Maxilla Up Mandible Forward Max Up + Mandible Forward Predictable Max Forward + Mandible Back Assymmetry Mandible Back Maxilla Down Less Widen Maxilla

Effectiveness and Stability of MMA Comparative effectiveness of MMA MMA Long-term Stability Boyd, JOMS 2013 Journal of Clinical Sleep medicine

What Role does Esthetics Play in treatment Planning Maxillomandibular advancement ?

u Pts who underwent MMA for OSAS noted moderate changes in facial appearance u Despite significant maxillomandibular protrusion based on postoperative cephalometric analysis more than 90% gave either positive or neutral responses to changes in facial appearance

Pre MMA Post MMA

Complications u Major N=4 ~ 1% Cardiac Arrests, new Dysrhythmia, Mandibular Fxs u Minor 1) Temporary Paresthesia – 100 % 2) Permanent Paresthesia - 14 % 3) Relapse 4) Minor Bleeding, infections – 3%

CONCLUSIONS u Surgical candidates should be determined by correctly identifying sites of disproportionate UA anatomy u Counterclockwise rotation of the maxillomandibular complex allows for oropharyngeal enlargement and esthetically acceptable facial appearance u MMA has a high therapeautic efficacy either as a primary or secondary operation