Stacy Geisler DDS, PhD
Maxillomandibular advancement surgery has been found to reduce the apnea-hypopnea index (AHI) in some patients with obstructive sleep apnea though further research is needed to guide patient selection and determine safety.
Limited evidence suggests that maxillomandibular advancement surgery may be a promising surgical intervention for patients with obstructive sleep apnea who do not comply with nonsurgical therapy.
Among patients with obstructive sleep apnea who are intolerant of positive airway pressure (PAP), which surgical modifications of the upper airway are the most effective at reducing the AHI?
The authors conducted an electronic search of four databases using terms related to sleep, sleep apnea and surgery, seeking articles published from 1966 through June 2008. Two reviewers working independently extracted data from all eligible studies. They calculated inter-reviewer agreement and resolved any disagreement through consensus with a third party. They calculated ratio of means with corresponding 95 percent confidence intervals (CI) for each surgical outcome of interest.
The authors identified a total of 79 studies that were eligible for the meta-analysis. Following maxillomandibular advancement surgery, there was an overall reduction of the AHI by 87 percent (95 percent CI 80 percent to 92 percent). Following uvulopalatopharyngoplasty (UPPP), there was a reduction of the AHI by 33 percent (95 percent CI 23 percent to 42 percent). Laser assisted uvulopalatoplasty (LAUP) resulted in an average pooled reduction of the AHI by 32 percent. Results from pooling of three studies evaluating soft palate implants demonstrated a reduction of the AHI by 26 percent (95 percent CI 9 percent to 39 percent).
Results across studies of maxillomandibular advancement surgery demonstrated a substantial reduction of the AHI. Isolated pharyngeal and/or soft palate interventions were inconsistent in reducing the AHI. In some cases, isolated pharyngeal procedures worsened sleep apnea as compared to baseline measures, although these results may arise from regression to the mean. Results of all studies, however, should be interpreted with some reservation as there were very few high quality studies available for review. In addition, morbidity and mortality was not reported for maxillomandibular advancement surgery.
Source of Funding:
American Academy of Sleep Medicine
Importance and Context:
Obstructive sleep apnea (OSA) is a common disorder affecting approximately 2% to 4% of the adult population. Collapse of the upper airway during sleep can result in hypoxemia, hypercapnia, surges in sympathetic neural output and sleep fragmentation. First line therapy for patients with OSA often consists of PAP. For various reasons, some patients fail to use PAP consistently. For such patients, surgical interventions may be an attractive alternative to nonsurgical therapy.
Strengths and Weaknesses of the Systematic Review:
The authors of this review provide a concise, well thought out strategy for assessing the literature on surgical options for patients with OSA. Their statistical analysis and methodology is particularly strong. Inclusion and exclusion criteria were well considered and applied. A weakness of the review was the reliance on the apnea-hypopnea index as the only outcome measure of improvement for patients with obstructive sleep apnea. The authors however acknowledge this limitation.
Strengths and Weaknesses of the Evidence:
Overall, the meta-analysis suggests that maxillomandibular advancement surgery may be an effective treatment for patients with OSA. Weaknesses of the evidence include a lack of morbidity and mortality data in the literature for the procedure as well as a lack of large, randomized clinical trials. Data evaluating quality of life and cardiovascular outcomes is also limited.
Implications for Dental Practice:
Dentists who work closely with oral and maxillofacial surgeons in their communities are in an good position to alert patients who have OSA about the possible benefits of maxillomandibular advancement surgery. Patients who have expressed frustration and/or shown inconsistency with using PAP may benefit from this surgical intervention. Referral to the oral and maxillofacial surgeon allows for a discussion of the risks, costs and benefits of maxillomandibular advancement surgery for the patient with OSA - allowing patients to make an informed decision regarding surgery.