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24.10.2017
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Constan'nusPoli's,MD,DDS,MM,MHA,PhDProfessor&ChairpersonOral&MaxillofacialSurgeryUZLeuvenPhone-dect:+3216341780mka@uzleuven.beUniversityHospitalsLeuven,CampusSint-RafaëlKapucijnenvoer33,3000LeuvenBelgium
MaxillomandibularadvancementfortreatmentofobstrucRvesleepapnea:Reviewoftheliteraturewithemphasisonlong-termresultsSeptember23,2017iBEDSMAsymposium2017
EmanShaheen,Ir.PhDOMFS-IMPATHResearchGroupKULeuven3D-OMFS-labUZLeuven
RobinSnel,MD,DDSOMFS-IMPATHResearchGroupKULeuvenOMFS-Resident
HOWDOESMMAFOROSASDIFFERFROMREGULARMMA?
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NON-OSASrelatedMMA
mental strain lipincompetence
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GUMMY SMILE !!
• proalveoly • gingivitis • narrow maxilla • buccal corridor • mental strain • lipincompetence • mouth breathing
sagittal relation between upper and lower jaw: ok retrognathic chin
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abscence11,21proalveolygingiviRscrowdinglowerteethconstricteddentalarches
⑊ ⑊
extraction 44,34 mesialisation 12,22
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2nd day postop
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2 3 4 2 3 4 5 6 5 6
1 2 3 5 6 1 2 3 5 6
with prosthetic teeth 11,21 with natural teeth
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OSASrelatedMMA
paRentwithorthodonRcpretreatment
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AHI39,1• Juvenilerheumatoidarthri's• DMtypeI• AHT• BMI:25.72• Genioplastyin2004
870831M074
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totalresorpRonofthecondyles
R L
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preoperaRve
postoperaRve
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cephalometricanalysis
3DsuperposiRon1wpostop
Preopvspostop
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3DsuperposiRon1wpostop
Postopregisteredoppreopcranialebone
measurements on this type of superposition generate less errors of accuracy compared with measurement on separate CBCT’s (landmark-based) comparing volumes
Gaber, Ramy M., et al. "A systematic review to uncover a universal protocol for accuracy assessment of 3D virtually planned orthognathic surgery." Journal of Oral and Maxillofacial Surgery (2017).
3DsuperposiRon1wpostop
Postopairway(yellow)Volume:21872mm3
Preopairway(green)Volume:6397mm3
• PreopairwayVolume:6397mm3
• PostopairwayVolume:21872mm3
• Volumeincreased3,4Rmes
• Differencetussenpreenpostop:– Mean:4,6mm(±3,7)– Minimum:-2,18mm– Maximum:15,75mm
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3DsuperposiRon1wpostop
pre-operaRve post-operaRve
differencesbetweennon-OSASrelatedMMAandOSASrelatedMMAnon-osasMMA
• IDENTICALTECHNICALPROCEDURE• SAMEPEROPERATIVERISK• lowpostoperaRverisk• youngerpaRents• comorbidiRes:few• ±alwaysmalocclusionpresent• ogensmalldisplacements• alltypesofmovementspossible
osasMMA
• IDENTICALTECHNICALPROCEDURE• SAMEPEROPERATIVERISK• higherpostoperaRveriskfirst24h• olderpaRents• comorbidiRes:frequent• ogenNOmalocclusionpresent• usuallylargedisplacements• typeofmovement:
– moreogenposteriorextrusionmaxilla– moreogenanteriorintrusionmaxilla– moreogengenioplastyincluded
JournalofCranio-Maxillo-FacialSurgery43(2015)1113-1118M.Camacho-R.W.Riley
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RELEVANCEOFTHEQUESTIONPOSED?
MaxillomandibularadvancementfortreatmentofobstrucRvesleepapnea:Reviewoftheliteraturewithemphasisonlong-termresults
Maxillomandibularadvancement(MMA)
OMFS SLEEPMEDICINE
=BONEstabilityvsrelapse
=BONE+SOFTTISSUE+FUNCTIONrelapse/airwayvolume/AHI-index?
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Maxillomandibularadvancement
OMFS SLEEPMEDICINE
=BONE
cavé:wastargetreached?
• =BONE+SOFTTISSUE+FUNCTION
• AHI-index?
• isAHIfucRonofbonychange?
25%relapse
0%relapse
relapsemeaningfulonlyiftargetwasreached
wasclinicalOSASoutcomeretainedevenif• targetwasnotreached?• relapsewassignificant
theposteriorextrusionofthemaxillaalmostneverapproachesthedesiredamountandissystemaRcallyunderachieved.
-4
-2
0
2
4
6
8
0 1 2 3 4 5 6 7
Posterior Vertical Extrusion Planning (x-axis) vs Results T1 (y-axis)
Posterior Vertical Extrusion Perfect Outcome Linear (Posterior Vertical Extrusion)
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MMA:onlyoneofpossibleapproaches
maxilla
LeFortI– intrusion– posteriorextrusion– advancement+++– rotaRon– segmentaRon+expansion
SARPE– TPD– HYRAXSARPEbeforeLeFortI
other
• bonegrags• costochondral
grags• tracheotomy• m.genioglossus
suspension• genioplastyin
children?• distracRon?• reducRon
macroglossia
mandible
• BSSOadvancement• genioplasty• mandibularexpansion• segmentedsurgery
maxilla+mandible
MMA• +genioplasty?• +segmentaRon• +previoussurgery?
MMA:onlyoneofpossibleapproaches
maxilla
LeFortI– intrusion– posteriorextrusion– advancement+++– rotaRon– segmentaRon+expansion
SARPE– TPD– HYRAXSARPEbeforeLeFortI
other
• bonegrags• costochondral
grags• tracheotomy• m.genioglossus
suspension• genioplastyin
children?• distracRon?• reducRon
macroglossia
mandible
• BSSOadvancement• genioplasty• mandibularexpansion• segmentedsurgery
maxilla+mandible
MMA• +genioplasty?• +segmentaRon• +previoussurgery?ONLY
ADULTS!
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syndromicpaRentswithosas
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studies:inclusioncriteria?relevance?
MMA
OSAS
THEREALITYONTHEFIELD:TOWHOMARERESULTSRELEVANT?
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orthognathicsurgerynumbersnumberofpa'ents 2013 2014 2015
orthognathicsurgery 158 174 175
finishedtreatments 507
OSAS=mainindicaRon 11
referredby:orthodonRstoromfs-colleague
11 2/11:CPAPAHI:20,1–45,5
referredby:othermedicaldepartments
0
referredbutnotoperatedduetocontra-indicaRon
1
16paRentsrequesRngMMAforOSAS-7alreadyreceivedCPAPwithinsufficientresults:intreatment-9didnothaveCPAPyet:referredtoOSAS-centreinUZLeuven
2015
whydonon-surgicalspecialResFEARMMA?
2016
even the best do not understand the nature of this intervention…. tracheostomy is NOT part of a MMA procedure
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HOWISMMASUPPOSEDTOWORK?
effectsofMMA• enlargestheupperairway
– intheanteroposteriorand– inthelateraldimensions,butalso
• raisesthehyoid
airway
howdoesitaffectairwayhowdoesitaffectsogRssuesliningthebone?
bony skeleton
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effectsofMMA
airway
bony skeleton
bonyskeleton:2Dmeasurementssag/verRcairway:3DsogRssues:??future.
PARAMETERSOFSUCCESS?
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forallparameters:whatislong-term
• inOMFSmost“long-term”studiesare:– european:2y– USA:1y
• inOSAS-relatedMMAonlyfewlong-termstudiesexistwithFU>10y.
parametersofsuccess?
parameterofsuccess
• norelapse– cephalometrics?– 3Dvolumedataset?
• AHIchange?• “airway”gain?• paRentsaRsfacRon?• partnersaRsfacRon?• cardiovascularsymptoms?• trafficaccidents?
measurementtechnique
• cephalometrics?• 3Dvolumedataset
– CBCTupright?– CBCTsupine
• CTsupine• MRIsupine• QuesRonnaire:ESS• QuesRonnaire:OSAQoL• accidentrate?• 3Dnumericalmodelsfor
computaRonalfluiddynamics
validaRon?
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criteriaofcure/success?
• nonecessityofCPAP• sleepquality?
• cure:AHI<5events/hour• surgicalsuccess:
– reducRoninAHIof50%– AHIof<20eventsperhouragerMMA
• 3Dchangesairway(CBCT)• qualityoflife(ESS–OSAQoLquesRonnaire)• 11paRents• 6mnthsCBCT
prospecRve
well-execut
ed
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prospecRve
well-execut
ed
predicRvefactors:youngerpaRentsaremorelikelytoexperiencealargerdropinAHIagerMMAsurgerythanolderpaRents
prospecRve
well-execut
ed
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prospecRve
well-execut
ed
CorrelaRonbetweenthedecreaseinapnoea–hypopnoeaindex(AHI,eventsperhour)andupperairwaysub-regionvolumeincrease
prospecRve
well-execut
ed
AHI ESS
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curevssucces
trigeminalneuralgia
• CURE– JanneyaoperaRon
• not100%successful• notwithoutrisks
• SUCCESS– medicaRon
• carbamazepine• baclofen
• RELAPSE
osas
• CURE– MMA
• not100%successful• notenRrelywithoutrisks
• SUCCESS– CPAP– MRA– Lifestyle
• RELAPSE
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OWNDATA
• QueryKWS:allpaRentswithorthognathicsurgeryand“snoring”or“obstrucRvesleepapnea”termsinfile
• 263paRënts agerfileanalysis:19paRëntsincludedwithCBCTdatapre-andpost-operaRveavailable
• typeofsurgeryBSSO/LF1/BIMAX/iliaccrestbonegraf/genioplasty
• 2Dcephalometricanalysis:OnyxCeph• 3DanalysisinAmirasogwareonuprightCBCTdata:
– accordingtoVeysB.,etal.:onlyoropharynxisstudied
RETROSPECTIVESTUDY
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Mean SD Min Max
Volumepre-op(mm3) 18663,44 8395,26 6397,00 36918,54
Volumepost-op(mm3) 29853,51 13010,64 10409,63 56083,37
Difference(%) 70,24 59,99 -11,82 241,91
• meanvolumegain 70,24%• 1ptreduc'onofairwayvolume!!!unexpected
-11,82%• largestpostopera'veincreaseofvolume 241,91%
RESULTS
Withcutoffpoint10mmpogadvancementOrange:8/19paRentshadapogadvof<10mmBlue: 11/19paRentshadapogadvof>10mmConclusion:largerpogadvdonotpar'cularlyleadtolargeroropharynxvolume
RESULTS
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Withcutoffpoint4mmU1(upperincisor)advancementOrange:9/19paRentshadaU1advof<4mmBlue: 10/19paRentshadaU1advof>4mmConclusion:nodifferenceinvolumeincreasewithsmallorlargemaxillaryadvancementmeasuredatU1(duetoinclina'onocclusalplane)
RESULTS
skeletalchanges-%airwaychange
• mostoldstudiesarebasedon2Dcephalometry• =sagiyalmovement• =sagiyallandmarks(pogonion,Iisd)• transversechangesnotconsidered
• airway=3D– necessitatesvalidated3Dmeasurementtools
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upperjaw
lowerjaw
MMAopRon1:advancementupper+lowerjaw–noposteriorextrusionmaxilla
MMAopRon2:advancementupper+lowerjawANDposteriorextrusionmaxilla
NO MALOCCLUSION
upperjaw
lowerjaw
MMAopRon1:advancementupper+lowerjaw–noposteriorextrusionmaxilla
MMAopRon2:advancementupper+lowerjawANDposteriorextrusionmaxilla
MALOCCLUSION
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paRentwithoutorthodonRcpretreatment
case
indicaRonfortreatment
indica'on
osbstrucRvesleepapneasyndrome
typeoftreatment
o LeFortIo Advancement5mmo Posteriorextrusion4mmo Anteriorintrusion1mm
o BSSOadvancemento Advancementgenioplasty6mmo iliaccrestbonegrag
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651117V196
AHI38,3previoussurgeryonnoseseptumpsychiatricbackground
18-11-2015
noorthodonRcspossibleduetodentalimplants
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3D Planning
Postop:Bimax:LeFort1adv.5mm,post.Extr.4mm,ant.Intr.1mm+BSSO+kinplasReadv.6mm
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postoperative
postoperative
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cephalometric analysis
Preop Postop superposition
measurements on this type of superposition generate less errors of accuracy compared with measurement on separate CBCT’s (landmark-based) comparing volumes
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airway
Preop Postop superposition
airway
Preop Postop
Volumepreop: 23118,26mm3Volumepostop: 56083,37mm3Difference: 32965,11mm3volumechangein%:142,59%
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paRentwithorthodonRcpretreatment
case
deepbitewithverRcalbonelossandlossofheightandOSAS
• LeFort1– advancement5mm– anteriorextrusion4mm– posteriorextrusion4mm
• BSSOadvancement+steprotaRon+canRng43-33• Iliaccrestgrag
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AHI11
medicaRon:
• Cipramil, 20 mg, 1/d
• Cymbalta, 30 mg, 1/d
• Pantomed, 40 mg, 1/d
670114V017
670114V017
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670114V017
670114V017
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3D planning preopera-ve
Intermediate: Le Fort I (adv. 5mm, Extr ant en post 4mm)
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Le Fort I (adv. 5mm, Extr ant en post 4mm) + BSSO
postopera-ve
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cephalometric analysis
airway
Preop Postop superposiRon
superposiRon
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airway superposiRon
Volumepreop: 36918,54mm3Volumepostop: 32556,06mm3Difference: -4362,48mm3volumechangein%: -11,82%
LITERATURE
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ISMMAASKELETALLYSTABLEPROCEDUREINTHELONGTERM?
ThehierarchyofstabilityandpredictabilityinorthognathicsurgerywithrigidfixaRon:anupdateandextensionHead&FaceMedicine2007WilliamRProffitTimothyATurveyCeibPhillips
• 2264paRentswithorthognathicsurgery• 1475>1yfollow-up• 507>5yfollow-up
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08.05.1991 operatiedatum 27.10.1990 6 mnd postop
21101972GA201 ♀ 19 j
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21101972GA201 ♀ 36 j operatiedatum 27.10.1990 18 years postop
09.05.1996 13.10.1974TD101 22 j
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09.05.2007 operatie in 1997 10 y F.U.
22.07.1975OK201 03.08.1994 preoperatief gummy smile 19 y R/ lefort I intrusie
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22.07.1975 operatiedatum: 12.11.2008 33 y
1994
22071975OK201
12.11.2008 15 y follow-up: no relapse
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META-ANALYSISORSYSTEMATICREVIEWONMMAFOROSAS?
evidence
MMAinpa'entswithoutdento-facialdysharmonyMMAisahighlyeffecRvetreatmentforpersistentOSAagerphaseIsurgeryinpaRentswhootherwisedonothavemaxillomandibulardeficiencypaRentsaRsfacRonisextremelyhighconcernsofunfavorablepostoperaRvefacialestheRcsandTMJ-dysfuncRondonotappeartobesignificant.
MaxillomandibularadvancementforthetreatmentofobstrucRvesleepapnea:AsystemaRcreviewandmeta-analysis• 627adultswithOSA+320OSAsubjects
withindividualdata• AHI↓from63.9/hto9.5/h• surgicalsuccessrate:86%
– successasanAHI<20and– 50%reducRoninAHIpost-MMA
• surgicalcureasanAHI<5:43%• complicaRonrate:major1%-minor3%• MMAisasafeandhighlyeffecRve
treatmentforOSA
Laryngoscope,110:1684–1688,2000Li-ChrisJanGuilleminault
SleepMedicineReviews14(2010)287–297Holty-Guilleminault
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evidence
longterm?56paRents:MMAforOSAS;>24mnthsFUnosignificantdifferencebetweentheshort-term(3–6months)andlong-term(>24months;mean44months!!)postopera'veAHI.BMIincreasedfrom30.6±6.1kg/m2preoperaRvelyto32.2±6.3kg/m2(longestfollow-up)withoutapparentclinicaleffectonOSA.
MaxillomandibularadvancementforthetreatmentofobstrucRvesleepapnea:AsystemaRcreviewandmeta-analysis• 627adultswithOSA+320OSAsubjects
withindividualdata• AHI↓from63.9/hto9.5/h• surgicalsuccessrate:86%
– successasanAHI<20and– 50%reducRoninAHIpost-MMA
• surgicalcureasanAHI<5:43%• complicaRonrate:major1%-minor3%• MMAisasafeandhighlyeffecRve
treatmentforOSA
SleepMedicineReviews14(2010)287–297Holty-Guilleminault
evidence
longterm?56paRents:MMAforOSAS;>24mnthsFUnosignificantdifferencebetweentheshort-term(3–6months)andlong-term(>24months;mean44months!!)postoperaRveAHI.BMIincreasedfrom30.6±6.1kg/m2preoperaRvelyto32.2±6.3kg/m2(longestfollow-up)withoutapparentclinicaleffectonOSA.
MaxillomandibularadvancementforthetreatmentofobstrucRvesleepapnea:AsystemaRcreviewandmeta-analysis• overallsurgicalcurerate:43,2%• surgicalcurerateforthosewith
peroperaRveAHI<30:66,7%
SleepMedicineReviews14(2010)287–297Holty-Guilleminault
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evidenceMaxillomandibularadvancementforthetreatmentofobstrucRvesleepapnea:AsystemaRcreviewandmeta-analysis
• predic'onforsurgicalsuccess:– youngerage– lowerpreopera'veweight– lowerpreopera'veAHI– greaterdegreeofmaxillaryadvancement(butnotmandibularadvancement)
SleepMedicineReviews14(2010)287–297Holty-Guilleminault
evidence
longterm?NO!!
MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis• 518uniquepaRentswithMMA• meanFU6months(2-6months)• 512of518paRents(98.8%)experienced
animprovementofAHI• PaRentswithmoreseverepreoperaRve
AHIvaluesexperiencedthegreatestmagnitudeofreducRoninthepostoperaRveAHI.
• althoughtheydidinfacthavethelowestchanceofachievingtheendpointsofsurgicalsuccessandcure
JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
ChangeinApnea-HypopneaIndex(ΔAHI)byPreoperaRveAHISeverity
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evidence
longterm?
MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis• PaRentswithlessseveremeasuresofOSA
experienceasmallermagnitudeofchangeinAHIpostoperaRvely,
• buttheyhavethehighestchanceofachievingsurgicalsuccessandcure.
JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
ChangeinApnea-HypopneaIndex(ΔAHI)byPreoperaRveAHISeverity
evidence
longterm?
MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis• overallsurgicalcurerate:38,5%
– 20%curerateifpreopAHI>90– 56%curerateifpreopAHI<30
• overallsurgicalsuccesrate:85,5%
JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
ChangeinApnea-HypopneaIndex(ΔAHI)byPreoperaRveAHISeverity
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evidence
longterm?
MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis• Resultsfromcenterswithlargersample
sizesandexperiencereportedhigherlevelsofsurgicalsuccessthanreportedinthismeta-analysis
• surgicalexperiencemayers
JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
ChangeinApnea-HypopneaIndex(ΔAHI)byPreoperaRveAHISeverity
evidence
longterm?
MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis• longerfollow-upisneededbecause
recurrencesofOSAhavebeennotedat10to15yearsagerMMAsurgery
• goodlong-termgaininanteroposteriordirecRonbutlimitedgaininthelateraldimensionofthepharyngealairway
JAMA Otolaryngology–Head & Neck Surgery January 2016 Volume 142, Number 1
ChangeinApnea-HypopneaIndex(ΔAHI)byPreoperaRveAHISeverity
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JClinSleepMed.2015Jul15;11(7):699–708.Bboyde.a.• 6.6±2.8yearsagerMMA• 30adultpaRents• MMAwithoutCCWorCW;advancement9,2mm(<10mm)• AHIdecreasedfromameanof49to10.9events/h(p<0.0001)
– with46.7%ofpaRentsobtaininganAHI<5(cure)– 83.4%ofpaRentsayaininganAHI=15events/h(success)
JClinSleepMed.2015Jul15;11(7):699–708.Bboyde.a.• 6.6±2.8yearsagerMMA;30adultpaRents• MMAwithoutCCWorCW;advancement9,2mm(<10mm)• substanRalandsustainedreducRonsin
– theAHI,– diastolicBP,and– subjec'vesleepinesswithconcomitantimprovementsinQOL
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JournalofCranio-Maxillo-FacialSurgery45(2017)183-191.Vignerone.a.• 88paRents• FUmean12,5y• "SuccessratewasdefinedbyanAHI<10withatleasta50%reducRon“– Longtermsuccessrate:28%fortheenRregroup,– Successrate100%for
• youngpaRents(age<45)• BMI<25and• IAH<45and• SNB<75 and• narrowretrobasinlingualspace(<8mm)• preoperaRveorthodonRcs(=exisRngmalocclusion)
JournalofCranio-Maxillo-FacialSurgery45(2017)183-191.Vignerone.a.• EstheRcandsleepresultswerebeyerwithamoderatemaxillaryadvancementandanteriorimpacRon.
• Therewasnoskeletalrelapse.• ThemajorpostoperaRvecomplicaRonwasinferioralveolarnervehypoesthesia
CCWrotaRon
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before2000 aper2000
JournalofCranio-Maxillo-FacialSurgery45(2017)183-191.Vignerone.a.
purelysagiyalMMA,withamaxillaryadvancementof10-12mm.
• maxillaryadvancementsmaller(5-6mm)but+• anteriorimpacRon(4-5mm)
• increaseposteriororopharyngealdimension• limitnasalandupperlipmodificaRon.
• 12-mmchinadvancementwassRllachievedbycounterclockwiserotaRonofthemandible
JournalofCranio-Maxillo-FacialSurgery45(2017)183-191.Vignerone.a.
riskoffailure↑if:• preopBMI>24,8• preopage>45y• men• preopAHI>44,5• preopSNB>75°• maxillaryadvancement>11mm
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evidence
MMA:everylineisonepa'entESS,8jfollow-up
BJOMFS2013:e37-e39AMC,Nederland
MMA:everylineisonepa'entAHI–index,8jfollow-up
BJOMFS2013:e37-e39AMC,Nederland
OMFS
MRA
• MRAvsMMA
• MRAgoodpredictorofMMAsuccess?
MMA
• bonymarkers• bonyproporRons• sogRssueproporRons
• anygoodpredictorsforsuccess?
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JOralMaxillofacSurg.2006Jun;64(6):886-91.Oralappliancesandmaxillomandibularadvancementsurgery:analternaRvetreatmentprotocolfortheobstrucRvesleepapnea-hypopneasyndrome.HoekemaA,deLangeJ,StegengaB,deBontLG.
• MRAwithmodifiedHERBST-appliance!!– ifMRAhasposiJveeffect:goodpredictorofsuccessfulMMA
– ifMARhasnoposiJveeffect:nopredicJonpossible
• retrospecJve• only4pa<ents
levelofevidence:expert-opinion:ownresults
• case–series• MMA=rouRnesurgerywithexcellentresultsandverylowmorbidity(4000orthognathicoperaRons/yearinBELGIUM)
• MMAsurgeryforOSASdoesnotdiffer,butpaRentsdo:postoperaRvemorbidityfirst24hduetoexisRngcomorbidiRes
• mostpaRentstreatedwithMMAinBelgium:malocclusion+osas
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GUIDELINES
guidelinesMMAinBelgium
• MMAwithoutOSAS:non-exisRng• MMAwithOSAS:non-exisRng
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GuidelinestheNetherlands2015• itislikelythataMMAinselectedOSASpaRentsdoesyieldsimilarresultsasCPAPonAHI
• itislikelythataMMAinselectedOSASpaRentsdoesyieldsuccessfulresults
• althoughworseningofAHIhasbeenreported,mostresultsareindicaRveoflong-termstableimprovementsagerMMAinOSASpaRents
• itislikelythataMMAresultsinsignificantimprovementofthearousalindex.
• itislikelythataMMAresultsinsignificantimprovementofsleepinesscomplaints
• itislikelythataMMAresultsinsignificantimprovementofQoL
• itislikelythataMMAresultsinsignificantimprovementofsystolicanddiastolicbloodpressure.
• itislikelythataMMAresultsinsignificantimprovementofcogniRon.
GuidelinestheNetherlands2015
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CONCLUSIONS
Q-A• areskeletalchangesofMMAstableoverRme?YES
• areairwaychangesofMMAstableoverRme?nolongtermdataareavailable–CBCTisrecentlyintroduced
• areAHIchangesofMMAstableoverRme?yes,44monthsofFUfor56paRentsyes,12,5yearsofFUfor88paRentsyes,8yearsofFUfor8paRentsyes,6,6yearsofFUfor30paRents
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evidencefromownpaRentdata-sets
• actualindicaRoninourcentreisNOT“OSAS”but“failedCPAP”or“notoleranceforCPAP”:arepaRentsofferedachoicebetween“cure”–“containment”?
• OSASsurgery:– highpaRentsaRsfacRon– verysafesurgery– nolinearcorrelaRonbetween
• magnitudeofairwaygainin3D• advancementofPog
indicaRon
• thepreciseindicaRonforMMAsurgeryinOSASmanagementiscurrentlyindefinite
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ADVICE
proposal
present
“surgicalintervenRonforpaRentswithsleepapneaisreservedonlyforthosewhocannotorwillnotacceptconRnuousposiRveairwaypressuretherapy”
future
certainlytoyoungpaRentswithAHI<30thechoiceforatreatmentwhichcanCUREOSASshouldbeoffered:
– permanentresults– resultswhicharenotonly
“successful”butcancure– lowincidenceofcomplicaRonsin
thatagegroup
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evidenceindicatesthatMMAshouldbethoughtofasthefirstandonly
surgicalopRonforsomepaRents.• considerMMAastheirfirstandbestopRonfor:
– paRentswithsignificantmaxillomandibulardeficiency– paRentswithmoderate-to-severeOSAwithnosignificantpharyngealredundancy
– youngpaRentswhoneedlong-termOSAsoluRons– paRentswhowantthemosteffecRvesingle-stageapproach
Dentalabstracts,Volume57,Issue1,January–February2012,Pages18-19
future
• 10mmadvancementisbasedonthe2D-eraofcephalometrics
• theinfluenceofthetransversedimensionontheresultswillprobablybethescienRficbenefitofthe3Dera
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“longterm”
• Morewell-controlledprospecRvestudiesarenecessaryinthelongterm(morethan6months)”
British Journal of Oral and Maxillofacial Surgery 51 (2013) 834–840
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4mthspostSARPE
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4mthspostSARPE
15.3 mm 14.5 mm
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masRcatoryproblem:solvedsnoring:solvedmouthbreathing→nosebreathing
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Superposition pre- and post- ceph
Change of volume of airway
Increase22%
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MMAresearchtopics:
• sarpechangesDUALplaneinMONOplane• whatdeliveredgreatesteffectonairway
– sarpehyrax– LeFortI
• sarpechangedtheinclinaRonoftheupperjaw