Who needs maxillofacial or jaw surgery?
Dental patients and sleep apnea patients have a lot in common. Crowded teeth can be due to abnormally shaped jaw or a small upper or lower jaw leading to a crossbite or malocclusion. Sleep apnea patients with small jaws or a malocclusion can have airway obstruction secondary to their dental skeletal abnormality. Our approach to the orthognathic patients with aesthetic, dental skeletal deformity, and obstructive sleep apnea is discussed for patient education purposes.
Maxillofacial surgery considers the facial aesthetic, functional airway, and dental skeletal tooth alignment in patients with malocclusion and obstructive sleep apnea. Surgical planning is based on cosmetic considerations from the patient and the surgeon’s aesthetic sense. The functional goal for a dental skeletal malocclusion may be a class I occlusion but is only reasonable within the constraints of achieving a functional airway.
Why see Dr. Jose Barrera, MD, for maxillofacial surgery?
San Antonio Facial Plastic Surgeon Dr. Jose Barrera, M.D., is triple board certified having earned certification in Otolaryngology and in the subspecialty of Sleep Medicine from the American Board of Otolaryngology as well as in Facial Plastic and Reconstructive Surgery from the American Board of Facial Plastic Surgery. Dr. Barrera is fellowship trained in Sleep Surgery and Facial Plastic and Reconstructive Surgery from Stanford University by world reknown maxillofacial surgeons Drs. Robert Riley and Nelson Powell in maxillofacial surgery.
What does maxillofacial surgery involve?
The main tools in maxillofacial surgery include the maxillary impaction and advancement surgery using the LeFort I osteotomy with or without mandibular advancement surgery. Mandibular advancement surgery may include the bilateral sagittal split-ramus osteotomy and the genioglossal advancement (GA) surgery to advance the tongue in patients with sleep apnea. A sliding geniplasty operation may be used instead of the genioglossal advancement in order to bring the chin point into balance. A sliding genioplasty has the advantage of advancing the chin, or reducing, augmenting, or correcting an asymmetric chin.
How do you balance cosmetic desires with functional need in maxillofacial surgery?
Relying strictly on cephalometric analysis of seemingly normal individuals may be flawed in the individual patient with differing ethnic background and proportions. Cephalometric analysis is a guide not a rule. Many normally proportioned individuals are not attractive, and there are strikingly beautiful people whose facial measurements fall outside normal ranges. Cephalometric data are limited to the midsagittal plane and gives no information regarding the soft tissue. For sleep apnea patients, the soft tissue volume significantly impacts surgical success in improving apneas and hypopneas and treating obstructive sleep apnea. Aesthetic decisions are made by physical examination and not x-ray evaluation. Airway decisions to treat sleep apnea are made by polysomnogram (sleep study), upper airway endoscopy, clinical evaluation, and Drug Induced Sleep Endoscopy (DISE). The dynamic relationship between the underlying skeletal foundation, the airway and its encompassing soft tissue, and the overlying face must be made with prudent clinical judgment.
How are sleep apnea patients managed?
For patients with obstructive sleep apnea, obstruction can occur at the level of the soft palate, tongue, or tonsil and pharyngeal walls. Retropalatal obstruction is dealt with a uvulopalatopharyngoplasty or UPPP. UPPP with tonsillectomy involves palate shortening with closure of mucosal incisions, tonsillectomy, and lateral pharyngoplasty. UPPP results in symptomatic improvement in the patient and eliminates habitual snoring in almost all cases; however, reports show that significant objective improvement on the postoperative polysomnogram ranges only from 41% to 66%. This procedure only eliminates the obstruction at the level of the soft palate, and does not address obstructions occurring in the hypopharyngeal and base of tongue areas. Most patients have more than one site of obstruction. If UPPP is performed when the presurgical evaluation demonstrates obstruction localized to the soft palate-tonsil area, then the success rate of the surgical procedure approaches 90% in treating OSA. Hypopharyngeal or tongue base obstruction is treated with maxillofacial surgery including a genioglossal advancement (GA), or Maxillomandibular Advancement (MMA). GA is a simple technique that does not move the teeth or jaw, and therefore does not affect the dental bite. GA is a procedure performed as a solitary hypopharyngeal procedure or in combination with MMA. The technique places the genioglossus under tension, and this tension may be sufficient to keep the base of tongue region open during sleep. This procedure does not gain more room for the tongue, and thus must be considered a limited procedure that is dependent on the thickness of the individual’s anterior mandible (mean thickness 12–18 mm). Patients who have had incomplete response or who failed to respond to Phase I intervention may be considered for a Phase II operation or MMA. The advancement of the midface provides more room for the tongue, and sagittal split osteotomy of the mandible places additional tension on the tongue-hyoid complex. Combined advancement of the maxilla and mandible is the most recent and efficacious surgical procedure for the treatment of OSA. The surgical technique includes a standard Le Fort I osteotomy, in combination with a mandibular sagittal split osteotomy. A concomitant GA, as previously described, is recommended to improve tongue advancement. This surgery may result in some facial change, which most often may be favorable.
What are the surgical results with sleep surgery?
Riley and colleagues reported the largest series of obstructive sleep apnea patients (306 patients) treated with a phased protocol. Phase I consisted of UPPP and genioglossus advancement with hyoid myotomy/suspension (GAHM), resulting in a 61% success rate (239 patients). Unsuccessful Phase I patients (84 patients) and patients who had skeletal deformity (7 patients) underwent MMA. MMA yielded overall 90% or greater success, based on a postoperative RDI of less than 20, with at least a 50% reduction in the RDI if the RDI was initially less than 20 compared with the preoperative study. The posterior airway space (PAS), critical to improving obstructive sleep apnea, consistently increases with maxillomandibular advancement; however, there may be cases in which a small gain in PAS is seen and yet improvement is realized. MMA is the most efficacious procedure for expanding the pharyngeal airway and improving or eliminating OSA. It remains the best current alternative to tracheotomy. Dr. Barrera uses virtual surgical planning when considering MMA surgery with a success rate greater than 90% in patients undergoing MMA.