European Journal of Internal Medicine 24 (2013) e94–e95
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Maxillomandibular advancement in obstructive sleep apnea syndrome Keywords: Obstructive sleep apnea Cardiovascular risk Maxillomandibular advancement polysomnography Orthognathic surgery
Mannarino and colleagues published in this journal an interesting review article on the obstructive sleep apnea syndrome (OSAS) [1]. They enlisted several therapeutic options of this syndrome that, if severe and left untreated, has a 4-year mortality rate of 20% [2]. They stated that surgical treatments remain controversial, mainly because controlled studies and standardized criteria to define surgical efficacy are lacking. We believe that these considerations are debatable regarding the maxillo-mandibular advancement (MMA) procedure, which nowadays is the most powerful therapeutic option to treat patients with severe forms of OSAS, with a strong rationale that supports indications and results. The surgical indications for MMA in the OSAS in adults are linked to an accurate diagnosis based on international guidelines, patient refusal to begin or continue treatment with continuous positive airway pressure (CPAP), evidence of severe disease with apnea– hypopnea index (AHI) N 20 events/h) and patient health conditions compatible with this surgery. The diagnosis of OSAS is based upon teleradiography of the skull on a lateral projection, carried out in order to evaluate the opportunity for each patient to have a maxillofacial consultation and hence to consider MMA. Data stemming from teleradiography are usually interpreted in terms of eumorphy or dismorphy of the maxillomandibular skeleton, based exclusively on the results of the cephalometric analysis. Nevertheless, the use of only cephalometry may be a limitation, and its interpretation might not allow to decide for MMA and hence for the cure of the OSAS. It is not possible to make a therapeutic choice on the basis of this test only, that is strictly dependent on the technique used to take the X-ray image, the skull typology (dolichocephaly, brachycephaly) and the resulting inclination of the skull base in the sella-nasion-A (SNA) and sella-nasion-B (SNB) determinations. A more valuable alternative to cephalometry is tridimensional computer tomography and magnetic resonance of the head, which provide data that can be used for surgery and predict the increase in volume of the proximal airway spaces. With this background, we claim that MMA is at least as effective as CPAP in the reduction of the number of apnoic obstructive events in OSAS. Furthermore, different from CPAP which controls symptoms without curing the syndrome and must to be used chronically (every night of the entire life), MMA has an immediate therapeutic effect, which is obtained in one surgical operation and is stable with time [3]. The OSAS is also a social healthcare issue,
because the costs for its chronic treatment with CPAP might become very high compared to the costs of MMA, with equal efficiency. Hence, we state that all patients with severe or moderately severe OSAS in good clinical conditions should undergo a maxillofacial consultation, in order to evaluate the opportunity to undergo MMA [4]. However, it must be emphasized that MMA should be carried out by surgeons with a specific experience in orthognatic surgery, with the additional availability of odontoiatric and orthodontist expertise in order to avoid problems related to dental occlusion and its related functions [5,6]. The most frequent complication of MMA is dehiscence of the surgical wound leading to injuries in the maxillary and mandibular trigeminal components of the somatic and proprioceptive sensitivity. In our experience a series of 40 patients was treated with MMA with no severe complication, whereas a few minor complications (transitory trigeminal impairment, plates exposure and surgical access dehiscence) were not considered serious in patients with severe or moderately severe OSAS who in terms of quality of life and cost-effectiveness managed to stop CPAP. In conclusion, the therapeutic solution of MMA proposed by the maxillofacial surgeon aims to re-establish a better anatomy with no damage for the organs involved in OSAS. The role of this specialist in the management of the OSAS is fundamental, because nowadays he can provide the most successful short- and long-term therapeutic tool with the lowest morbidity. If planned and carried out adequately, MMA can lead to a nearly 100% cure of OSAS [7]. Furthermore, this operation is more acceptable by patients than tracheotomy (that is able to bypass the upper airway resolving the obstruction) and CPAP, because it is more successful in the longterm than conservative methods. In terms of healthcare economy, the cost of a long-lasting treatment such as CPAP is much higher than that of MMA. Accordingly, the use of MMA is the treatment of choice in OSAS, instead of using it only for severe cases or after the failure of additional surgical procedures such as uvulopalatoplasty or tongue base resections among patients with or without important maxillomandibular dismorphosis.
References [1] Mannarino MR, Di Filippo F, Pirro M. Obstructive sleep apnea syndrome. EJIM 2012;23:586–93. [2] Partinen M, Jamieson A, Guilleminault C. Long-term outcome for obstructive sleep apnea syndrome patients. Chest 1988;94:1200–4. [3] Randerath W, Bauer M, Blau A, Fietze I, Galetke W, Hein H, et al. Are there alternative therapeutical options other than CPAP in the treatment of the obstructive sleep apnea syndrome. Pneumologie 2007;61:458–66. [4] Prinsell JR. Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 1999;116:1519–29. [5] Ronchi P, Novelli G, Colombo L, Valsecchi S, Oldani A, Zucconi M, et al. Effectiveness of maxillo-mandibular advancement in obstructive sleep apnea patients with and without skeletal anomalies. Int J Oral Maxillofac Surg 2010;39:541–7. [6] Li KK, Riley RW, Powell NB, Guilleminault C. Patient's perception of the facial appearance after maxillomandibular advancement for obstructive sleep apnea syndrome. J Oral Maxillofac Surg 2001;59:377–80.
0953-6205/$ – see front matter © 2013 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. http://dx.doi.org/10.1016/j.ejim.2013.10.008
Letter to the Editor [7] Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Long-term results of maxillomandibular advancement surgery. Sleep Breath 2000;4:137–40.
Francesco Laganà⁎ Raffaele Sacco Aldo Bruno Giannì Dipartimento Neuroscenze, Unità operativa di Chirurgia Maxillo-Facciale, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi Milan, Italy ⁎Corresponding author at: U.O. Neuroscenze Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi Milan, Via Francesco Sforza 35,20122, Milan, Italy. Tel.: +39 0255032745; fax: +39 0255032558. E-mail address: [email protected] (F. Laganà).
e95
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Letter to the Editor Maxillomandibular advancement in obstructive sleep apnea syndrome Keywords: Obstructive sleep apnea Cardiovascular risk Maxillomandibular advancement polysomnography Orthognathic surgery
Mannarino and colleagues published in this journal an interesting review article on the obstructive sleep apnea syndrome (OSAS) [1]. They enlisted several therapeutic options of this syndrome that, if severe and left untreated, has a 4-year mortality rate of 20% [2]. They stated that surgical treatments remain controversial, mainly because controlled studies and standardized criteria to define surgical efficacy are lacking. We believe that these considerations are debatable regarding the maxillo-mandibular advancement (MMA) procedure, which nowadays is the most powerful therapeutic option to treat patients with severe forms of OSAS, with a strong rationale that supports indications and results. The surgical indications for MMA in the OSAS in adults are linked to an accurate diagnosis based on international guidelines, patient refusal to begin or continue treatment with continuous positive airway pressure (CPAP), evidence of severe disease with apnea– hypopnea index (AHI) N 20 events/h) and patient health conditions compatible with this surgery. The diagnosis of OSAS is based upon teleradiography of the skull on a lateral projection, carried out in order to evaluate the opportunity for each patient to have a maxillofacial consultation and hence to consider MMA. Data stemming from teleradiography are usually interpreted in terms of eumorphy or dismorphy of the maxillomandibular skeleton, based exclusively on the results of the cephalometric analysis. Nevertheless, the use of only cephalometry may be a limitation, and its interpretation might not allow to decide for MMA and hence for the cure of the OSAS. It is not possible to make a therapeutic choice on the basis of this test only, that is strictly dependent on the technique used to take the X-ray image, the skull typology (dolichocephaly, brachycephaly) and the resulting inclination of the skull base in the sella-nasion-A (SNA) and sella-nasion-B (SNB) determinations. A more valuable alternative to cephalometry is tridimensional computer tomography and magnetic resonance of the head, which provide data that can be used for surgery and predict the increase in volume of the proximal airway spaces. With this background, we claim that MMA is at least as effective as CPAP in the reduction of the number of apnoic obstructive events in OSAS. Furthermore, different from CPAP which controls symptoms without curing the syndrome and must to be used chronically (every night of the entire life), MMA has an immediate therapeutic effect, which is obtained in one surgical operation and is stable with time [3]. The OSAS is also a social healthcare issue,
because the costs for its chronic treatment with CPAP might become very high compared to the costs of MMA, with equal efficiency. Hence, we state that all patients with severe or moderately severe OSAS in good clinical conditions should undergo a maxillofacial consultation, in order to evaluate the opportunity to undergo MMA [4]. However, it must be emphasized that MMA should be carried out by surgeons with a specific experience in orthognatic surgery, with the additional availability of odontoiatric and orthodontist expertise in order to avoid problems related to dental occlusion and its related functions [5,6]. The most frequent complication of MMA is dehiscence of the surgical wound leading to injuries in the maxillary and mandibular trigeminal components of the somatic and proprioceptive sensitivity. In our experience a series of 40 patients was treated with MMA with no severe complication, whereas a few minor complications (transitory trigeminal impairment, plates exposure and surgical access dehiscence) were not considered serious in patients with severe or moderately severe OSAS who in terms of quality of life and cost-effectiveness managed to stop CPAP. In conclusion, the therapeutic solution of MMA proposed by the maxillofacial surgeon aims to re-establish a better anatomy with no damage for the organs involved in OSAS. The role of this specialist in the management of the OSAS is fundamental, because nowadays he can provide the most successful short- and long-term therapeutic tool with the lowest morbidity. If planned and carried out adequately, MMA can lead to a nearly 100% cure of OSAS [7]. Furthermore, this operation is more acceptable by patients than tracheotomy (that is able to bypass the upper airway resolving the obstruction) and CPAP, because it is more successful in the longterm than conservative methods. In terms of healthcare economy, the cost of a long-lasting treatment such as CPAP is much higher than that of MMA. Accordingly, the use of MMA is the treatment of choice in OSAS, instead of using it only for severe cases or after the failure of additional surgical procedures such as uvulopalatoplasty or tongue base resections among patients with or without important maxillomandibular dismorphosis.
References [1] Mannarino MR, Di Filippo F, Pirro M. Obstructive sleep apnea syndrome. EJIM 2012;23:586–93. [2] Partinen M, Jamieson A, Guilleminault C. Long-term outcome for obstructive sleep apnea syndrome patients. Chest 1988;94:1200–4. [3] Randerath W, Bauer M, Blau A, Fietze I, Galetke W, Hein H, et al. Are there alternative therapeutical options other than CPAP in the treatment of the obstructive sleep apnea syndrome. Pneumologie 2007;61:458–66. [4] Prinsell JR. Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 1999;116:1519–29. [5] Ronchi P, Novelli G, Colombo L, Valsecchi S, Oldani A, Zucconi M, et al. Effectiveness of maxillo-mandibular advancement in obstructive sleep apnea patients with and without skeletal anomalies. Int J Oral Maxillofac Surg 2010;39:541–7. [6] Li KK, Riley RW, Powell NB, Guilleminault C. Patient's perception of the facial appearance after maxillomandibular advancement for obstructive sleep apnea syndrome. J Oral Maxillofac Surg 2001;59:377–80.
0953-6205/$ – see front matter © 2013 Published by Elsevier B.V. on behalf of European Federation of Internal Medicine. http://dx.doi.org/10.1016/j.ejim.2013.10.008
Letter to the Editor [7] Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Long-term results of maxillomandibular advancement surgery. Sleep Breath 2000;4:137–40.
Francesco Laganà⁎ Raffaele Sacco Aldo Bruno Giannì Dipartimento Neuroscenze, Unità operativa di Chirurgia Maxillo-Facciale, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi Milan, Italy ⁎Corresponding author at: U.O. Neuroscenze Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Università degli Studi Milan, Via Francesco Sforza 35,20122, Milan, Italy. Tel.: +39 0255032745; fax: +39 0255032558. E-mail address: [email protected] (F. Laganà).
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