Maxillomandibular advancement for treatment of obstrucRve … · 2017. 10. 26. · Professor & Chairperson Oral & Maxillofacial Surgery UZLeuven Phone-dect:+32 16 341780 [email protected]

24.10.2017

1

Constan'nusPoli's,MD,DDS,MM,MHA,PhDProfessor&ChairpersonOral&MaxillofacialSurgeryUZLeuvenPhone-dect:[email protected],CampusSint-RafaëlKapucijnenvoer33,3000LeuvenBelgium

MaxillomandibularadvancementfortreatmentofobstrucRvesleepapnea:Reviewoftheliteraturewithemphasisonlong-termresultsSeptember23,2017iBEDSMAsymposium2017

EmanShaheen,Ir.PhDOMFS-IMPATHResearchGroupKULeuven3D-OMFS-labUZLeuven

RobinSnel,MD,DDSOMFS-IMPATHResearchGroupKULeuvenOMFS-Resident

HOWDOESMMAFOROSASDIFFERFROMREGULARMMA?

24.10.2017

2

NON-OSASrelatedMMA

mental strain lipincompetence

24.10.2017

3

GUMMY SMILE !!

•  proalveoly •  gingivitis •  narrow maxilla •  buccal corridor •  mental strain •  lipincompetence •  mouth breathing

sagittal relation between upper and lower jaw: ok retrognathic chin

24.10.2017

4

abscence11,21proalveolygingiviRscrowdinglowerteethconstricteddentalarches

⑊ ⑊

extraction 44,34 mesialisation 12,22

24.10.2017

5

2nd day postop

24.10.2017

6

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

24.10.2017

7

OSASrelatedMMA

paRentwithorthodonRcpretreatment

24.10.2017

8

AHI39,1•  Juvenilerheumatoidarthri's•  DMtypeI•  AHT•  BMI:25.72•  Genioplastyin2004

870831M074

24.10.2017

9

totalresorpRonofthecondyles

R L

24.10.2017

10

preoperaRve

postoperaRve

24.10.2017

11

cephalometricanalysis

3DsuperposiRon1wpostop

Preopvspostop

24.10.2017

12


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).


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

24.10.2017

13


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

24.10.2017

14

RELEVANCEOFTHEQUESTIONPOSED?

MaxillomandibularadvancementfortreatmentofobstrucRvesleepapnea:Reviewoftheliteraturewithemphasisonlong-termresults

Maxillomandibularadvancement(MMA)

OMFS SLEEPMEDICINE

=BONEstabilityvsrelapse

=BONE+SOFTTISSUE+FUNCTIONrelapse/airwayvolume/AHI-index?

24.10.2017

15

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)

24.10.2017

16

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!

24.10.2017

17

syndromicpaRentswithosas

24.10.2017

18

studies:inclusioncriteria?relevance?

MMA

OSAS

THEREALITYONTHEFIELD:TOWHOMARERESULTSRELEVANT?

24.10.2017

19

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

24.10.2017

20

HOWISMMASUPPOSEDTOWORK?

effectsofMMA•  enlargestheupperairway

–  intheanteroposteriorand–  inthelateraldimensions,butalso

•  raisesthehyoid

airway

howdoesitaffectairwayhowdoesitaffectsogRssuesliningthebone?

bony skeleton

24.10.2017

21

effectsofMMA

airway

bony skeleton

bonyskeleton:2Dmeasurementssag/verRcairway:3DsogRssues:??future.

PARAMETERSOFSUCCESS?

24.10.2017

22

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?

24.10.2017

23

criteriaofcure/success?

•  nonecessityofCPAP•  sleepquality?

•  cure:AHI<5events/hour•  surgicalsuccess:

–  reducRoninAHIof50%–  AHIof<20eventsperhouragerMMA

•  3Dchangesairway(CBCT)•  qualityoflife(ESS–OSAQoLquesRonnaire)•  11paRents•  6mnthsCBCT

prospecRve

well-execut

ed

24.10.2017

24

prospecRve

well-execut

ed

predicRvefactors:youngerpaRentsaremorelikelytoexperiencealargerdropinAHIagerMMAsurgerythanolderpaRents

prospecRve

well-execut

ed

24.10.2017

25

prospecRve

well-execut

ed

CorrelaRonbetweenthedecreaseinapnoea–hypopnoeaindex(AHI,eventsperhour)andupperairwaysub-regionvolumeincrease

prospecRve

well-execut

ed

AHI ESS

24.10.2017

26

curevssucces

trigeminalneuralgia

•  CURE–  JanneyaoperaRon

•  not100%successful•  notwithoutrisks

•  SUCCESS–  medicaRon

•  carbamazepine•  baclofen

•  RELAPSE

osas

•  CURE–  MMA

•  not100%successful•  notenRrelywithoutrisks

•  SUCCESS–  CPAP–  MRA–  Lifestyle

•  RELAPSE

24.10.2017

27

OWNDATA

•  QueryKWS:allpaRentswithorthognathicsurgeryand“snoring”or“obstrucRvesleepapnea”termsinfile

•  263paRënts agerfileanalysis:19paRëntsincludedwithCBCTdatapre-andpost-operaRveavailable

•  typeofsurgeryBSSO/LF1/BIMAX/iliaccrestbonegraf/genioplasty

•  2Dcephalometricanalysis:OnyxCeph•  3DanalysisinAmirasogwareonuprightCBCTdata:

–  accordingtoVeysB.,etal.:onlyoropharynxisstudied

RETROSPECTIVESTUDY

24.10.2017

28

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

24.10.2017

29

Withcutoffpoint4mmU1(upperincisor)advancementOrange:9/19paRentshadaU1advof<4mmBlue: 10/19paRentshadaU1advof>4mmConclusion:nodifferenceinvolumeincreasewithsmallorlargemaxillaryadvancementmeasuredatU1(duetoinclina'onocclusalplane)

RESULTS

skeletalchanges-%airwaychange

•  mostoldstudiesarebasedon2Dcephalometry•  =sagiyalmovement•  =sagiyallandmarks(pogonion,Iisd)•  transversechangesnotconsidered

•  airway=3D–  necessitatesvalidated3Dmeasurementtools

24.10.2017

30

upperjaw

lowerjaw

MMAopRon1:advancementupper+lowerjaw–noposteriorextrusionmaxilla

MMAopRon2:advancementupper+lowerjawANDposteriorextrusionmaxilla

NO MALOCCLUSION

upperjaw

lowerjaw

MMAopRon1:advancementupper+lowerjaw–noposteriorextrusionmaxilla

MMAopRon2:advancementupper+lowerjawANDposteriorextrusionmaxilla

MALOCCLUSION

24.10.2017

31

paRentwithoutorthodonRcpretreatment

case

indicaRonfortreatment

indica'on

osbstrucRvesleepapneasyndrome

typeoftreatment

o LeFortIo Advancement5mmo Posteriorextrusion4mmo Anteriorintrusion1mm

o BSSOadvancemento Advancementgenioplasty6mmo iliaccrestbonegrag

24.10.2017

32

651117V196

AHI38,3previoussurgeryonnoseseptumpsychiatricbackground

18-11-2015

noorthodonRcspossibleduetodentalimplants

24.10.2017

33

24.10.2017

34

3D Planning

Postop:Bimax:LeFort1adv.5mm,post.Extr.4mm,ant.Intr.1mm+BSSO+kinplasReadv.6mm

24.10.2017

35

postoperative

postoperative

24.10.2017

36

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

24.10.2017

37

airway

Preop Postop superposition

airway

Preop Postop

Volumepreop: 23118,26mm3Volumepostop: 56083,37mm3Difference: 32965,11mm3volumechangein%:142,59%

24.10.2017

38

paRentwithorthodonRcpretreatment

case

deepbitewithverRcalbonelossandlossofheightandOSAS

•  LeFort1–  advancement5mm–  anteriorextrusion4mm–  posteriorextrusion4mm

•  BSSOadvancement+steprotaRon+canRng43-33•  Iliaccrestgrag

24.10.2017

39

AHI11

medicaRon:

•  Cipramil, 20 mg, 1/d

•  Cymbalta, 30 mg, 1/d

•  Pantomed, 40 mg, 1/d

670114V017

670114V017

24.10.2017

40

670114V017

670114V017

24.10.2017

41

3D planning preopera-ve

Intermediate: Le Fort I (adv. 5mm, Extr ant en post 4mm)

24.10.2017

42

Le Fort I (adv. 5mm, Extr ant en post 4mm) + BSSO

postopera-ve

24.10.2017

43

cephalometric analysis

airway

Preop Postop superposiRon

superposiRon

24.10.2017

44

airway superposiRon

Volumepreop: 36918,54mm3Volumepostop: 32556,06mm3Difference: -4362,48mm3volumechangein%: -11,82%

LITERATURE

24.10.2017

45

ISMMAASKELETALLYSTABLEPROCEDUREINTHELONGTERM?

ThehierarchyofstabilityandpredictabilityinorthognathicsurgerywithrigidfixaRon:anupdateandextensionHead&FaceMedicine2007WilliamRProffitTimothyATurveyCeibPhillips

•  2264paRentswithorthognathicsurgery•  1475>1yfollow-up•  507>5yfollow-up

24.10.2017

46

08.05.1991 operatiedatum 27.10.1990 6 mnd postop

21101972GA201 ♀ 19 j

24.10.2017

47

21101972GA201 ♀ 36 j operatiedatum 27.10.1990 18 years postop

09.05.1996 13.10.1974TD101 22 j

24.10.2017

48

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

24.10.2017

49

22.07.1975 operatiedatum: 12.11.2008 33 y

1994

22071975OK201

12.11.2008 15 y follow-up: no relapse

24.10.2017

50

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

24.10.2017

51

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


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%


24.10.2017

52

evidenceMaxillomandibularadvancementforthetreatmentofobstrucRvesleepapnea:AsystemaRcreviewandmeta-analysis

•  predic'onforsurgicalsuccess:–  youngerage–  lowerpreopera'veweight–  lowerpreopera'veAHI–  greaterdegreeofmaxillaryadvancement(butnotmandibularadvancement)


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

24.10.2017

53

evidence

longterm?

MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis•  PaRentswithlessseveremeasuresofOSA

experienceasmallermagnitudeofchangeinAHIpostoperaRvely,

•  buttheyhavethehighestchanceofachievingsurgicalsuccessandcure.



evidence

longterm?

MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis•  overallsurgicalcurerate:38,5%

–  20%curerateifpreopAHI>90–  56%curerateifpreopAHI<30

•  overallsurgicalsuccesrate:85,5%



24.10.2017

54

evidence

longterm?

MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis•  Resultsfromcenterswithlargersample

sizesandexperiencereportedhigherlevelsofsurgicalsuccessthanreportedinthismeta-analysis

•  surgicalexperiencemayers



evidence

longterm?

MaxillomandibularAdvancementforTreatmentofObstrucRveSleepApneaAMeta-analysis•  longerfollow-upisneededbecause

recurrencesofOSAhavebeennotedat10to15yearsagerMMAsurgery

•  goodlong-termgaininanteroposteriordirecRonbutlimitedgaininthelateraldimensionofthepharyngealairway



24.10.2017

55

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

24.10.2017

56

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

24.10.2017

57

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

24.10.2017

58

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?

24.10.2017

59

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

24.10.2017

60

GUIDELINES

guidelinesMMAinBelgium

•  MMAwithoutOSAS:non-exisRng•  MMAwithOSAS:non-exisRng

24.10.2017

61

GuidelinestheNetherlands2015•  itislikelythataMMAinselectedOSASpaRentsdoesyieldsimilarresultsasCPAPonAHI

•  itislikelythataMMAinselectedOSASpaRentsdoesyieldsuccessfulresults

•  althoughworseningofAHIhasbeenreported,mostresultsareindicaRveoflong-termstableimprovementsagerMMAinOSASpaRents

•  itislikelythataMMAresultsinsignificantimprovementofthearousalindex.

•  itislikelythataMMAresultsinsignificantimprovementofsleepinesscomplaints

•  itislikelythataMMAresultsinsignificantimprovementofQoL

•  itislikelythataMMAresultsinsignificantimprovementofsystolicanddiastolicbloodpressure.

•  itislikelythataMMAresultsinsignificantimprovementofcogniRon.

GuidelinestheNetherlands2015

24.10.2017

62

CONCLUSIONS

Q-A•  areskeletalchangesofMMAstableoverRme?YES

•  areairwaychangesofMMAstableoverRme?nolongtermdataareavailable–CBCTisrecentlyintroduced

•  areAHIchangesofMMAstableoverRme?yes,44monthsofFUfor56paRentsyes,12,5yearsofFUfor88paRentsyes,8yearsofFUfor8paRentsyes,6,6yearsofFUfor30paRents

24.10.2017

63

evidencefromownpaRentdata-sets

•  actualindicaRoninourcentreisNOT“OSAS”but“failedCPAP”or“notoleranceforCPAP”:arepaRentsofferedachoicebetween“cure”–“containment”?

•  OSASsurgery:–  highpaRentsaRsfacRon–  verysafesurgery–  nolinearcorrelaRonbetween

• magnitudeofairwaygainin3D•  advancementofPog

indicaRon

•  thepreciseindicaRonforMMAsurgeryinOSASmanagementiscurrentlyindefinite

24.10.2017

64

ADVICE

proposal

present

“surgicalintervenRonforpaRentswithsleepapneaisreservedonlyforthosewhocannotorwillnotacceptconRnuousposiRveairwaypressuretherapy”

future

certainlytoyoungpaRentswithAHI<30thechoiceforatreatmentwhichcanCUREOSASshouldbeoffered:

–  permanentresults–  resultswhicharenotonly

“successful”butcancure–  lowincidenceofcomplicaRonsin

thatagegroup

24.10.2017

65

evidenceindicatesthatMMAshouldbethoughtofasthefirstandonly

surgicalopRonforsomepaRents.•  considerMMAastheirfirstandbestopRonfor:

–  paRentswithsignificantmaxillomandibulardeficiency–  paRentswithmoderate-to-severeOSAwithnosignificantpharyngealredundancy

–  youngpaRentswhoneedlong-termOSAsoluRons–  paRentswhowantthemosteffecRvesingle-stageapproach

Dentalabstracts,Volume57,Issue1,January–February2012,Pages18-19

future

•  10mmadvancementisbasedonthe2D-eraofcephalometrics

•  theinfluenceofthetransversedimensionontheresultswillprobablybethescienRficbenefitofthe3Dera

24.10.2017

66

“longterm”

•  Morewell-controlledprospecRvestudiesarenecessaryinthelongterm(morethan6months)”

British Journal of Oral and Maxillofacial Surgery 51 (2013) 834–840

24.10.2017

67

4mthspostSARPE

24.10.2017

68

4mthspostSARPE

15.3 mm 14.5 mm

24.10.2017

69

masRcatoryproblem:solvedsnoring:solvedmouthbreathing→nosebreathing

24.10.2017

70

Superposition pre- and post- ceph

Change of volume of airway

Increase22%

24.10.2017

71

MMAresearchtopics:

•  sarpechangesDUALplaneinMONOplane•  whatdeliveredgreatesteffectonairway

–  sarpehyrax–  LeFortI

•  sarpechangedtheinclinaRonoftheupperjaw

Documents

Maxillomandibular advancement for treatment of obstrucRve … · 2017. 10. 26. · Professor & Chairperson Oral & Maxillofacial Surgery UZLeuven Phone-dect:+32 16 341780 [email protected]