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Compendium
March 2016
Volume 37, Issue 3

Mandibular osteotomy with genioglossus advancement—When upper airway obstruction occurs at the base of the tongue, moving the geniotubercle or the hyoid complex forward will stabilize the tongue base as well as the related pharyngeal dialators.21 With mandibular osteotomy with genioglossus advancement, a limited parasagittal mandibular osteotomy is used to advance the geniotubercle of the mandible forward, force an anterior advancement of the tongue base, and enlarge the retrolingual airway. Depending on the severity of the sleep-disordered breathing, success rates for this procedure have ranged from 35% to 60%, with the most serious complications being mandibular fracture, infection, permanent anesthesia, and seroma.21 However, it is usually performed with uvulopalatopharyngoplasty (UPPP) to enhance the upper airway space and eliminate the need for additional procedures, such as hyoid myotomy suspension.

Hyoid myotomy suspension—Considered part of phase I treatment—although not necessarily performed simultaneously with mandibular osteotomy with genioglossus advancement—hyoid myotomy suspension focuses on moving the hyoid complex forward to enhance the airway space behind the tongue.21 Many patients, however, find this procedure difficult to tolerate, which is why alternative approaches (eg, mandibular osteotomy with genioglossus advancement combined with UPPP) are undertaken.21

Uvulopalatopharyngoplasty (UPPP)—This surgical approach excises the uvula, posterior palatal area, and trims and reorients the posterior and anterior lateral pharyngeal pillars in order to enlarge the retropalatal airway, and is also considered part of phase I treatment.21,22 In recent years, lasers have been used for tissue incisions and vaporization when shortening the uvula and modifying the soft palatal tissue.23 Usually performed in combination with other procedures (eg, adenotosillectomy, advancement), UPPP has only been 41% successful in treating sleep-disordered breathing—particularly obstructive sleep apnea syndrome—is quite uncomfortable, and only 5% effective if retrolingual narrowing exists.22 Complications have included dysphagia, persistent dryness, and nasopharyngeal stenosis,21 and, overall, inconsistent outcomes and adverse effects have been reported as a result of pharyngeal surgeries.23

Further, the success of such surgical interventions is predicated on precisely locating the soft tissue and obstruction,12 which underscores the need for appropriate techniques when analyzing cephalometric and/or radiographic images. UPPP is not recommended when imaging has confirmed a retrolingual narrowing or retrolingual collapse during apneas.22 Instead, maxillofacial surgery is recommended for patients suspected of having hypopharyngeal collapse.22

Maxillomandibular advancement osteotomy (MMA)—In MMA surgery, the velo-orohypopharyngeal airway is enlarged by advancing the soft palate, tongue base, and suprahyoid musculature (ie, anterior pharyngeal tissues) that are attached to the maxilla, mandible, and hyoid bone.23 The multilevel skeletal surgery also involves LeFort I and bilateral sagittal split rami osteotomies and stabilization using bone grafts, plates, or screws.23 Considered part of phase II treatment, MMA has been shown to produce substantial and consistent reductions in the apnea-hypopnea index (AHI).23

Although MMA surgery can help to reduce the health risks associated with obstructive sleep apnea,24 the efficacy of surgical interventions overall for the treatment and management of sleep-disordered breathing remains a topic of debate and study, particularly when the condition cannot be attributed to specific anatomic attributes of the upper airway.8 Nevertheless, advancing the mandibular arch through MMA has proven more successful than other surgical techniques in reducing AHI, but more research is still needed in the areas of morbidity, patient selection, and long-term efficacy.23

Conclusion

Several screening, diagnostic, and treatment advancements for patients with sleep-disordered breathing—and published literature regarding their efficacy and appropriateness for identifying and resolving different types of obstructions—have become available in recent years. Combined, they provide dentists and their sleep physician colleagues with resources on which to base their decisions regarding how best to treat patients with sleep-disordered breathing.

Paramount to the success of any treatment that is undertaken is knowledge of the cause of the problem (ie, type, extent, and location of the obstruction). Although some of these causes can be determined through a visual oral examination, others must be more thoroughly identified through precise diagnostic imaging. Additionally, given the growing body of evidence that supports and/or cautions against the application of different diagnostic techniques and treatment approaches, it is incumbent upon dentists working with patients with sleep-disordered breathing conditions to pursue quality and reputable ongoing continuing education and training, as well as develop strong and mutually respectful collaborative relationships with sleep physician colleagues.

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