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ITALIAN JOURNAL OF MAXILLOFACIAL SURGERY
A Journal on Maxillofacial Surgery
Official Journal of the Italian Society of Maxillofacial Surgery
Rivista Italiana di Chirurgia Maxillo-Facciale 2001 April;12(1):9-16
Maxillo-mandibular advancement surgery in serious Obstructive Sleep Apnea Syndrome (OSAS). Techniques and results
Ronchi P., Colombo L., Panigatti S., Novelli G., Oldani A. *, Zucconi M. *
From the Maxillo-Facial Operative Unit Sant’Anna Hospital, Como
* Sleep Centre, San Raffaele Hospital, Milan
Background. The effectiveness of maxillo-mandibular advancement surgery in treating serious and persistent obstructive sleep apnea syndrome (OSAS) is studied. This syndrome is known to be characterized by subjective symptoms (headache on awakening, marked daytime somnolence, tiredness) as well as serious subjective symptoms (high blood pressure, arythmia, cardiopulmonary problems). Indeed, during crises of apnea, there is a progressive decrease in arterial oxygen saturation and an increase in arterial CO2 pressure; in the long-term, these phenomena seriously affect cardiac activity. In serious forms of OSAS with a high number of obstructive apneas and retrolingual posterior air space (PAS) below 6-7 mm surgical maxillo-mandibular advancement is indicated.
Methods. Seven patients suffering from serious and persistent OSAS were studied; they were investigated with polysomnograph examination, cephalometric analysis and clinical evaluation before surgery, 5-7 days afterwards and at a distance (mean follow-up at 13 months, minimum 4 months, maximum 27 months). In all patients a maxillo-mandibular advancement was performed, with classic Le Fort I type maxillary osteotomy and bilateral sagittal osteotomy of the mandible as described by Obwegeser Dal Pont. In four patients preoperative orthodontic treatment was required; in three patients partial removable prostheses were prepared.
Results. In all patients there was a marked increase in the PAS (in five cases it more than doubled) and complete remission of the subjective daytime symptoms; this remission was in all cases sudden and dramatic. The number of apneas decreased drastically in all patients (the mean desaturation index (ODI) before and after surgery was 52.5 and 10.1 respectively). These results were found to be stable over time, with no difference between immediate post-surgery and follow-up.
Conclusions. Surgical treatment of the more serious forms of OSAS has the primary aim of resolving serious subjective and objective symptomatology and freeing the patient from the use of N-CPAP (nasal continuous positive airway pressure) to which they are always of necessity subjected. An analysis of the literature shows that, of all the surgical treatments proposed, maxillo-mandibular advancement is the most reliable in resolving the clinical and instrumental situation, with high success rates, including long-term. Maxillo-mandibular advancement stands as the treatment of choice for a certain number of patients affected by serious and persistent OSAS who have specific cephalometric and morphological characteristics. The operation is only apparently difficult in relation to the underlying disease: in reality with good surgical and anaesthesiological experience in the field of dysmorphism surgery these patients can be managed with no particular problems both during surgery and post-operatively.