ORIGINAL ARTICLES   

Rivista Italiana di Chirurgia Maxillo-Facciale 2001 April;12(1):9-16

Copyright © 2002 EDIZIONI MINERVA MEDICA

language: English

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.