ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Maxillomandibular Advancement (MMA) Is The Best Primary Surgical Intervention For Obstructive Sleep Apnea (OSA) Patients Who Do Not Comply With Or Tolerate CPAP
Clinical Question In obstructive sleep apnea patients who do not comply with or tolerate continuous positive air pressure (CPAP), does maxillomandibular advancement provide the best surgical outcome compared to uvulopalatopharyngoplasty (UPPP)?
Clinical Bottom Line MMA as the primary intervention was the most effective treatment for patients who were unable to comply with or tolerate CPAP. Results showed MMA yielded the best results, in regards to mean change in Apnea Hypopnea Index (AHI), compared to UPPP. Furthermore, there was no difference between performing MMA alone versus a staged surgical method that includes MMA.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 21605790Pirklbauer/201121 studiesSystematic Review
Key resultsA chronological approach of surgical procedures was evaluated using less-invasive surgeries such as UPPP and genioglossus advancement before bimaxillary osteotomies. All studies used Apnea Hypopnea Index (AHI) and Respiratory Disturbance Indices (RDI) to compare pre- and postoperative results. The systematic review recommended MMA as the first surgical intervention in selected patients due to the surgical risk of palatal scarring and velopharyngeal insufficiency with the earlier phase treatments. Furthermore, skeletal advancement surgery appears to be much more stable than other surgical interventions.
#2) 23219145Boyd/2013106 patients with obstructive sleep apnea surgical interventionAnalysis of Medical Records
Key resultsComparing the results among surgical techniques after adjusting for differences in baseline AHI, there was a significantly larger mean change in AHI for patients receiving the MMA (40.5) compared to the UPPP alone (19.4), p < 0.0001. Furthermore, there was no significant difference between combined UPPP/MMA staged surgeries and simply going straight to an MMA alone, p = 0.684.
Evidence Search (maxillomandibular[All Fields] AND advancement[All Fields] AND ("obstructive sleep apnoea"[All Fields] OR "sleep apnea, obstructive"[MeSH Terms] OR ("sleep"[All Fields] AND "apnea"[All Fields] AND "obstructive"[All Fields]) OR "obstructive sleep apnea"[All Fields] OR ("obstructive"[All Fields] AND "sleep"[All Fields] AND "apnea"[All Fields]))) AND (Meta-Analysis[ptyp] OR systematic[sb] OR Comparative Study[ptyp])
Comments on
The Evidence
Validity: The analysis of medical records compared the effects of the various surgical procedures. These studies were not randomized or controlled; thus, efforts were made to allow for comparable baseline AHI data, yielding a potential source of bias. The systematic review assessed the studies according to the Oxford Centre of evidence-based medicine criteria. In doing so, the systematic review investigated the best available information available in the literature regarding MMA as a primary intervention for OSA. However, a diverse range was obtained resulting in a success rate of 65-100% for MMA. The high variability in results, especially with changes in AHI and the threshold defining successful treatment, may be of concern with regards to the consistency of these results in both studies. Furthermore, higher levels of evidence are necessary to directly compare surgical techniques, in order to develop a more definitive conclusion. Perspective: A major concern with treating patients with MMA is the possibility of skeletal relapse and the return of OSA. Studies have shown a positive outcome within the first five years post surgically; however, no long-term studies are available to provide any perspective on this issue. Additionally, more studies may be necessary to more directly compare MMA to the surgical techniques other than UPPP.
Applicability For patients who do not comply with or tolerate CPAP therapy, surgical therapy may be a beneficial option for the treatment of OSA. While many surgical procedures provide variable relief from the symptomatology of OSA, MMA seems to be the most consistent and reproducible surgical technique. Using a conventional phased surgical approach to treat OSA patients places them at risk of needing multiple surgeries. If surgical treatment is being considered, MMA should be considered as an initial option instead of initially subjecting patients to less definitive treatments.
Specialty/Discipline (General Dentistry) (Oral Surgery)
Keywords Maxillomandibular advancement, MMA, Obstructive Sleep Apnea, OSA
ID# 2770
Date of submission: 10/27/2014spacer
E-mail tibbitts@livemail.uthscsa.edu
Author Luke Tibbitts
Co-author(s) Sammy Houari
Co-author(s) e-mail houaris@livemail.uthscsa.edu
Faculty mentor/Co-author Edward Ellis III, DDS
Faculty mentor/Co-author e-mail ellise3@uthscsa.edu
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