**5. Treatment of OSA syndrome**

*4.2.1.5. Associated comorbidities*

*4.2.2. Objective testing*

clinical prediction rules for sleep apnea. [22, 44]

of uvula are visible. Class IV: Soft palate is not visible at all. 49

376 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

A clinical examination should not ignore respiratory, cardiovascular, and neurologic systems. In this area, medication history must be taken into account especially with regard to drugs that are associated with OSA (Barbiturates, Benzodiazepines...), those that sedate and/or decrease respiratory drive (Antihistamines, Antispasmodics, Anxiolytics, Muscle relaxants...) and those that impair sleep onset or maintenance (Anticholesterol agents, Appetite suppressants, Benzodiazepines, Caffeine, Nicotine, Diuretics...). Furthermore, since hypertension is descri‐ bed as independently associated with OSA, blood pressure has been integrated into several

**Figure 9.** Modified Mallampati classification of oropharyngeal visualization. Class I: Soft palate, tonsils, pillars, and uvula, are clearly visible. Class II: Soft palate, pillars, and uvula are visible. Class III: only part of soft palate and base

To establish OSA severity, objective testing is required. There are two accepted methods:

Polysomnography is the golden standard method for diagnosing OSA. It records sleepbreathing pattern and oxygen saturation overnight via a minimum of 12 channels of physio‐ logical signal such as electroencephalogram, electrocardiogram, electromyogram, oronasal airflow, electroocculogram, respiratory effort, body position and oxygen saturation. This

laboratory polysomnography (PSG) and home testing with portable monitors (PM)

Therapeutic approach of OSA requires interdisciplinary communication among healthcare professionals and long-term management with a regular follow-up. Patient adherence to therapy, potential side effects and further stability of results must be continually moni‐ tored. On the other hand, outcomes assessment should be performed after all therapy has been undertaken. The criteria used to determine successful treatment of OSA varies widely. A task force of AASM have reported some indicators for assessment of treatment results; these include resolution of sleepiness, OSA specific quality of life measures, patient and spousal satisfaction, adherence to therapy, avoidance of factors worsening disease, obtaining an adequate amount of sleep, practicing proper sleep hygiene and weight loss for over‐ weight/obese patients. Objectively, clinicians strive to achieve at least 50% reduction in the baseline AHI in addition to reduction in AHI to <5 events per hour or <10 events per hour. However, less stringent definitions can be adopted. Treatment modalities of OSA can be divided into surgical and non-surgical treatment to which adjunctive therapies can be associated. Less invasive treatment should be selected whenever possible. Also, patients must be advised about surgical success rates and complications, the availability of alterna‐ tive options and their levels of effectiveness. [52, 53]

### **5.1. Non-surgical treatments of OSA**

This category includes continuous positive airway pressure (CPAP), behavior modifications, and oral appliances.

#### *5.1.1. Continuous positive airway pressure (Figure 10)*

First described by Sullivan in 1981, CPAP was to become the golden standard of moderate to severe OSA treatment. [54].It consists of delivering, during sleep, compressed air into the airway to keep it open, by positive pressure across the airway walls and pneumatic splinting effect. CPAP can be applied through oral, nasal or oro-nasal interface; and the optimal level of positive airway pressure is determined by full-night, attended in-laboratory PSG. Successful therapy with CPAP depends greatly on individual patient acceptance and compliance that can fall for numerous reasons including functioning noise, discomfort, feelings of claustrophobia, and skin irritation. Thus, CPAP prescription requires explanation of benefits and medical reasons for its use. Patients should also be informed about the function and maintenance of equipment. According to the American college of Physician (ACP), moderate quality evidence has showed that CPAP improves sleep measurement in patients with at least moderate OSA (AHI > 15events/h), and there are no data to determine which patients benefit most from specific treatment strategies. [55] However, OSA remains at present the preferred treatment for OSA, as it could effectively reduce AHI and arousal index scores, and increase the minimum oxygen saturation. Finally, if CPAP use fails, based on objective monitoring and symptom evaluation, more efforts should be implemented to improve PAP use or consider alternative therapies.

**Figure 10.** CPAP device requiring the use of mask interface, sealed tubing and flow generator providing airflow. [56]

### *5.1.2. Behavior modifications or conservative treatments*

**5.1. Non-surgical treatments of OSA**

378 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

*5.1.1. Continuous positive airway pressure (Figure 10)*

and oral appliances.

therapies.

This category includes continuous positive airway pressure (CPAP), behavior modifications,

First described by Sullivan in 1981, CPAP was to become the golden standard of moderate to severe OSA treatment. [54].It consists of delivering, during sleep, compressed air into the airway to keep it open, by positive pressure across the airway walls and pneumatic splinting effect. CPAP can be applied through oral, nasal or oro-nasal interface; and the optimal level of positive airway pressure is determined by full-night, attended in-laboratory PSG. Successful therapy with CPAP depends greatly on individual patient acceptance and compliance that can fall for numerous reasons including functioning noise, discomfort, feelings of claustrophobia, and skin irritation. Thus, CPAP prescription requires explanation of benefits and medical reasons for its use. Patients should also be informed about the function and maintenance of equipment. According to the American college of Physician (ACP), moderate quality evidence has showed that CPAP improves sleep measurement in patients with at least moderate OSA (AHI > 15events/h), and there are no data to determine which patients benefit most from specific treatment strategies. [55] However, OSA remains at present the preferred treatment for OSA, as it could effectively reduce AHI and arousal index scores, and increase the minimum oxygen saturation. Finally, if CPAP use fails, based on objective monitoring and symptom evaluation, more efforts should be implemented to improve PAP use or consider alternative

**Figure 10.** CPAP device requiring the use of mask interface, sealed tubing and flow generator providing airflow. [56]

Behavior strategy includes all practices that enhance life routines and hygiene. It involves weight loss (ideally to a BMI of 25 kg/m2 or less), positional therapy, and avoidance of smoking, alcohol and sedatives 3h before sleep. Weight loss has been shown to improve AHI in obese patients with OSA. It is recommended for all overweight OSA patients and should be com‐ bined with a primary treatment for OSA. Sleeping in the supine position can affect airway size and patency with a decrease in the area of the lateral dimension of upper airway. Positional therapy keeps the patient in a non-supine position by positioning device like alarm, pillow, back-pack or tennis ball is an effective secondary therapy or can be a supplement to primary therapies for OSA in patients who have a low AHI in the non-supine position. To ascertain treatment outcomes, indicators, such as self-reported compliance, objective position monitor‐ ing, are used. However, studies argue that CPAP is still superior to positional therapy in reducing the severity of sleep apnea and increasing the oxygen saturation level during sleep in patients with positional OSA. [50]-[57]

#### *5.1.3. Oral appliances (figure 11-13)*

Pierre Robin was the first orthodontist to have used oral appliances (OAs) in the 1900s for glossoptosis. Since the 80s, these oral devices were used as a non-invasive treatment for OSA. This therapy has proven to be effective in reducing the apnea and hypopnea index, improving oxygen saturation during sleep, and reducing snoring. OAs are recommended as an alternative therapy to CPAP for mild to moderate OSA patients with CPAP adverse effects or for those who do not tolerate or adhere to CPAP or those who refuse surgery. They are also appropriate for patients with primary snoring, who do not respond to treatment with behavioral measures such as weight loss or sleep position change. [44, 50]-[58]

Both Mandibular advancement devices (MADs) and tongue-retaining devices were described (TRD). But MADs are the most commonly used and evaluated in the literature. Orthodontists must indicate the most appropriate design of MADs for each patient, depending on dental history and complete examination of the stomatognathic system (soft tissues, dental occlusion, masticatory muscles and the temporomandibular joint). MADs cover the upper and lower teeth and hold the mandible in an advanced position with respect to the resting position. The appliance is constructed, adjusted, and gradually titrated (advanced forward) over several weeks until the snoring and daytime sleepiness are reduced to an acceptable level, or the patient cannot tolerate further advancement. They are worn during sleep and they act by enlarging obstructed upper airway by moving the mandible and tongue anteriorly and then the activation of airway dilator muscles. Craniofacial changes induced by OA were evaluated using cephalometric analysis. Significant modifications were reported: Retroclination of the maxillary incisors, proclination of the mandibular incisors, increased lower facial height, and changes in molar relationship. Loss of edema, caused by snoring and repetitive apneas, associating OAs seems to result in palatal length decrease and pharyngeal area increase. OAs have some side effects: Dry mouth, excessive salivation, jaw discomfort, myofacial pain and tooth grinding. However, they are frequently reported as mild, acceptable, and transient. 4.1.3. **Oral appliances** (figure 11‐13)

position change. 44, <sup>50</sup>‐<sup>58</sup>

4.1.2. **Behavior modifications or conservative treatments**

Another inconvenience of OAs is the time needed for titration, which makes it a second choice for severe or high symptomatic OSA treatment. [58] by snoring and repetitive apneas, associating OAs seems to result in palatal length decrease and pharyngeal area increase. OAs have some side effects: Dry mouth, excessive salivation, jaw discomfort, myofacial pain and tooth grinding. However, they are frequently reported as mild, acceptable, and transient. Another inconvenience of OAs is

cephalometric analysis. Significant modifications were reported: Retroclination of the maxillary incisors, proclination of the mandibular incisors, increased lower facial height, and changes in molar relationship. Loss of edema, caused

Behavior strategy includes all practices that enhance life routines and hygiene. It involves weight loss (ideally to a BMI of 25 kg/m2 or less), positional therapy, and avoidance of smoking, alcohol and sedatives 3h before sleep. Weight loss has been shown to improve AHI in obese patients with OSA. It is recommended for all overweight OSA patients and should be combined with a primary treatment for OSA. Sleeping in the supine position can affect airway size and patency with a decrease in the area of the lateral dimension of upper airway. Positional therapy keeps the patient in a non‐supine position by positioning device like alarm, pillow, back‐pack or tennis ball is an effective secondary therapy or can be a supplement to primary therapies for OSA in patients who have a low AHI in the non‐ supine position. To ascertain treatment outcomes, indicators, such as self‐reported compliance, objective position monitoring, are used. However, studies argue that CPAP is still superior to positional therapy in reducing the severity

Pierre Robin was the first orthodontist to have used oral appliances (OAs) in the 1900s for glossoptosis. Since the 80s, these oral devices were used as a non‐invasive treatment for OSA. This therapy has proven to be effective in reducing the apnea and hypopnea index, improving oxygen saturation during sleep, and reducing snoring. OAs are recommended as an alternative therapy to CPAP for mild to moderate OSA patients with CPAP adverse effects or for those who do not tolerate or adhere to CPAP or those who refuse surgery. They are also appropriate for patients with primary snoring, who do not respond to treatment with behavioral measures such as weight loss or sleep

Both Mandibular advancement devices (MADs) and tongue‐retaining devices were described (TRD). But MADs are the most commonly used and evaluated in the literature. Orthodontists must indicate the most appropriate design of MADs for each patient, depending on dental history and complete examination of the stomatognathic system (soft tissues, dental occlusion, masticatory muscles and the temporomandibular joint). MADs cover the upper and lower teeth and hold the mandible in an advanced position with respect to the resting position. The appliance is constructed, adjusted, and gradually titrated (advanced forward) over several weeks until the snoring and daytime sleepiness are reduced to an acceptable level, or the patient cannot tolerate further advancement. They are worn

of sleep apnea and increasing the oxygen saturation level during sleep in patients with positional OSA. <sup>50</sup>‐<sup>57</sup>

The Academy of Dental Sleep Medicine suggested the use of cephalograms as a diagnostic aid at the initial dental examination of every patient receiving OA treatment. In addition, some cephalometric predictors like longer maxilla, shorter soft palate and decreased distance between mandibular plane and hyoid bone have been related to successful MAD treatment of OSA. [4] the time needed for titration, which makes it a second choice for severe or high symptomatic OSA treatment. <sup>58</sup> The Academy of Dental Sleep Medicine suggested the use of cephalograms as a diagnostic aid at the initial dental examination of every patient receiving OA treatment. In addition, some cephalometric predictors like longer maxilla, shorter soft palate and decreased distance between mandibular plane and hyoid bone have been related to successful MAD treatment of OSA. <sup>4</sup>

**Figure 11. A 27‐year‐old man with mild OSA: initial profile view (A), and initial occlusal views (B). We can note a severe retrognathia compensated with a class I dental occlusion. Figure 11.** A 27-year-old man with mild OSA: initial profile view (A), and initial occlusal views (B). We can note a severe retrognathia compensated with a class I dental occlusion.

**Figure 12. A MAD device was indicated for night.**

**Figure 12.** A MAD device was indicated for night. **Figure 12. A MAD device was indicated for night.**

**4.2. Surgical treatments of OSA** Surgical management was the first therapeutic modality employed to treat SDB by placement of a tracheotomy tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches **Figure 13. Lateral Cephalograms before (left) and after (right) oral appliance positioning showing change in hyoid bone position and slight enlargement of retroglossal area of pharynx Figure 13.** Lateral Cephalograms before (left) and after (right) oral appliance positioning showing change in hyoid bone position and slight enlargement of retroglossal area of pharynx

to upper airway treatment in OSA, which consist of upper airway tissue reduction or reconstruction at different levels. OSA surgical management often involves several procedures that can be at times multi‐phased or a combination of multi‐level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous

Surgical management was the first therapeutic modality employed to treat SDB by placement of a tracheotomy tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches to upper airway treatment in OSA, which consist of upper airway tissue reduction or reconstruction atdifferent levels. OSA surgical management often involves several procedures that can be at times multi‐phased or a combination of multi‐level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous

OSA surgery should be determined after clinical diagnosis and severity assessment by objective testing. It is recommended for patients who are medically and psychologically able to tolerate the operation ; primary surgery is advocated in mild OSA and severe obstructing anatomy feasible to treat surgically such as tonsillar hypertrophy and nasal obstruction; surgery is recommended secondarily in cases of ineffective treatment or intolerance to the other non‐invasive therapies in mild, moderate and severe OSA. Surgical treatment involves evaluation of three anatomic

OSA surgery should be determined after clinical diagnosis and severity assessment by objective testing. It is recommended for patients who are medically and psychologically able to tolerate the operation ; primary surgery is advocated in mild OSA and severe obstructing anatomy feasible to treat surgically such as tonsillar hypertrophy and nasal obstruction; surgery is recommended secondarily in cases of ineffective treatment or intolerance to the other non‐invasive therapies in mild, moderate and severe OSA. Surgical treatment involves evaluation of three anatomic

Thus, surgical procedures can be classified as intra‐pharyngeal or skeletal. Intra‐pharyngeal surgery includes all procedures directed towards soft tissues of upper airway, the most common being uvulopalatopharyngoplasty (UPPP). Hard tissues surgery includes maxillomandibular advancement (MMA) (**Figures 14‐16**) and genioglossus

Thus, surgical procedures can be classified as intra‐pharyngeal or skeletal. Intra‐pharyngeal surgery includes all procedures directed towards soft tissues of upper airway, the most common being uvulopalatopharyngoplasty (UPPP). Hard tissues surgery includes maxillomandibular advancement (MMA) (**Figures 14‐16**) and genioglossus

1‐the nose (alar cartilage deformities, septal deviations, enlarged turbinates, nasal floor constriction),

1‐the nose (alar cartilage deformities, septal deviations, enlarged turbinates, nasal floor constriction),

preoperative multidisciplinary assessment and rests on the surgeon's experience. <sup>59</sup>

sections of the airway for detection of collapse‐related abnormalities namely:

preoperative multidisciplinary assessment and rests on the surgeon's experience. <sup>59</sup>

3‐the retroglossal area and the tongue (mandibular retrognathia).

3‐the retroglossal area and the tongue (mandibular retrognathia).

sections of the airway for detection of collapse‐related abnormalities namely:

2‐ the retropalatal area (lymphoid hyperplasia, retrusive maxilla, long palate) and

advancement (GGA) (**Figure 17**)

advancement (GGA) (**Figure 17**)

**4.2. Surgical treatments of OSA**

2‐ the retropalatal area (lymphoid hyperplasia, retrusive maxilla, long palate) and

### **5.2. Surgical treatments of OSA**

Another inconvenience of OAs is the time needed for titration, which makes it a second choice

Behavior strategy includes all practices that enhance life routines and hygiene. It involves weight loss (ideally to a BMI of 25 kg/m2 or less), positional therapy, and avoidance of smoking, alcohol and sedatives 3h before sleep. Weight loss has been shown to improve AHI in obese patients with OSA. It is recommended for all overweight OSA patients and should be combined with a primary treatment for OSA. Sleeping in the supine position can affect airway size and patency with a decrease in the area of the lateral dimension of upper airway. Positional therapy keeps the patient in a non‐supine position by positioning device like alarm, pillow, back‐pack or tennis ball is an effective secondary therapy or can be a supplement to primary therapies for OSA in patients who have a low AHI in the non‐ supine position. To ascertain treatment outcomes, indicators, such as self‐reported compliance, objective position monitoring, are used. However, studies argue that CPAP is still superior to positional therapy in reducing the severity

Pierre Robin was the first orthodontist to have used oral appliances (OAs) in the 1900s for glossoptosis. Since the 80s, these oral devices were used as a non‐invasive treatment for OSA. This therapy has proven to be effective in reducing the apnea and hypopnea index, improving oxygen saturation during sleep, and reducing snoring. OAs are recommended as an alternative therapy to CPAP for mild to moderate OSA patients with CPAP adverse effects or for those who do not tolerate or adhere to CPAP or those who refuse surgery. They are also appropriate for patients with primary snoring, who do not respond to treatment with behavioral measures such as weight loss or sleep

Both Mandibular advancement devices (MADs) and tongue‐retaining devices were described (TRD). But MADs are the most commonly used and evaluated in the literature. Orthodontists must indicate the most appropriate design of MADs for each patient, depending on dental history and complete examination of the stomatognathic system (soft tissues, dental occlusion, masticatory muscles and the temporomandibular joint). MADs cover the upper and lower teeth and hold the mandible in an advanced position with respect to the resting position. The appliance is constructed, adjusted, and gradually titrated (advanced forward) over several weeks until the snoring and daytime sleepiness are reduced to an acceptable level, or the patient cannot tolerate further advancement. They are worn during sleep and they act by enlarging obstructed upper airway by moving the mandible and tongue anteriorly and then the activation of airway dilator muscles. Craniofacial changes induced by OA were evaluated using cephalometric analysis. Significant modifications were reported: Retroclination of the maxillary incisors, proclination of the mandibular incisors, increased lower facial height, and changes in molar relationship. Loss of edema, caused by snoring and repetitive apneas, associating OAs seems to result in palatal length decrease and pharyngeal area increase. OAs have some side effects: Dry mouth, excessive salivation, jaw discomfort, myofacial pain and tooth grinding. However, they are frequently reported as mild, acceptable, and transient. Another inconvenience of OAs is the time needed for titration, which makes it a second choice for severe or high symptomatic OSA treatment. <sup>58</sup> The Academy of Dental Sleep Medicine suggested the use of cephalograms as a diagnostic aid at the initial dental examination of every patient receiving OA treatment. In addition, some cephalometric predictors like longer maxilla, shorter soft palate and decreased distance between mandibular plane and hyoid bone have been related to

of sleep apnea and increasing the oxygen saturation level during sleep in patients with positional OSA. <sup>50</sup>‐<sup>57</sup>

The Academy of Dental Sleep Medicine suggested the use of cephalograms as a diagnostic aid at the initial dental examination of every patient receiving OA treatment. In addition, some cephalometric predictors like longer maxilla, shorter soft palate and decreased distance between mandibular plane and hyoid bone have been related to successful MAD treatment of

**Figure 11. A 27‐year‐old man with mild OSA: initial profile view (A), and initial occlusal views (B). We can note a severe retrognathia compensated with a class I dental occlusion.**

**Figure 12. A MAD device was indicated for night.**

**Figure 13. Lateral Cephalograms before (left) and after (right) oral appliance positioning showing change in hyoid bone position and slight enlargement of retroglossal area of pharynx**

Surgical management was the first therapeutic modality employed to treat SDB by placement of a tracheotomy tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches to upper airway treatment in OSA, which consist of upper airway tissue reduction or reconstruction at different levels. OSA surgical management often involves several procedures that can be at times multi‐phased or a combination of multi‐level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous

**Figure 13. Lateral Cephalograms before (left) and after (right) oral appliance positioning showing change in hyoid bone position and slight enlargement of retroglossal area of pharynx**

**Figure 13.** Lateral Cephalograms before (left) and after (right) oral appliance positioning showing change in hyoid

OSA surgery should be determined after clinical diagnosis and severity assessment by objective testing. It is recommended for patients who are medically and psychologically able to tolerate the operation ; primary surgery is advocated in mild OSA and severe obstructing anatomy feasible to treat surgically such as tonsillar hypertrophy and nasal obstruction; surgery is recommended secondarily in cases of ineffective treatment or intolerance to the other non‐invasive therapies in mild, moderate and severe OSA. Surgical treatment involves evaluation of three anatomic

OSA surgery should be determined after clinical diagnosis and severity assessment by objective testing. It is recommended for patients who are medically and psychologically able to tolerate the operation ; primary surgery is advocated in mild OSA and severe obstructing anatomy feasible to treat surgically such as tonsillar hypertrophy and nasal obstruction; surgery is recommended secondarily in cases of ineffective treatment or intolerance to the other non‐invasive therapies in mild, moderate and severe OSA. Surgical treatment involves evaluation of three anatomic

Surgical management was the first therapeutic modality employed to treat SDB by placement of a tracheotomy tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches to upper airway treatment in OSA, which consist of upper airway tissue reduction or reconstruction at different levels. OSA surgical management often involves several procedures that can be at times multi‐phased or a combination of multi‐level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous

Thus, surgical procedures can be classified as intra‐pharyngeal or skeletal. Intra‐pharyngeal surgery includes all procedures directed towards soft tissues of upper airway, the most common being uvulopalatopharyngoplasty (UPPP). Hard tissues surgery includes maxillomandibular advancement (MMA) (**Figures 14‐16**) and genioglossus

Thus, surgical procedures can be classified as intra‐pharyngeal or skeletal. Intra‐pharyngeal surgery includes all procedures directed towards soft tissues of upper airway, the most common being uvulopalatopharyngoplasty (UPPP). Hard tissues surgery includes maxillomandibular advancement (MMA) (**Figures 14‐16**) and genioglossus

1‐the nose (alar cartilage deformities, septal deviations, enlarged turbinates, nasal floor constriction),

1‐the nose (alar cartilage deformities, septal deviations, enlarged turbinates, nasal floor constriction),

preoperative multidisciplinary assessment and rests on the surgeon's experience. <sup>59</sup>

sections of the airway for detection of collapse‐related abnormalities namely:

preoperative multidisciplinary assessment and rests on the surgeon's experience. <sup>59</sup>

3‐the retroglossal area and the tongue (mandibular retrognathia).

bone position and slight enlargement of retroglossal area of pharynx

3‐the retroglossal area and the tongue (mandibular retrognathia).

sections of the airway for detection of collapse‐related abnormalities namely:

2‐ the retropalatal area (lymphoid hyperplasia, retrusive maxilla, long palate) and

2‐ the retropalatal area (lymphoid hyperplasia, retrusive maxilla, long palate) and

**Figure 11.** A 27-year-old man with mild OSA: initial profile view (A), and initial occlusal views (B). We can note a

**A B B** B

**Figure 12.** A MAD device was indicated for night. **Figure 12. A MAD device was indicated for night.**

for severe or high symptomatic OSA treatment. [58]

380 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

severe retrognathia compensated with a class I dental occlusion.

**4.2. Surgical treatments of OSA**

**4.2. Surgical treatments of OSA**

advancement (GGA) (**Figure 17**)

advancement (GGA) (**Figure 17**)

4.1.2. **Behavior modifications or conservative treatments**

4.1.3. **Oral appliances** (figure 11‐13)

OSA. [4]

successful MAD treatment of OSA. <sup>4</sup>

position change. 44, <sup>50</sup>‐<sup>58</sup>

Surgical management was the first therapeutic modality employed to treat SDB by placement of a tracheotomy tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches to upper airway treatment in OSA, which consist of upper airway tissue reduction or reconstruction at different levels. OSA surgical management often involves several procedures that can be at times multi-phased or a combination of multilevel simultaneous surgeries. The selection of the most adequate surgery entails a meticulous preoperative multidisciplinary assessment and rests on the surgeon's experience. [59]

OSA surgery should be determined after clinical diagnosis and severity assessment by objective testing. It is recommended for patients who are medically and psychologically able to tolerate the operation ; primary surgery is advocated in mild OSA and severe obstructing anatomy feasible to treat surgically such as tonsillar hypertrophy and nasal obstruction; surgery is recommended secondarily in cases of ineffective treatment or intolerance to the other non-invasive therapies in mild, moderate and severe OSA. Surgical treatment involves evaluation of three anatomic sections of the airway for detection of collapse-related abnor‐ malities namely:


Thus, surgical procedures can be classified as intra-pharyngeal or skeletal. Intra-pharyngeal surgery includes all procedures directed towards soft tissues of upper airway, the most common being uvulopalatopharyngoplasty (UPPP). Hard tissues surgery includes maxillo‐ mandibular advancement (MMA) (Figures 14-16) and genioglossus advancement (GGA) (Figure 17)

**Figure 14: Profile views of a 34‐year‐old man with severe OSA. A: before treatment, B: after OSA management including orthognathic surgery (mandibular advancement osteotomy) Figure 14.** Profile views of a 34-year-old man with severe OSA. A: before treatment, B: after OSA management includ‐ ing orthognathic surgery (mandibular advancement osteotomy)

**Figure 15: lateral cephalograms showing posterior airway space enlargement Before treatment (left) and after surgical mandibular advancement (right)**

**Figure 16: PSG registration: before treatment (left) and after mandibular advancement and**

. Moderate OSA.

**adenoidectomy (right).**

**Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea events: 30,

**After treatment:** total number of obstructive apnea events: 22, total number of hypopnea events: 108,

**Sleep parameters evaluation for this clinical case:**

AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2

AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m<sup>2</sup> (Severe OSA).

**A B**

**Figure 14: Profile views of a 34‐year‐old man with severe OSA. A: before treatment, B: after OSA management**

**Figure 15: lateral cephalograms showing posterior airway space enlargement Figure 15.** lateral cephalograms showing posterior airway space enlargement Before treatment (left) and after surgical mandibular advancement (right) **Figure 15: lateral cephalograms showing posterior airway space enlargement** 

**Before treatment (left) and after surgical mandibular advancement (right)**

**Before treatment (left) and after surgical mandibular advancement (right)**

**adenoidectomy (right).**

**Figure 16: PSG registration: before treatment (left) and after mandibular advancement and Figure 16.** PSG registration: before treatment (left) and after mandibular advancement and adenoidectomy (right).

#### **Sleep parameters evaluation for this clinical case:** *5.2.1. Sleep parameters evaluation for this clinical case*

**Figure 16: PSG registration: before treatment (left) and after mandibular advancement and adenoidectomy (right). Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea events: 30, AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m<sup>2</sup> (Severe OSA). **After treatment:** total number of obstructive apnea events: 22, total number of hypopnea events: 108, **Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea events: 30, AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m2 (Severe OSA).

**Sleep parameters evaluation for this clinical case: Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea events: 30, AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2 . Moderate OSA. **After treatment:** total number of obstructive apnea events: 22, total number of hypopnea events: 108, AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2 . Moderate OSA.

AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m<sup>2</sup> (Severe OSA). **After treatment:** total number of obstructive apnea events: 22, total number of hypopnea events: 108, AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2 . Moderate OSA. Powell et al. have created a two-phase directed protocol (Powell-Riley surgical protocol) for surgical treatment of upper airway obstruction at several levels in order to avoid unnecessary surgery. Phase I surgery is designed essentially to treat the upper airway soft tissue (nose, palate, and tongue base) without dental occlusion or facial skeleton modifications. Clinical response is assessed, after adequate healing, four to six months following surgery by PSG. Persistent OSA requires phase II surgery indications. Phase II surgery refers to maxilla-

**Figure 14: Profile views of a 34‐year‐old man with severe OSA. A: before treatment, B: after OSA management including orthognathic surgery (mandibular advancement osteotomy)**

**A B**

**Figure 14: Profile views of a 34‐year‐old man with severe OSA. A: before treatment, B: after OSA management including orthognathic surgery (mandibular advancement osteotomy)**

**A B**

382 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 15: lateral cephalograms showing posterior airway space enlargement Before treatment (left) and after surgical mandibular advancement (right)**

**Figure 15: lateral cephalograms showing posterior airway space enlargement Before treatment (left) and after surgical mandibular advancement (right)**

**Figure 15.** lateral cephalograms showing posterior airway space enlargement Before treatment (left) and after surgical

**Figure 16: PSG registration: before treatment (left) and after mandibular advancement and**

**Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea events: 30,

**After treatment:** total number of obstructive apnea events: 22, total number of hypopnea events: 108,

**Figure 16: PSG registration: before treatment (left) and after mandibular advancement and adenoidectomy (right).**

. Moderate OSA.

(Severe OSA).

. Moderate OSA.

. Moderate OSA.

**adenoidectomy (right).**

**Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea events: 30,

**After treatment:** total number of obstructive apnea events: 22, total number of hypopnea events: 108,

**Sleep parameters evaluation for this clinical case:**

*5.2.1. Sleep parameters evaluation for this clinical case*

mandibular advancement (right)

AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2

AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m<sup>2</sup> (Severe OSA).

events: 108, AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2

AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2

events: 30, AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m2

**Sleep parameters evaluation for this clinical case:**

AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m<sup>2</sup> (Severe OSA).

**Figure 16.** PSG registration: before treatment (left) and after mandibular advancement and adenoidectomy (right).

**Before treatment**: total number of obstructive apnea events: 51, number of total hypopnea

**After treatment:** total number of obstructive apnea events: 22, total number of hypopnea

Powell et al. have created a two-phase directed protocol (Powell-Riley surgical protocol) for surgical treatment of upper airway obstruction at several levels in order to avoid unnecessary surgery. Phase I surgery is designed essentially to treat the upper airway soft tissue (nose, palate, and tongue base) without dental occlusion or facial skeleton modifications. Clinical response is assessed, after adequate healing, four to six months following surgery by PSG. Persistent OSA requires phase II surgery indications. Phase II surgery refers to maxilla-

**Figure 17. Genioglossus advancement technique. (A): rectangular osteotomy is created in the anterior mandible. (B) : The genial tubercle and the attached genioglossus muscle are advanced anteriorly. The bony fragment is rotated 90° to overlap the inferior border of the mandible and secured to the mandible with a titanium screw. <sup>59</sup> Figure 17.** Genioglossus advancement technique. (A): rectangular osteotomy is created in the anterior mandible. (B) : The genial tubercle and the attached genioglossus muscle are advanced anteriorly. The bony fragment is rotated 90° to overlap the inferior border of the mandible and secured to the mandible with a titanium screw. [59]

mandibular advancement osteotomy, which physically creates more space for the tongue, thus enlarging the posterior airway space. [59] Powell et al. have created a two‐phase directed protocol (Powell‐Riley surgical protocol) for surgical treatment of upper airway obstruction at several levels in order to avoid unnecessary surgery. Phase I surgery is designed essentially to treat the upper airway soft tissue (nose, palate, and tongue base) without dental occlusion or facial skeleton modifications. Clinical response is assessed, after adequate healing, four to six months following surgery by

UPPP has been developed to alleviate isolated obstructing tissues of the soft palate, lateral pharyngeal walls, and tonsils. However, according to ACP, it does not reliably normalize AHI when treating moderate to severe OSA, as a sole procedure. Furthermore, with regards to MMA, there is a need for more understanding of the relative risks and benefits of MMA compared to other treatment modalities. CPAP or OAs should generally be suggested ahead of MMA if the patient is consenting. These recommendations do not corroborate with other findings having reported a success rate of 89% obtained by physically expanding the facial skeletal framework and increasing tissue tension, which decreases velopharyngeal and suprahyoid musculature collapsibility. [53, 61] PSG. Persistent OSA requires phase II surgery indications. Phase II surgery refers to maxilla‐mandibular advancement osteotomy, which physically creates more space for the tongue, thus enlarging the posterior airway space. 59 UPPP has been developed to alleviate isolated obstructing tissues of the soft palate, lateral pharyngeal walls, and tonsils. However, according to ACP, it does not reliably normalize AHI when treating moderate to severe OSA, as a sole procedure. Furthermore, with regards to MMA, there is a need for more understanding of the relative risks and benefits of MMA compared to other treatment modalities. CPAP or OAs should generally be suggested ahead of MMA if the patient is consenting. These recommendations do not corroborate with other findings having reported a success rate of 89% obtained by physically expanding the facial skeletal framework and increasing tissue tension, which decreases velopharyngeal and suprahyoid musculature collapsibility. 53,61 Complications of maxilla‐mandibular advancement surgery have been reported, including side effects such as neurosensory deficit, infection, bleeding, or temporomandibular joint problems; but patients' satisfaction is

Complications of maxilla-mandibular advancement surgery have been reported, including side effects such as neurosensory deficit, infection, bleeding, or temporomandibular joint problems; but patients' satisfaction is reported to be as high as 95%. Finally, long-term stability depends on the body mass index, the amount of skeletal advancement, and the skill and experience of the surgeon.[60, 61] reported to be as high as 95%. Finally, long‐term stability depends on the body mass index, the amount of skeletal advancement, and the skill and experience of the surgeon . 60, 61 The palatal implant is a new treatment option for snoring that emerged in 2003. It is composed of polyethylene terephthalate, a biocompatible material, and inserted into the soft palate to reduce vibration and collapsibility by stiffening the soft palate, thus reducing palatal flutter and snoring. Additional stiffening of the palate is achieved by fibrosis and formation of capsule in response to the inflammatory reaction. Studies have showed that they may be effective in some patients with mild obstructive sleep apnea, who cannot tolerate or do not adhere to positive

airway pressure therapy, or in whom oral appliances have been considered and found to be ineffective or

The palatal implant is a new treatment option for snoring that emerged in 2003. It is composed of polyethylene terephthalate, a biocompatible material, and inserted into the soft palate to reduce vibration and collapsibility by stiffening the soft palate, thus reducing palatal flutter and snoring. Additional stiffening of the palate is achieved by fibrosis and formation of capsule in response to the inflammatory reaction. Studies have showed that they may be effective in some patients with mild obstructive sleep apnea, who cannot tolerate or do not adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found to be ineffective or undesirable. However, at the present time, it is difficult to predict if it will be a reliably effective intervention or not. [55, 59, 62] undesirable. However, at the present time, it is difficult to predict if it will be a reliably effective intervention or not. 55, 59, 62 **4.3. Adjunctive treatment:** 4.3.1. **Pharmacological therapy** A wide range of medication targeting OSA treatment has been explored in the literature. Except for hypothyroidism or acromegaly in which medication can improve AHI, there are no really effective pharmacotherapies for OSA. Topical nasal corticosteroids can be used in patients with OSA and concomitant rhinitis especially in children, and thus may be a useful adjunct to primary therapies for OSA. In addition, Modafinil, a psychostimulant, is recommended for the treatment of residual excessive daytime sleepiness despite effective PAP treatment and absence of other evident causes for their sleepiness. 44,63 A Cochrane review issued in 2013 showed insufficient evidence to recommend any systemic pharmacological treatment for OSA; drug therapy needs to be targeted depending on the presence or absence of obesity and the

predominance of OSA in a particular sleep stage. The review also reported that among all drugs evaluated, Donepezil

is the most promising for further research. <sup>64</sup>

### **5.3. Adjunctive treatment**

#### *5.3.1. Pharmacological therapy*

A wide range of medication targeting OSA treatment has been explored in the literature. Except for hypothyroidism or acromegaly in which medication can improve AHI, there are no really effective pharmacotherapies for OSA. Topical nasal corticosteroids can be used in patients with OSA and concomitant rhinitis especially in children, and thus may be a useful adjunct to primary therapies for OSA. In addition, Modafinil, a psychostimulant, is recommended for the treatment of residual excessive daytime sleepiness despite effective PAP treatment and absence of other evident causes for their sleepiness. [44, 63]

A Cochrane review issued in 2013 showed insufficient evidence to recommend any systemic pharmacological treatment for OSA; drug therapy needs to be targeted depending on the presence or absence of obesity and the predominance of OSA in a particular sleep stage. The review also reported that among all drugs evaluated, Donepezil is the most promising for further research. [64]

### *5.3.2. Bariatric surgery*

Bariatric surgery consists of a variety of operative techniques performed to promote weight reduction such reducing gastric banding, gastric and jujenoileal bypass or gastroplasty. It is often recommended for treatment of morbid obesity, particularly when associated with other medical complications (BMI ≥ 35 kg/m2) or those with a BMI ≥ 35 kg/m2 when dietary efforts fail at weight control. Therefore women seem likely to be candidates for this method of weight loss. [44, 65]
