**8. Treatment options**

#### **8.1. Conservative treatment**

After diagnosis of OSA, conservative treatment is indicated. It includes weight reduction, positional treatment, CPAP and oral appliances. Increase in BMI is a risk factor for OSA. Although high BMI is a risk factor for OSA, 30% of OSA patients are not obese. BMI is defined as the weight in kilograms divided by the height in meters squared (kg/m2 ). Overweight is considered when BMI of more than 25 kg/m2 while obese is a BMI of more than 30 kg/m2 . Constriction of the hypopharynx and oropharynx are due to increase in neck circumference and increased fatty deposits in the peripharyngeal area [29]. In the Wisconsin Sleep Cohort Study, a 10% weight gain predicted a 32% increase in AHI, whereas a 10% weight loss predicted a 26% decrease in AHI [14].

**Continuous positive airway pressure** (CPAP) or nasal Continuous Positive Airway Pressures (nCPAP) are effective treatments for OSA. They are the 1st line treatment strategies when the patient is diagnosed with OSA. CPAP/ nCPAP work as a pneumatic splint to open the airway via tight fitting facemask or nasal mask and oxygen pump. There are many studies reporting the success of CPAP treatment. CPAP can stop and reverse all OSA complications. Treatments with CPAP result in decreased sympathetic tone, which will lead to decrease in blood pressure, AHI, oxygen desaturation and improve sleep efficiency, [30-32]. CPAP compliance however is only 65-80%, with 8% to 15% of patients stopping the treatment after the first night. This low compliance rate is due to many associated complications such as nasal dryness and congestion, sinus discomfort, massive epistaxis, skin rash and conjunctivitis from air leak. These compli‐ cations plus the physical discomfort, noise and difficult transporting the unit lowers the CPAP tolerance [33,34].

OSA patients should be advised not to sleep in supine position; gravity is a factor that can cause upper airway collapse. Positional behavioral therapy is to educate the patient to alter their sleep position by using a pillow or body belt; patients can alter their sleeping to a more lateral position that could open the airway and reduce collapsibility [35].

Mild to moderate OSA patients who are unable to tolerate CPAP can be treated with oral appliances. It simply prevents the mandible and associated muscles from going backward during sleep; some appliances actually advance the mandible from centric occlusion. Oral appliances should be adjusted on a periodic basis to prevent occlusal disturbances and temporomandibular joint dysfunction [36].

### **8.2. Surgical options**

1969 Kuhlo et al was the first to recommend tracheostomy for OSA treatment [37]. Although tracheostomy is the most effective surgical procedure to treat OSA, it has morbidity and many adverse effects on the quality of life namely wound infection, stenosis and bleeding. Because of this many surgical techniques have developed to treat OSA. Based on the level of obstruction there are many surgical options; for example nasal surgeries such as septoplasty, turbinoplasty, polypectomy, adenectomy and tonsillectomy will address nasal obstruction. There are several palatal surgeries to address retropalatal obstruction for example: uvulopalatopharyngoplasty (UPPP), uvulopalatopharyngoplasty laser assisted (UPPP-LA), palatal pillar implants, radiofrequency ablation of the soft palate, and many others. Tongue operations like tongue suspension, radiofrequency ablation of the tongue, genial tubercle advancement with or without hyoid suspension are used for retrolingual obstruction. On the other hand maxillo‐ mandibular advancement with or without combined procedures address retropalatal and retrolingual levels of obstruction [26] [38].

The following section of this chapter will address some surgical techniques.

#### **8.3. OSA treatment protocols**

Successful OSA treatments depend on the recognition of the level of obstruction. Stanford University Sleep Disorders and Research Center proposed a protocol for OSA based on the site of obstruction.

**Phase I protocol includes**: UPPP, genioglossus advancement, and/or hyoid suspension then

**Phase II protocol** maxillomandibular advancement if the patient fails phase I treatment. MMA can be used to treat OSA as a primary or secondary procedure. MMA is consid‐ ered primary when it is the 1st surgical procedure done to address multi-level of obstruc‐ tion, when MMA done after phase one treatment it is called secondary MMA. Recently some surgeons prefer MMA advancement as the 1st surgical procedure especially if the patient has maxillary or mandibular deficiencies [26,39]. MMA is indicated if the diagno‐ sis is confirmed severe OSA with RDI >50 and SaO2 <60%, non-compliance or tolerance to CPAP, retroglossal obstruction, failure to respond to other surgical treatment such as UPPP and maxillomandibular hypoplasia [1].

### **8.4. Uvulopalatopharyngoplasty**

their sleep position by using a pillow or body belt; patients can alter their sleeping to a more

Mild to moderate OSA patients who are unable to tolerate CPAP can be treated with oral appliances. It simply prevents the mandible and associated muscles from going backward during sleep; some appliances actually advance the mandible from centric occlusion. Oral appliances should be adjusted on a periodic basis to prevent occlusal disturbances and

1969 Kuhlo et al was the first to recommend tracheostomy for OSA treatment [37]. Although tracheostomy is the most effective surgical procedure to treat OSA, it has morbidity and many adverse effects on the quality of life namely wound infection, stenosis and bleeding. Because of this many surgical techniques have developed to treat OSA. Based on the level of obstruction there are many surgical options; for example nasal surgeries such as septoplasty, turbinoplasty, polypectomy, adenectomy and tonsillectomy will address nasal obstruction. There are several palatal surgeries to address retropalatal obstruction for example: uvulopalatopharyngoplasty (UPPP), uvulopalatopharyngoplasty laser assisted (UPPP-LA), palatal pillar implants, radiofrequency ablation of the soft palate, and many others. Tongue operations like tongue suspension, radiofrequency ablation of the tongue, genial tubercle advancement with or without hyoid suspension are used for retrolingual obstruction. On the other hand maxillo‐ mandibular advancement with or without combined procedures address retropalatal and

lateral position that could open the airway and reduce collapsibility [35].

The following section of this chapter will address some surgical techniques.

Successful OSA treatments depend on the recognition of the level of obstruction. Stanford University Sleep Disorders and Research Center proposed a protocol for OSA based on the

**Phase I protocol includes**: UPPP, genioglossus advancement, and/or hyoid suspension then

**Phase II protocol** maxillomandibular advancement if the patient fails phase I treatment. MMA can be used to treat OSA as a primary or secondary procedure. MMA is consid‐ ered primary when it is the 1st surgical procedure done to address multi-level of obstruc‐ tion, when MMA done after phase one treatment it is called secondary MMA. Recently some surgeons prefer MMA advancement as the 1st surgical procedure especially if the patient has maxillary or mandibular deficiencies [26,39]. MMA is indicated if the diagno‐ sis is confirmed severe OSA with RDI >50 and SaO2 <60%, non-compliance or tolerance to CPAP, retroglossal obstruction, failure to respond to other surgical treatment such as UPPP

temporomandibular joint dysfunction [36].

398 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

retrolingual levels of obstruction [26] [38].

and maxillomandibular hypoplasia [1].

**8.3. OSA treatment protocols**

site of obstruction.

**8.2. Surgical options**

Historically UPPP was an available option instead of tracheostomy until the recent expansion in surgical treatment of OSA. In 1981 Fujita et al introduced the concept of uvulopalatophar‐ yngoplasty (UPPP) to enlarge retropalatal airway. UPPP involves partial excision of the uvula and redundant pharyngeal and palatal tissues, with primary closure of the anterior and posterior pillars under general anesthesia [40]. In 1991 O'Leary and Millman modify Fujita UPPP by excising the palatopharyngeus muscle [41]. Uvulopalatal flap is another modification published in 1996 by Powell et al [42]. UPPP complications range from velopharyngeal insufficiency, dysphagia (difficulty swallowing), voice changes, and death from general anesthesia [43]. With the advances in laser surgery uvulopalatopharyngoplasty–laser assisted (UPPP-LA) was developed using the same principle of scalpel UPPP [44]. Variable success rates reported in the literature is up to 70% and 78% respectively [45, 46]. Other studies show only 40 % success in eliminating snoring [47].

Today UPPP or UPPP-LA is rarely used as a single treatment modality; this is primarily due to the understanding of multilevel obstruction in most OSA patients. It is usually part of a staged protocol for OSA treatment [48]. UPPP can be performed with genioglossus advance‐ ment or with MMA. Hendler and Barry in 2001 published their data about 41 OSA patients; 33 of them treated with combined UPPP and modified mortised genioglossus advancement while the others had MMA combined procedures. All patients had pre-operative and postoperative polysomnography to evaluate treatment success. They reported comparable success rate of 86% in both groups concluding that UPPP/mortised genioglossus advancement is effective for the treatment of obstructive sleep apnea. Maxillomandibular advancement is effective for treating severe sleep apnea, and MMA can be done combined with UPPP/mortised genioglossus advancement in some cases as long as it is indicated in order to avoid multiple procedures [49].

#### **8.5. Genioglossus advancement**

Genioglossus muscle is a major pharyngeal dilator that plays an important role in OSA pathophysiology. In 1984 Riley et al. first reported advancing the genial tubercle with its genioglossus muscle attachment. The procedure was called inferior sagittal osteotomy [50]. If hyoid suspension to the inferior mandible is done at the same time it is called genioglos‐ sus advancement-hyoid myotomy [51]; the later was modified by suspending the hyoid to the thyroid cartilage. By advancing the genioglossus muscle the tension will increase at the tongue base thereby stabilize the hypopharyngeal airway [52]. In 1991 Riley et al modi‐ fied the technique by limiting the osteotomy to a rectangular window and called it anterior mandibular osteotomy; this modification decreased anterior mandibular fracture [53]. In 2000, Lee and Woodson introduced a circular osteotomy of the genial tubercle [54]. All these modifications were done to address postoperative complications such as bone necrosis and anterior teeth pulp necrosis. Inferior sagittal osteotomy is indicated for patients with a deficient mandible in anteroposterior dimension, it involves genial tubercle advance‐ ment with the inferior border of the mandible while the occlusal relations ship is un‐ changed. On the other hand anterior mandibular osteotomy is indicated for patients with normal mandibular anteroposterior dimension [52]; it requires careful assessment of the genial tubercle, based on a study done by Mintz et al [55] on 14 human skulls, the superior border of the genial tubercle is 6.45 mm inferior to the apices of central incisors with 35.4% of the genial tubercle were located less than 5mm inferiorly. After estimating genial tubercle location a rectangular window osteotomy is performed leaving the inferior border of the mandible intact then advancing the segment to stabilize the hypopharyngeal airway. It will require a 90 degree rotation of the osteotomized segment and placing the lingual cortical plate anterior to the buccal/labial cortical plate [52]. Trephine osteotomy approach is another technique using the same concept but with trephine burr in an attempt to decrease postoperative complications (anterior teeth roots amputation) [54]. Foltán and René [56] published a follow-up of 31 patients who had genioglossus advancement by the modified genioplasty with hyoid myotomy. They reported 74% success rate showed by significant dropping in RDI and oxygen desaturation index. Genioglossus advancement with or without hyoid suspension is a valid technique to treat OSA; it could be performed alone or as an adjunct to UPPP [57]. Another technique to address retrolingual obstruction is tongue base surgeries. Tongue suspension is a revisable minimally invasive surgery performed via submental incision. By introducing a large suture into the base of the tongue and suspending the tongue to the mandibular lingual surface. Omur et al reported high success (81.81%)of tongue base surgery with UPPP. They conclude that tongue base suspension combined with UPPP has been shown to reduce RDI better than UPPP alone [58].

#### **8.6. Maxillomandibular advancement**

It is well recognized that patients with maxillomandibular deficiencies will ultimately develop OSA; from this observation MMA is advocated for OSA treatment even in patients with normal skeletal proportion [59]. MMA will increase the posterior airway dimension by physically expanding the skeletal structure. The forward movement of the maxilloman‐ dibular complex improves the tension and collapsibility of the velopharyngeal and suprahyoid muscles [60] [61]. Since the majority of OSA patients are middle age with a saggy and droopy soft tissue; forwarded movement of the mandibulomaxillary complex will not only bypass the obstruction; it will also provide facial rejuvenation by augment‐ ing soft tissue support [62]. MMA has many advantages such as decrease number of surgeries needed by utilizing one surgery to bypass several sites of obstructions (by performing Le Fort I advancement; it will open the nasal valve and consequently im‐ prove air flow, tighten the soft palate and pharyngeal muscles at the same time while mandibular advancement will tighten genioglossus and suprahyoid muscles), avoid the need for tracheostomy in the postoperative period and ultimately decrease medical costs by decreasing hospital stay. If the patient will undergo simultaneous MMA and soft tissue procedure such as UPPP or tongue reduction surgeries; temporary tracheostomy may be indicated to ensure patent airway. Other indications for temporary tracheostomy are difficult airway, RDI >60 and Sao2 <60, morbid obesity and significant craniofacial abnormality [1] [59]. MMA is considered one of the most successful treatment modalities for OSA after tracheostomy and CPAP [63] [64]. MMA success rate is very high compar‐ ing to other surgical treatment. Riley et al [65] reported the largest MMA series with success rate of 98%. In 2004 Dattilo and Drooger [66] reported 93% success rate in 14 of 15 cases, whereas Hochban et al in 1997 reported 97% success rate in 37 of 38 cases [67].

MMA as a surgical techniques per se is the same as classical orthognathic surgery it involve maxillary Le Fort I advancement and mandibular advancement simultaneously. The amount of advancement is usually 10mm - the maximum amount of possible advancement. There are some differences that should be considered with MMA e.g. vascular supply, bone healing and the need of adjunctive surgical procedures. Most of MMA candidate patients had unsuccessful UPPP; palatal scar may cause difficulty in advancing the maxilla or compromise its blood supply. Patients treated with UPPP may have or be at risk for velopharyngeal insufficiency (VPI). Advancing the maxilla may theoretically cause VPI or worsen existing VPI. During MMA surgery, based on cephalometrics and model surgery, the mandible is advanced first; this is because the amount of advancement is arbitrary and without any considerations of the maxillary incisors esthetic position or functional occlusion. [1,59,68]

Holty and Guilleminault published a meta-analysis of 53 reports describing 627 OSA patients with maxillomandibular advancement for the treatment of obstructive sleep apnea; they concluded that major and minor complication rates for MMA were 1.0% and 3.1%, respectively with cardiac complications as the most major complications. Facial paresthesia is the most common complication after MMA with 86% of cases resolved by 12 months after surgery. No postoperative deaths were reported. Most subjects reported satisfaction after MMA with improvements in quality of life measures [69]. Patients with poor response to MMA often have had UPPP. The possible cause is failure of the airway to stretch laterally in the retropalatal area caused by soft palate scarring from the previous surgery, making the tissues of the lateral pharyngeal walls stiffer and thus less responsive to advancement [1,59].
