Maxillofacial-Mandibular Advancement and Oral Appliance Therapy

Creating A Pathway To Successful Treatment

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Choosing the appropriate sleep apnea treatment for your patients depends on a number of factors, including the cause and severity of their condition, their medical history, and their personal preferences. Understanding when to utilize an oral appliance or when to explore the option of maxillofacial-mandibular advancement (MMA) surgery is vital to your practice and to the health of your patients.
Our Oral Appliance Protocol
clinical_taylor_quoteAn oral appliance may be an ideal solution for patients with mild to moderate obstructive sleep apnea, especially those who do not need to use or do not wish to use a CPAP device. However, it is important to approach oral appliance use deliberately, so as to best understand its effectiveness with each patient. We follow this protocol:

  • The patient undergoes an attended sleep study to determine the diagnosis and apnea-hypopnea index (AHI). If the patient has an AHI of 15 or under and otherwise seems like a good candidate for oral appliance therapy, that treatment option is pursued.
  • The patient undergoes a 3D airway scan. This scan, which is done before the appliance is made as well as after the appliance is made, correlates the sleep study findings and analyzes the anatomical effects of the appliance. The fit is assessed by noting the position of the condyles with respect to the articular eminence. The goal is to keep them in as normal alignment as possible. The airway volume and anatomy is evaluated with and without the appliance. This information is combined with the home study and clinical parameters to assess the effectiveness of appliance therapy.
  • An oral appliance is fabricated with the assistance of an experienced dentist.
  • The patient participates in three home sleep studies: two without the appliance and one while using the appliance. These three sleep studies help determine the effectiveness of the appliance. The appliance may need to be altered or another type of treatment may need to be pursued if the patient continues to have mild to moderate sleep apnea symptoms and their AHI remains elevated. The first two nights are utilized to establish a baseline, as there is some inherent disruption of sleep from simply using the apparatus. It is not unusual to find that the first night is the most severe with some stabilization during the second night. Hopefully, the third night with the oral appliance will give a true assessment with minimum disruption from the testing apparatus.

Maxillofacial-Mandibular Advancement for OSA
For patients with moderate to severe obstructive sleep apnea – and for those who are not helped by oral appliances, maxillofacial-mandibular advancement surgery, also known as bimaxillary advancement surgery, may be the best solution. This OSA surgery pulls both the upper and lower jaw forward, opening the airway, and increases the rigidity of the air column, making it easier for patients to breathe at night.
MMA surgery is an ideal option for symptomatic patients with an AHI above 20 and who have not responded well to other forms of therapy such as oral appliances and CPAP. MMA surgery has a much higher success rate than other sleep apnea surgeries, including UPPP. MMA surgery should only be considered for patients who are in good health and who have a full understanding of the procedure and its likely results.
At Surgical Sleep Solutions, we have been performing MMA surgery for 25 years, and over the past 11 years have performed this procedure as an outpatient procedure. During this time, we have had a success rate of above 90 percent with no unplanned hospital admissions. Our treatment model results in shorter recovery times and a result that often allows patients to forego the use of their CPAP device.
In some cases, patients with severe sleep apnea may still have an above-normal AHI after surgery. In this case, an oral appliance is an excellent way to further treat symptoms after the MMA procedure. This is especially true if the patient chose the surgery because they had difficulty with CPAP therapy (for any number of reasons).
The Financial Aspects of OSA Surgery
Despite its many advantages for some patients, Maxillofacial-mandibular advancement surgery is understandably a more expensive treatment and solution than oral appliances and some other types of therapies. While the health and quality of life of the patient is of first importance, patients are understandably concerned with whether they can afford the procedure and which of the procedure’s costs are covered by their health insurance policy. We have been successful in obtaining insurance coverage for the majority of our patients. Originally, our outpatient treatment model, which takes place in our private facility, was developed so that the patient could benefit from having a single surgical team comprised of experts on the procedure; an anesthesiologist specifically trained for the operation; and one-on-one, minute-to-minute nursing care following the operation. But not only did all three of these aspects greatly improve operating times, blood loss, postoperative pain thresholds, it also dramatically reduced the cost of the procedure. In addition our patients returned to light normal activity and a soft chewing diet in 7-10 days. A retrospective evaluation of the costs associated with outpatient delivery revealed that in most cases, the costs were reduced by more than half over having the procedure done in a hospital. In most cases, costs were reduced by more than half.
The combination of factors listed above has made the utilization of this procedure much more acceptable to the average patient. It is because of these factors that it is our procedure of first choice in the treatment of moderate to severe obstructive sleep apnea in patients who wish to eliminate CPAP therapy for any number of reasons.
Making the Right Choice for Patients
When seeking the best route to health for each patient, it is imperative to take the following steps:

  • Understand the patient’s medical history.
  • Learn about the patient’s sleep apnea presentation and severity.
  • Learn about the patient’s sleep apnea treatment history.
  • Start with less invasive and expensive treatments, such as oral appliances (for less severe cases).
  • Consider MMA surgery in cases of moderate to severe OSA and in cases where CPAP use is not possible or not preferred.
  • Analyze the effectiveness of your chosen treatment and act accordingly. Consider the use of oral appliances if mild symptoms persist following surgery.

Clark O. Taylor, BA, MD, DDS, has been practicing medicine and performing surgery for three decades and is the Founder and Director of Surgical Sleep Solutions. He received his bachelor’s degree from Wichita State University, his Doctor of Dental Surgery (DDS) from The University of Missouri, Kansas City, and his Doctor of Medicine (MD) from Northeastern Ohio Universities College of Medicine.
taylor_headshotDr. Taylor has been actively involved with the teaching of residents and postgraduate training fellows in the field of maxillofacial surgery. Throughout the course of his career, Dr. Taylor has maintained active academic appointments at major teaching hospitals where he provides training and continuing education for a variety of surgical specialties. He also treats patients and continues to educate physicians through his practices in Missoula, Montana, and Palm Desert, California.
 
 

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