What is Sleep Apnea?

Corrective jaw surgery, or “Orthognathic” jaw surgery, is performed to correct facial skeletal abnormalities, misaligned jaws, and dental irregularities. While a patient’s appearance may be dramatically enhanced as a result of orthognathic surgery, corrective jaw surgery is performed primarily to correct functional problems, including the relief of facial pain, headaches, snoring and obstructive sleep disorders, including sleep apnea.

Orthognathic jaw surgery may reposition all or part of the upper jaw, lower jaw and/or the chin. Patients with sleep apnea may require surgery of the upper jaw and lower jaw often called “double jaw surgery”, or Maxillo-Mandibular Advancement (MMA), or bimaxillary advancement.

Abnormality of the maxillofacial skeleton is a well-recognized risk factor of Obstructive Sleep Apnea (OSA). Sleep Apnea patients often have small, narrow, or recessed jaws that result in smaller airway dimension, which leads to obstruction. Maxillo Mandibular Advancement achieves enlargement of the entire upper airway through expansion of the skeletal framework that encircle the airway. The procedure involves of mobilizing the upper and lower jaws, and advancing them up to 10-12mm. The jaws are stabilized with titanium plates and screws in the advanced position. This procedure is technically very challenging as the bone cuts need to be precise, and the positioning of the teeth to match correctly after the advancement is critical. Patients sometimes have to have their teeth wired shut for several weeks while the bones heal. For MMA Surgery, the long-term success rates approach 90%. Very few surgeons are qualified to perform this procedure frequently due to the complexity, increased surgical risks and potential for complications. Dr Joseph is very skilled in Orthognathic Surgery and uniquely qualified to treat these maxillofacial abnormalities.

Snoring and Sleep Apnea

Snoring is a sound produced during sleep, usually from vibration of structures inside the throat.  Snoring may be a problem for your bed partner. However, it may be a sign of a more-serious problem called Obstructive Sleep Apnea (OSA) that can lead to sleepiness and fatigue during the day and create serious health problems.

Who is at risk for Sleep Apnea?

Risk factors include being male, overweight, and the natural aging process. Many structures of the head and neck can effect the risk of developing snoring and sleep apnea.

What are the causes of Sleep Apnea?

Typically, the snoring sound comes from the back of the roof of the mouth (soft palate and uvula), but successful treatment of snoring and obstructive sleep apnea is much more complex than just focusing on that one area. Different patients have different causes. The importance of identifying the causes and an individualized treatment plan is very important

How do I find out if I have Snoring or Obstructive Sleep Apnea?

Individuals with loud snoring or other symptoms like sleepiness during the day or fatigue should have a sleep study. A sleep study can be performed in a sleep lab or at home.  A sleep study will establish a diagnosis of snoring vs sleep apnea.

Why do we treat snoring?

Snoring alone, without sleep apnea has important effects on personal relationships and often disturbs the sleep of others. It can lead to fatigue, sleepiness, and decreased quality of life. Snoring may also directly affect the person who snores with health risks and sleepiness.

Why should I get treated for Obstructive Sleep Apnea?

There are three potential reasons to treat obstructive sleep apnea:

  • Snoring. Some patients (and bed partners) are more concerned with snoring than with the other two consequences of obstructive sleep apnea. Although the primary purpose of treating obstructive sleep apnea is not to improve snoring, it is often very important to patients and bed partners.
  • Health impacts. When blockage in breathing occurs, patients often have drops in oxygen levels and wake themselves up with a response like an adrenaline rush. This places stress on the cardiovascular (heart), pulmonary (lung), and endocrine (metabolism) systems. Obstructive sleep apnea is strongly associated with the risks of developing hypertension, stroke, heart attack, and early death. These risks are greatest in those with more severe sleep apnea.
  • Sleep disruption, fatigue, memory problems, and decreased quality of life. Sleep apnea can prevent patients from getting refreshing sleep because the blockage in breathing is often worse during deep sleep. Interestingly, the degree of sleepiness or other symptoms is not related to sleep study results, so that some patients with what is called mild obstructive sleep apnea can experience significant symptoms, and vice versa. The bottom line is that if patients are not getting good sleep, they need treatment to function well during the day.

Treatment for Snoring and Sleep Apnea

Conservative Treatment

  • Weight Loss can improve snoring and sleep apnea, especially in men, depending on the amount of weight loss. It is estimated that a 10% weight loss was associated with a 25% reduction in the severity of sleep apnea.
  • Avoid Sleeping on your back A bed partner often knows whether body position during sleep affects snoring, and a sleep study may determine how body position affects breathing patterns in sleep apnea.
  • Avoid Alcohol or other sedating medications within 3 hours of bed time because they produce muscle relaxation and other effects to worsen snoring, sleep apnea, and sleep quality.
  • Positive Airway Pressure (CPAP) works by delivering air pressure to prevent blockage of breathing in the throat. It is often the first-line treatment for obstructive sleep apnea because it works well in the ideal situation where patients can wear it and sleep comfortably through the night, every night. Unfortunately, many patients do not tolerate it well, and it is important that these patients undergo evaluation to improve compliance or seek alternative treatment.
  • Oral Appliances offer a non-surgical alternative for some patients with snoring or obstructive sleep apnea. Many dentists now have expertise in sleep dentistry and can identify patients who might benefit from these devices.

Surgical Treatment

Surgical treatment options must be individualized and focus on the areas that are responsible for snoring and airway narrowing or blockage. There are many procedures available to treat snoring and to enlarge and/or stabilize the airway.

Blockage of breathing in the areas of the nose, palate, and tongue and abnormalities of the maxillofacial skeleton (jaws) are usually responsible for the problem. Sometimes, more than one of these areas may be responsible and accurate identification and treatment is critical.

  • Nasal surgery,
  • Turbinate reduction and Septoplasty
  • UPPP or Uvulo palato pharyngo plasty
  • Hyoid bone advancement
  • Tongue advancement
  • Tongue base reduction
  • Tracheostomy

Jaw Advancement – Maxillo-Mandibular  Advancement (MMA)

Abnormality of the maxillofacial skeleton is a well-recognized risk factor of Obstructive Sleep Apnea (OSA). Sleep Apnea patients usually have small, narrow jaws that result in diminished airway dimension, which leads to nocturnal obstruction. Maxillo-Mandibular advancement  “MMA” (sometimes called bimaxillary advancement or double jaw advancement) moves the upper (maxilla) and lower (mandible) jaws forward.  “MMA” enlarges the entire upper airway in both the palate and tongue regions through expansion of the skeletal framework that encircle the airway. Compared to other single procedures, it generally provides the greatest improvement (approximately 90%) in treating obstructive sleep apnea.

The Surgical Procedure – MaxilloMandibular Advancement

MAXILLO-MANDIBULAR ADVANCEMENT

Maxillo-Mandibular Orthognathic Surgery is generally performed in patients who have not shown improvement in obstructive sleep apnea after conservative treatment. In patients with jaw abnormalities it can be a first-line surgical treatment.

How is the procedure performed?

Orthognathic Surgery is performed in the Hospital operating room under general anesthesia.  All incisions are made inside the mouth, except perhaps for small incisions on the cheeks. Braces or arch bars are applied on the teeth. The surgical procedure consists of mobilizing the upper and lower jaws, and advancing then up to 10-12mm. The jaws are stabilized with titanium plates in the advanced forward position.  Typically the jaws are not wired together, although rubber bands may be used in maintaining a stable bite while healing.

Jaw advancement surgery is different in the patients with OSA, involving greater movements of the jaws, and is technically more difficult to perform. This procedure is technically very challenging and needs to be precise, and the position of the teeth to match correctly after the advancement is critical. Dr Joseph is very skilled and uniquely qualified to treat these maxillofacial abnormalities. Very few surgeons are qualified to perform this procedure frequently due to the complexity.

Patients are on a soft diet and avoid chewing for 4-6 weeks.

MaxilloMandibular Advancement achieves enlargement of the entire upper airway by expanding the skeletal framework that encircle the airway.  For MMA Surgery, the long term success rates approach 90%.

OSA patients undergoing jaw advancement surgery usually involving greater movements of the jaws, being technically more difficult to perform.