Case Study By Michael Hutz, MD, and Tulsi Roy, MD
Case Study By Michael Hutz, MD, and Tulsi Roy, MD
A female patient in her 40s had a history of very severe of obstructive sleep apnea (OSA). She had failed multiple trials of continuous positive airway pressure (CPAP). She also had a history notable for bruxism (tooth grinding) and forward jaw posturing to help improve her daytime breathing.
The patient had significant maxillary and mandibular hypoplasia on physical exam. Her drug-induced sleep endoscopy (DISE) demonstrated complete concentric collapse (CCC) and lateral wall (LW) collapse.
Her apnea hypopnea index (AHI) was measured to be 65 (>30 is severe).
After extensive discussion of treatment options, she elected to proceed with maxillomandibular advancement surgery.
Treatment starts long before the patient arrives in the operating room. Following detailed preoperative physical examinations by Dr. Hutz and Dr. Roy, patients undergo preliminary foundational orthodontic treatment in preparation for jaw surgery.
After this initial treatment, a virtual surgical planning session takes place with clinical engineers and the patient’s orthodontist. Using their collective backgrounds in the surgical treatment of OSA, orthognathic surgery and aesthetic surgery, the desired forward movements and rotation of the upper and lower jaws are planned to preferentially advance the mandible and increase upper airway diameter. These movements are carefully designed with the overall facial profile in mind.
Together, Dr. Roy and Dr. Hutz focus on the three “B’s” of maxillomandibular advancement surgery — breathing, bite and (facial) balance. Based on this virtual plan, 3D-printed cutting guides and plates are fabricated to perform the surgery as precisely as possible, often to a fraction of a millimeter.
After intranasal intubation and induction of general anesthesia, both surgeons work together to perform performed bilateral Le Fort I osteotomies, bilateral sagittal split osteotomies, upper lip lengthening and septoplasty, with Botox injection to temporalis and masseter muscles to alleviate bruxism.
After maxillary disjunction and mobilization, custom plates are used to fixate the maxilla in its new position. After completion of the mandibular osteotomies, the mandible is mobilized, and a final splint is used to wire the maxilla and mandible into planned occlusion. The condyle is seated, and the mandible plates are secured. The wires are removed and the occlusion is tested by passively opening and closing the mouth to ensure the teeth fit together in the planned occlusion. The intraoral incisions are closed, tight dental elastics are used to maintain the final occlusion, and the patient is extubated.
The patient’s AHI returned to a normal level post-operatively (<5), and her snoring has fully resolved. She has had life-changing improvement in her sleep quality and daytime energy. Aesthetically, she notes improvement in facial balance, nasal tip support and jawline definition.
Maxillomandibular advancement surgery is generally considered the most effective surgical intervention for obstructive sleep apnea. It is a powerful tool that moves the upper and lower jaws forward to permanently increase the size of the upper airway and decrease collapse. Patients with OSA frequently have a skeletal contribution to their sleep disordered breathing, and MMA directly treats this underlying cause of their sleep apnea. Another key advantage of this surgery is that it is also highly effective in obese patients.
Dr. Hutz and Dr. Roy work together in one of the only multidisciplinary MMA programs in the country. They regularly treat patients recently diagnosed with OSA as well as those who have already failed other surgical therapies. Through their collaboration, Dr. Hutz and Dr. Roy can identify surgical candidates, create appropriate treatment plans and provide better form and function for their patients.
