UPPP & Maxillomandibular Advancement Effects on OSA

Dr. Wolford discusses results of simultaneously performed modified uvulopalatopharyngoplasty (UPPP) and double jaw surgery for advancement of the maxillomandibular complex in a counter-clockwise direction for correction of obstructive sleep apnea.

Modified Uvulopalatopharyngoplasty and Simultaneous Counter-Clockwise Maxillomandibular Advancement

by Marcos C. Pitta, DDS; Pushkar Mehra, BDS, DMD; Larry M. Wolford, DMD

Purpose:
To present the results of simultaneously performed modified uvulopalatopharyngoplasty (UPPP) and double jaw surgery for advancement of the maxillomandibular complex in a counter-clockwise direction for correction of sleep apnea.

Patients and Methods:
Eight patients (5 F, 3 M) having an average age 48.5 years (range 40 to 62), and with a diagnosis of obstructive sleep apnea based on presurgery polysomnography were treated with simultaneous modified UPPP and double jaw surgery. All patients had a history of snoring, daytime somnolence, and used C-PAP machines during sleep preoperatively. Average presurgery respiratory distress index (RDI) was 38.3 (range 33.8 to 46.8). Diagnosis included hypertrophic uvula, narrow faucial pillars, decreased oropharyngeal airway, and a dentofacial deformity.

All patients underwent segmental (3-piece) Le Fort 1 osteotomies with porous block hydroxyapatite grafting and rigid fixation, bilateral mandibular sagittal split osteotomies with rigid fixation, and modified UPPP with lateral inversion flaps. The maxillomandibular complex was advanced in a counter-clockwise direction by decreasing the occlusal plane (OP) in all cases. Presurgery (T1), immediate post surgery (T2), and longest follow-up (T3) acetate tracings of lateral cephalograms were used to calculate surgical change (T2-T1) and horizontal and vertical long-term stability (T3-T2) at Point A, Genial tubercles, mesial cusp tip of the maxillary first molar, and incisal tip of the maxillary central incisor.

Posterior airway space (PAS) change was calculated by measuring the narrowest airway dimension from the posterior pharyngeal wall to the tongue base and soft palate.

Results:
The average patient follow-up was 12 months (range 8 to 20). The average maxillary advancement at point A was 5.5mm (range 4 to 8), and the average mandibular advancement at the genial tubercles was 10.1 mm (range 8 to 14). The average decrease in OP was 7.5 degrees (range 2 to 10). Horizontal and vertical relapse at all measured landmarks was less than 0.5 mm. Long-term (T3-T1) PAS average increase change was 5.7 mm (range 4 to 7) at the tongue base, and 4.5 mm (range 4 to 6 mm) at the soft palate. The average increase in PAS was 55.5 % (range 44 to 70) of the mandibular advancement. The average change in soft palate/uvula length post surgically was – 8.2 mm (range –6 to -10).

Angulation of the soft palate was found to change by an average of 8.5O (range 6 to 12) in a downward and forward direction. None of the patients suffer from sleep apnea symptoms or use C-PAP machines post surgically. Vascular compromise of maxillary segments,  adverse speech/phonation changes, velopharyngeal incompetence, or palatal stenosis were not seen in any case.

Conclusions:
When indicated, the modified UPPP can be performed simultaneously with maxillomandibular advancement with counter-clockwise rotation for correction of sleep apnea and dentofacial deformities at the same operation with predictable outcomes.

References:

  • Reiche O, Wolford LM, Pitta MC, et al: Posterior airway space changes after double jaw surgery with counter-clockwise rotation. J Oral Maxillofac Surg 54: 96, 1996
  • Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea syndrome: A surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac Surg 51: 742, 1993