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Obstructive Sleep Apnea and Maxillomandibular Advancement
Contact OLYMPIA MEDICAL CENTER (800) 547-5189
Surgical Options: MAXILLOMANDIBULAR ADVANCEMENT
Most common cause of sleep apnea is the obstruction of the upper airway at the base of the tongue and soft palate. The goal of surgical procedures is geared to relief the obstruction. The surgical options for a Sleep Apnea patient may range from procedures involving nasal, soft palate/throat, or base of tongue, facial skeletal surgery also known as maxillomandibular Advancement (upper and lower jaw surgical advancement) to correct the airway passage during sleep.
Maxillomandibular Advancement is the most successful operation for alleviation of sleep apnea. Data in the medical literature shows that it has the highest success rate of any other sleep apnea surgical procedures. The success rates are in the 90th percentile.
Maxillomandibular Advancement procedure is performed by Joseph Broujerdi, M.D., D.M.D. at Olympia Medical Center to correct moderate to severe or refractory sleep apnea. Dr. Broujerdi will move both the upper and lower jaws forward, as is done for the correction of dento-facial deformities (this is known as Orthognathic Surgery or Corrective Jaw Surgery) This corrective operation not only increases airway space to cure sleep apnea, but at the same time, in many patients, can balance facial bone harmony which is often the cause of sleep apnea.
The surgical options for a Sleep Apnea patient may range from procedures involving nasal, soft palate/throat, or base of tongue, to maxillomandibular expansion -- upper and lower jaw surgeries to correct the airway passage during sleep.
Pre-operative airway analysis shows a narrow & collapsed airway in a patient with severe obstructive sleep apnea with before pictures
Post-operative airway analysis shows a wide patent airway in the same patient after Maxillomandibular Advancement and after pictures
Nasal surgeries vary from removing nasal polyps, nasal turbinates, and correcting deviated nasal septum. Palate/Throat surgeries include reducing the uvula/soft palate and/or removing tonsils & adenoids -- this reduces or removes snoring without effecting speech. Also, the base of the tongue sometimes needs to be moved forward with the chin, to increase airway space, or reduced, with a special laser, without affecting speech as well.
[Click here for information about Snoring]
Uncomfortable with face masks?
In the event that various techniques and devices are unsuccessful due to physically related issues, Olympia Medical Center will arrange for you to meet a physician who specializes in sleep disorders to review alternative treatments. If you are uncomfortable with your sleeping solutions, Olympia Medical Center can help you with Obstructive Sleep Apnea Surgery:
· Septoplasty
· Partial Turbinectomy
· Nasal Reconstruction
· Radiofrequency Reduction
· Uvulectomy
· UPPP
· Lateral Pharyngoplasty
· Pillar Procedure
· Genioglossal Advancement
· Maxillomandibular Advancement
· Maxillomandibular Expansion
· Hyoid Myotomy and Suture Suspension
· Distraction Osteogenesis
· Tracheostomy
Non-Surgical Options to Treat Sleep Apnea
The two most common and successful non-surgical approaches to treat Sleep Apnea include the:
1. Continuous Positive Airway Pressure (CPAP) Mask or Bilevel Positive
Airway Pressure (BiPAP) Mask.
2. Oral Appliance Therapy or Mandibular Repositioning Device.
The CPAP or BiPAP mask is a nighttime therapy that delivers a small amount of compressed air pressure through a mask worn over the nose and mouth during sleep. This pressurized air prevents the airway of the sleeper from collapsing so that air flows freely into the lungs. Through Oral Appliance Therapy, a "bite-guard" type splint device is worn in the mouth of the sleeper during the night which advances the lower jaw forward. Since the tongue is attached to the lower jaw, this adjustable movement pushes both jaw and tongue forward during sleep, aiding the sleeper in better breathing and allowing more unobstructed air down the sleeper's throat and into his lungs. Other treatment options include nasal appliance and oral &
pharyngeal exercise.
Medical Management:
· CPAP/ Nasal CPAP
· BiPAP
· Weight loss
· Sleep hygiene
· Dental Appliance/ Mandibular Repositioning Device
· Nasal Appliance
· Oral & Pharyngeal Exercise
General Indications for Medical or Surgical Management:
Excessive Daytime Sleepiness (EDS)
Apnea Hypoapnea Index (AHI) >20
Oxygen saturation < 90%
Arrhythmias and Cardiac disease
Negative esophageal pressure, and increased negative pressure than -10 cm H20 during sleep
The Benefits of Correcting Sleep Apnea
Through either surgical procedures or non-surgical treatments, patients who have been successfully treated for Sleep Apnea will dramatically improve the quality of their lives. They will be less drowsy during the daytime, note increased memory and concentration, see better work performance and a happier mood, and experience less health risks such as significant heart problems, high blood pressure or strokes.
What is Snoring?
During sleep, the throat muscles relax, the tongue falls backward, and the throat becomes narrow and "floppy." As an individual breathes, the walls of the throat begin to vibrate. These vibrations lead to the characteristic sound of snoring. 90 million Americans report snoring. Males were more likely than females to report snoring at least a few nights a week (42% vs. 31%). Not all patients whom snore have sleep apnea. The treatment for patients who snore is slightly different than patients whom their snoring is associated with sleep apnea. Snoring is a major social problem for the individual sharing the bed with the snore. Over time just simple snoring may turn into Obstructive sleep apnea if not controlled or treated. Snoring could be the initial sign of future Obstructive Sleep Apnea.
What are the risk factors for Snoring?
Snoring usually becomes more serious with age. It can lead to fragmented and un-refreshing sleep which translates into poor daytime function (tiredness and sleepiness). There are several factors which facilitate snoring such as:
1. The natural aging process leads to the relaxation of the throat muscles
2. Anatomical abnormalities of the nose and throat
3. Sleep position
4. Alcohol
5. Muscle relaxants pills
6. Obesity.
What are the health risks of Snoring?
Habitual snorers can be at risk for serious health problems. Obstructive sleep apnea is an illness that is often associated with chronic snoring. This condition creates several problems, including:
Long interruptions of breathing (more than 10 seconds) during sleep caused by partial or total obstruction or blockage of the airway. Serious cases can have total blockage episodes hundreds of times per night. Frequent waking from sleep, even though he or she may not realize it. Snorers with obstructive sleep apnea sleep lightly to try to keep their throat muscles tense enough to maintain airflow. Blood oxygen levels are often lowered, which causes the heart to pump harder and blood pressure to rise. The result is a poor night's sleep, which leads to drowsiness during the day and can interfere with the persons quality of life. Prolonged suffering from obstructed sleep apnea will result in higher blood pressure and may cause enlargement of the heart, with higher risks of heart attack and stroke.
What are the treatment options for Snoring?
The main treatment for snoring is to prevent the main risk factors for snoring are preventable, as well as good sleep hygiene. Any anatomical abnormalities can be treated with minor to moderate surgical procedures. The doctors will know where your main level of obstruction is after your clinical work up. The doctors will gear their treatment toward each patient separately. There are alternatives and conservative measurements as well.
1. Septoplasty, or correction of deviated septum
2. Turbinectomies, reduction of over sized air filters
3. UPPP
4. Pillar Procedure
5. Radiofrequency of;
a. Turbinates
b. Soft Palate
c. Base of Tongue
Simple Tips to a Good Night Sleep:
Restrict intake of caffeine (i.e. coffee, tea, soft drinks, chocolate) and nicotine (i.e. cigarettes and tobacco).
Do not use alcohol as a sleep aid. While it may help you fall asleep, it will severely compromise the quality of your sleep.
Avoid the use of sleeping pills and antihistamines prior to bedtime.
Avoid eating heavy meals 3 hours before bedtime.
Maintain a regular exercise routine, but complete your routine at least three hours prior to bedtime.
Utilize your bed exclusively for sleep. Avoid using your bed to do work.
If you are an insomniac, avoid napping during daytime hours.
Create a consistent enjoyable bedtime routine (such as stretching, massage, bathing).
Sleep on the side position rather than in a supine position in order to prevent turning. Sew a pocket with a tennis ball in the back of your pajamas.
If snoring disturbs an individual and or family member, consult a sleep specialist at Olympia Medical Center as the snoring may be an indicator of obstructive sleep apnea (OSA).
What is Sleep Apnea?
Quite simply, cessation of breathing during sleep. A normal person likely stops breathing up to 5 times an hour during sleep. However, if someone stops breathing more than 5 times, they suffer from one form of Sleep Apnea. There are three forms of Sleep Apnea:
1. Obstructive Sleep Apnea (OSA) the most common form, occurs when tissues and muscles in the throat and the tongue collapse and block the airflow to the lungs during sleep. Despite efforts to breathe, there is no airflow, so people with OSA struggle to breathe again and again and start choking, waking up repeatedly and making normal sleep impossible. This is highly stressful on the heart, because the rest of the organs in the body are not getting enough oxygen.
2. Central Sleep Apnea (CSA) a neurological result of the brain not signaling the body to breathe.
3. Mixed Sleep Apnea is a combination of OSA and CSA.
Obstructive Sleep Apnea (OSA) is a Sleep Disordered Breathing (SDB) which has become prevalent as the medical fields expands on there understanding of this sleep disorder. OSA is both the most often seen and most severe type of sleep apnea. OSA affects 2% - 5% of the US population and 20 million Americans suffer from this airway disease. Men are affected more than females (ratio of 4 to 1). For individuals with OSA, the muscles of the base of the tongue, soft palate and uvula become too relaxed and block the airway during sleep, causing cessation of breathing to occur typically lasting from ten to sixty seconds. When breathing becomes shallow it is called Hypoapnea. Complete cessation of breathing is known as Apnea.
Snoring is the loud sound the throat muscles make as air passes in a turbulent fashion by them. Snoring is a symptom of OSA and does not indicate sleep apnea by its self. As the oxygen level in the blood drops, the brain is signaled to awaken for a deep breath and deep sleep is interrupted. This interruption activates the throat muscles and forces the individual to gasp for air in their sleep. Every time breathing becomes shallow or stops, oxygen level in the red blood cells drops, this will causing the thickening in the blood vessel walls over time and increases the blood pressure which will make the heart work harder. The constant awaking of the brain during deep sleep will causes the general symptom of fatigue and grogginess in the mornings. Untreated OSA may cause Hypertension (increased blood pressure), Diabetes Mellitus, Heart Attacks, Strokes and Gastro-Esophageal Reflux Disease (GERD).
Olympia's sleep disorder team works very closely with Physician Sleep Specialists to treat patients wearing face mask devices such as the Continuous Positive Airway Pressure device (CPAP) or Bilevel Positive Airway Pressure (BiPAP) with OSA. There are multiple options including a variety of procedures from Radiofrequency soft tissue reduction to soft palate surgery, base of the tongue surgery (genioglossal advancement) and complex double jaw advancement to open and create more airway space. Olympia surgeons also performs nasal airway surgery to open any nasal obstruction such as septoplasty, turbinate reduction and spreader cartilage grafts for patient whom can not used their nasal CPAP or BiPAP device.
Symptoms of Sleep Apnea:
Loud, habitual snoring
Witnessed pauses in breathing during sleep
Excessive daytime sleepiness
Gasping/choking during sleep
Frequent daily napping
Frequent awakenings during sleep
Morning headaches
Dry mouth in the mornings
Personality changes
Sleep Centers
Your physician at Olympia Medical Center may make an evaluation based on your signs and symptoms or may refer you to a Sleep Disorder Center.
These Sleep Disorder Centers will have a specially equipped section in their facility designed for overnight sleep studies where highly trained technicians using the latest in state of the art monitoring equipment are able to monitor, observe and record such processes as sleep patterns, heart and respiratory activity and body movements.
Testing for Sleep Apnea
A Sleep Disorder Specialist affiliated with Olympia Medical Center can help you decide on your need for further evaluation and will help you determine whether surgical options will benefit you. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Physicians from an array of medical fields work closely together to provide patients with a comprehensive diagnosis and treatment options. The Sleep Disorder Center is also equipped with EKG, PFT (In-House), X-Ray, CT scan and MRI in the same facility for precise monitoring and the convenience of our patients.
Tests to detect sleep apnea may include:
1. Nocturnal polysomnography (sleep study). During this test, you're hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.
Portable monitoring devices. Under certain circumstances, your doctor may provide you with simplified tests to be used at home to diagnose sleep apnea. These tests usually involve measuring your heart rate, blood oxygen level, airflow and breathing patterns. If you have sleep apnea, the test results will show drops in your oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may be able to prescribe a therapy without further testing. Portable monitoring devices don't detect all cases of sleep apnea, so your doctor may still recommend a polysomnogram even if your initial results are normal.
2. Upper Airway Analysis. A 3 dimensional upper airway radiographic films are obtained with a Cone Beam Cat Scan (low dose radiation Cat Scan). The nasal and upper airway is analyzed for volume, surface area, blockage and choke points along the breathing tube. This exam will assist your doctors to determine the best treatment options for you.
3. Nasopharyngeal Endoscopy. A small flexible camera in inserted to view the nasal and throat airway passage. The exam is preformed under local anesthesia while the patient is laying on their back to mimic sleep position. This exam will assist your doctor in visualizing the nasal and throat soft tissue and muscles during real function. This will help determine the rigidity or laxity in throat soft tissue.
If you have obstructive sleep apnea, your doctor may refer you to an sleep apnea surgeon to rule out any blockage in your nose or throat. An evaluation by a heart doctor (cardiologist) or a doctor who specializes in the nervous system (neurologist) may be necessary to look for causes of central sleep apnea.
JOSPEH A. BROUJERDI, M.D., D.M.D.
Medical Director
Dr. Joseph Broujerdi is the medical director of the sleep apnea program at Olympia Medical Center.
Dr. Broujerdi is a Cranio-Maxillofacial Surgeon sub-specializing in Obstructive Sleep Apnea Surgery. He is board certified by the American Board of Oral & Maxillofacial Surgery and the American Board of Plastic Surgery. He is also a member of the American Society of Maxillofacial Surgeons, American Society Craniofacial Surgery, and American Association of Oral & Maxillofacial Surgeons.
He is a graduate of the University of Pennsylvania School of Dental Medicine and State University of New York (SUNY) Downstate Medical School.
Dr. Broujerdi’s trainings include Craniofacial/Pediatric Plastic Surgery at Stanford University Medical Center/Lucile Salter Packard Children's Hospital in Palo Alto California, Plastic & Reconstructive Surgery at Wayne State University/Detroit Medical Center in Detroit Michigan, General Surgery and Oral & Maxillofacial Surgery at SUNY Downstate/Kings County Hospital Center in Brooklyn New York.
Dr. Broujerdi is active in clinical research and new developments in the field of Sleep Apnea, Maxillofacial and Craniofacial Surgery, contributed to peer-reviewed journals, and co-authored a book chapter on Maxillofacial Surgery. He has given presentations and spoken at national and international conferences.
If you want more information on Maxillomandibular Expansion
and other Obstructive Sleep Apnea(OSA) options,
contact Olympia Medical Center at (800) 547-5189.
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