Surgical Treatment Of Sleep Apnea And Jaw Deformities

Presented by: Sabine Girod, MD, DDS, PhD
Associate Professor, Plastic and Reconstructive Surgery
Stanford University Medical Center
June 2, 2009

Lecture Overview:

• About one in every 15 people has obstructive sleep apnea, a condition that affects breathing during sleep.
• People with sleep apnea have a greater risk of stroke, heart disease, hypertension, arrhythmia, and stroke, and may be prone to accidents because of extreme daytime fatigue.
• Nonsurgical treatment can range from devices that open the sleeper’s nasal passages to a mouthpiece that repositions the jaw and a machine that uses a mask to force air pressure into airways.
• Soft tissue surgery includes the removal of tissue from the palate and throat, and implants to hold the tongue forward during sleep.
• Maxillo-mandibular advancement is a successful but invasive surgery that moves the jaw forward to enlarge the space behind the tongue and soft palate.

About one out of very four people—13 million Americans—have a condition known as obstructive sleep apnea (OSA), and many more don’t even realize they have this condition. OSA is the most common of all sleep disorders, and experts estimate that half the people who suffer from sleep apnea also have a snoring problem.

People with OSA experience extreme daytime fatigue throughout the day because their sleep is disrupted by recurrent episodes when their throat closes and they cannot pull enough air into their lungs. The muscles that hold the throat open while awake relax during sleep, allowing the throat to narrow and causing it to become blocked when trying to inhale. Obstructive apnea reduces the level of oxygen in the blood until the person awakes, which forces the air passage to open. This sleep-wake cycle may take place dozens of times a night, and sleeper has no idea it is happening.

“The brain says ’I need air’ and wakes you up. You start to breathe normally, and the brain says OK, and you fall back asleep. It’s a vicious cycle that you can’t escape,” said Sabine Girod, MD, DDS, PhD, director of oral and maxillofacial surgery at the Stanford Sleep Surgery Center who spoke about apnea surgery at a presentation sponsored by The Stanford Health Library.

This condition has a systemic effect on the body, since loss of sleep activates a protective adrenaline response, said Dr. Girod. People with untreated sleep apnea face a greater risk of stroke and are more likely to have heart disease, along with hypertension, arrhythmia, and stroke.

To determine whether a person does, in fact, have sleep apnea, physicians conduct a series of tests, including the Epworth Sleepiness Scale, a standardized questionnaire to evaluate levels of excessive sleepiness, and a session in a sleep study lab that assesses brain activity, muscle and eye movement, and heart function during sleep. These recordings are compiled into a system that grades the severity of the sleep apnea called an apnea-hypopnea index (AHI).

Patients with OSA are first treated nonsurgically: Many respond well to positional therapy to change their sleeping position, or weight loss, since obesity appears to exacerbate the problem. The most commonly prescribed treatment is continuous positive airway pressure (CPAP), a machine that delivers air pressure through a nasal mask that the patient wears while sleeping. The pressure keeps the throat open, allowing the patient to breathe normally all night.

Some patients also respond well to dental appliances, which bring the lower jaw forward to increase the size of the airway. This approach compares favorably to certain surgeries,” said Dr. Girod, since it mirrors the concept of moving the lower jaw into a position that keeps the air passages open.

For patients who require additional measures, the first step is Phase I surgery, which focuses on the soft tissue of the mouth and throat. Palate surgery involves a combination of tissue removal and tissue repositioning to increase the size of the airway without compromising normal function. Uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat, including the uvula, tonsils, and adenoids. These surgeries sometimes involve the use of radiosurgery to create scars in the tissue, making them less flexible and therefore less apt to overrelax into the air passages.

Dr. Girod was joined by Richard Goode, MD, former chair of the Department of Otolaryngology, who answered questions related to Phase I surgery.

Phase II surgery involves the bone. One type of Phase II surgery is tongue base suspension, in which surgeons insert a screw in the jaw that holds a sling in place to prevent the tongue from shifting backwards during sleep. A similar surgery is called a genioglossus advancement, in which a small window is cut in the front lower jaw to pull the back of the tongue forward, enlarging the air space behind it.

Dr. Girod is a specialist in maxillo-mandibular advancement, a more invasive surgery for OSA that moves the lower jaw forward about 10 to 15 millimeters. A titanium plate is used to stabilize the repositioned the jaw. Because the procedure not only corrects the compressed airways but also affects the person’s profile, she utilizes computer simulation to plan the operation, using three-dimensional virtual planning programs to anticipate the end result.

“Surgery is an effective way to treat OSA for certain patients,” said Dr. Girod, who showed several before-and-after photos of patients. “Studies have shown that this procedure has a 95 percent cure rate. It affects not only function but aesthetics, and most patients have been very happy with the results. But it is major surgery and it is not for everyone.”

About the Speaker
Sabine Girod, MD, DDS, PhD, is an associate professor in the Division of Plastic and Reconstructive Surgery and director of Stanford’s Oral and Maxillofacial / Sleep Surgery Center. She is also director of the Stanford Plastic Surgery Adult Clinic. An expert in oral and maxillofacial surgery, Dr. Girod has a special interest in refining virtual surgical simulations to plan surgical outcomes. She received her degree in dentistry from the University of Bonn in Germany and continued her medical training, residencies, and fellowship at Harvard Medical School, the University of Cologne, and Hannover Medical School in Germany.  She has been at Stanford since 2000.

For More Information:

Request a free information packet on this topic from Stanford Health Library

About Dr. Girod
http://med.stanford.edu/profiles/Sabine_Girod/

Stanford’s Division of Plastic Surgery
http://plasticsurgery.stanford.edu/

Stanford Sleep Disorders Clinic
http://med.stanford.edu/school/psychiatry/coe/

American Sleep Apnea Center
http://www.sleepapnea.org/

SleepQuest
http://www.sleepquest.com/sq_index.shtml