saving faces|changing lives

Position Paper®

American Association of Oral and Maxillofacial Surgeons

Evaluation and Management of
Obstructive Sleep Apnea – Overview
Obstructive Sleep Apnea (OSA) is a common disorderinvolving collapse of the upper airway during sleep. This
repetitive collapse results in sleep fragmentation, hypoxemia, hypercapnia, and increased sympathetic activity,
leading to a host of detrimental systemic medical conditions including hypertension, stroke, congestive heart
failure, excessive daytime sleepiness, diminished cognitive function and impaired quality of life. It is estimatedthat upwards of 18-20 million adults in the US require
treatment for this disorder; thereby making it a significant
public health problem.
OSA occurs over a wide continuum of airway narrowing.
Patients with milder forms of apnea may require lessintensive intervention when compared to patients withmore severe obstructive pathology. As the upper airway
anatomy is in intimate relation to (and in function with)the facial region, oral and maxillofacial surgeons possess unique knowledge and training in upper airway andfacial anatomy, physiology and surgery. As such, they are
uniquely qualified to provide important diagnostic input—
through physical examination and imaging studies—into
the evaluation of patients suspected of having OSA. Using
all available data, the diagnosis of OSA is ultimately madeby a qualified physician who is trained in sleep medicine.
In most adult patients with moderate to severe OSA,
continuous positive airway pressure (CPAP) is the first line
treatment. Successful long-term treatment of OSA with
CPAP is difficult to achieve, however, and fewer than 50%of patients on CPAP are adequately treated (as defined by 4hours of use 70% of nights [Weaver, TE, Level 2 evidence
and Kribbs, NB, Level 2 evidence]). It is therefore important that other treatment options are available to patientswith OSA.
Oral appliances have been shown to be an effective
therapy in a significant percentage of patients with mild tomoderate OSA. While not considered a first-line treatment
in patients with severe OSA, custom-made oral appliances
may be indicated for use in patients with severe OSA who

PAGE 1 Evaluation and Management of Obstructive Sleep Apnea

have failed first-line treatment with CPAP. Oral appliances
should be fitted by qualified dental personnel who aretrained and experienced in the overall care of oral health,
the temporomandibular joint, dental occlusion and associated oral structures (Kushida et al 2006). Oral and maxillofacial surgeons who have received the requisite experienceand training to provide oral appliance therapy are qualified
to provide this therapy to patients with OSA.
Surgical procedures may be considered as secondary treatment for OSA when the outcome of non-surgical therapy isinadequate, such as when the patient is intolerant of CPAP,
or CPAP therapy is unable to eliminate OSA. Surgery may
also be considered as a secondary therapy when there is aninadequate treatment outcome with an oral appliance (OA),
when the patient is intolerant of the OA, or the OA therapy
provides unacceptable improvement of clinical outcomesof OSA. Surgery may also be considered as an adjuncttherapy when obstructive anatomy or functional deficiencies compromise other therapies or to improve tolerance ofother OSA treatments [Epstein, EJ]. Surgery for OSA has
been shown to improve sleep disordered breathing, as wellas important clinical outcomes, including improvement
in sleepiness and quality of life. Oral and maxillofacial
surgeons utilize a variety of hard and soft tissue surgicaltreatments in the management of OSA. Outside of tracheostomy, maxillomandibular (Jaw) advancement surgery
is considered to be the most effective (and often the mostwell-accepted) therapy for severe obstructive sleep apnea.
In the clinical guidelines for evaluation, management
and long-term care of OSA in adults, it is recommended
that evaluation for primary surgical treatment be considered in select patients who have airway narrowing andanatomy that is surgically correctible, and in patients inwhom nonsurgical therapies, including continuous positive airway pressure (CPAP) therapy, are inadequate or
not tolerated by the patient. (Epstein, EJ, Evidence BasedClinical Guideline). While coordination of care with othermedical specialists is emphasized in both pediatric andadult patients, surgical treatment of severe, life-threatening

pediatric sleep disordered breathing may require facialskeletal (maxillofacial) procedures, such as distractionosteogenesis, in order to affect airway expansion.
Oral and maxillofacial surgeons receive extensive training
during their residencies in jaw advancement surgery andtechniques, as well as in the medical and perioperative
surgical management of these patients. The AAOMS advocates for routine OMS involvement and participation on
the sleep apnea treatment team, and supports the development of multidisciplinary comparative effectiveness trials
for management of the OSA patient.
References:
1. Epstein,EJ,(Chair), Kristo,D, Strollo, Jr.PJ, Clinical Guidelines for
the Evaluation, Management and Long-term Care of Obstructive
Sleep Apnea in Adults. J Clin Sleep Med 5(3):263-79, 2009.
2. Weaver TE, Grunstein RR; Adherence to continuous positive airway
pressure therapy: the challenge to effective treatment, Proc Am Thorac Soc. 5(2):173-8, 2008
3. Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am
Rev Respir Dis. 147:887-95.1993.
4. Kushida et al. Practice parameters for the treatment of snoring andobstructive sleep apnea with with oral appliances: an update for2005. Sleep 2006; 29: 240-3
5. Caples, SM, Rowley, JA, Prinsell, JR, et al: Surgical Modifications ofthe Upper Airway for Obstructive Sleep Apnea in Adults: A Systematic Review and Meta-Analysis. SLEEP 33 (10): 1396-1407, 2010
6. Aurora, RN, Casey, KR, Kristo, D. et al: Practice Parameters for theSurgical Modifications of the Upper Airway for Obstructive Sleep
Apnea in Adults. SLEEP 33 (10): 1408- 1413, 2010

© 2013 American Association of Oral and Maxillofacial Surgeons.
No portion of this publication may be used or reproduced without
the express written consent of the American Association of Oral andMaxillofacial Surgeons.

PAGE 2 Evaluation and Management of Obstructive Sleep Apnea

Position Paper