Abstract:
An implantable tissue suspension device and its method for use. The device includes first and second filamentary elements bonded together only at a central connection region such that first and second leading and trailing legs of the respective first and second filamentary elements extend outwardly from the central connection region. The method includes implanting the device such that the central connection region extends laterally across a patient&#39;s tongue and the first and second leading and trailing legs of the first and second filamentary elements extend through the tongue such that ends thereof are positioned external to the genioglossus muscle.

Description:
FIELD OF THE INVENTION 
       [0001]    The present invention relates generally to the field of medical devices, and more particularly to medical devices adapted to provide tongue suspension to treat sleep apnea conditions. 
       BACKGROUND 
       [0002]    Obstructive sleep apnea (OSA) is a medical condition that is caused by a blockage of the airway, which usually occurs when the soft tissue in the throat collapses and closes during sleep. According to the National Institutes of Health, OSA affects more than twelve million Americans. During each apnea event, the brain briefly arouses the sufferer in order to initiate the resumption of breathing. This type of sleep, however, is extremely fragmented and of poor quality. When left untreated, OSA may result in high blood pressure, cardiovascular disease, weight gain, impotency, headaches, memory problems, job impairment, and motor vehicle crashes. Despite the seriousness of OSA, a general lack of awareness among the public and healthcare professionals results in the vast majority of OSA sufferers remaining undiagnosed and untreated. 
         [0003]    In the human body, the air filled space between the nasal cavity and the larynx is referred to as the upper airway. The most critical part of the upper airway associated with sleep disorders is the pharynx. The pharynx has three different anatomical levels. The nasopharynx is the upper portion of the pharynx located in the back of the nasal cavity. The oropharynx is the intermediate portion of the pharynx containing the soft palate, the epiglottis, and the curve at the back of the tongue. The hypopharynx is the lower portion of the pharynx located below the soft tissue of the oropharynx. The oropharynx is the section of the pharynx that is most likely to collapse due to the high prevalence of soft tissue structure, which leaves less space for airflow. The hypopharynx lies below the aperture of the larynx and behind the larynx, and extends to the esophagus. 
         [0004]    As is well known to those skilled in the art, the soft palate and the tongue are both flexible structures. The soft palate provides a barrier between the nasal cavity and the mouth. In many instances, the soft palate is longer than necessary and it extends a significant distance between the back of the tongue and the posterior pharyngeal wall. 
         [0005]    Although the muscles relax throughout the body during sleep, most of the muscles of the respiratory system remain active. During inhalation, the diaphragm contracts and causes negative pressure to draw air into the nasal cavity and mouth. The air then flows past the pharynx, through the trachea and into the lungs. The negative pressure causes the tissue of the upper airway to deform slightly, which narrows the airway passage. In apneic patients, the soft palate, the tongue, and/or the epiglottis collapse against the posterior pharyngeal wall to block airflow into the trachea. As the airway narrows, airflow through the pharynx becomes turbulent which causes the soft palate to vibrate, generating a sound commonly known as snoring. 
         [0006]    During sleep, humans typically experience brief obstructions of airflow and/or small decreases in the amount of airflow into the trachea and lungs. An obstruction of airflow for more than ten seconds is referred to as apnea. A decrease in airflow by more than fifty percent is referred to as hypopnea. The severity of sleep disorders is measured by the number of apneas and hypopneas that occur during every hour of sleep. If apnea or hypopnea occurs more than five times per hour, most medical personnel diagnose the individual as having an upper airway resistance problem. Many of these patients exhibit symptoms related to sleep disorders including sleepiness during the day, depression, and difficulty concentrating. 
         [0007]    Individuals having ten or more episodes of apnea or hypopnea during every hour of sleep are officially classified as having obstructive sleep apnea syndrome. As the airway is obstructed, the individual makes repeated attempts to force inhalation. Many of these episodes are silent and are characterized by movements of the abdomen and chest wall as the individual strains to draw air into the lungs. Typically, episodes of apnea may last a minute or more. During this time, oxygen levels in the blood will decrease. Ultimately, the obstruction may be overcome by the individual generating a loud snore or awakening with a choking feeling. 
         [0008]    When an individual is awake, the back of the tongue and the soft palate maintain their shape and tone due to their respective internal muscles. As a result, the airway through the pharynx remains open and unobstructed. During sleep, however, the muscle tone decreases and the posterior surface of the tongue and the soft palate become more flexible and distensible. Without normal muscle tone to keep their shape and to keep them in place either alone or as a group, the posterior surface of the tongue, the epiglottis, and the soft palate SP tend to easily collapse to block the airway. 
         [0009]    One known treatment, commonly referred to as continuous positive airway pressure (CPAP), is currently the “gold standard” for treating OSA and operates by delivering air into a patient&#39;s airway through a specially designed nasal mask or pillow. The flow of air creates positive pressure when the patient inhales to keep the airway open. Although CPAP is considered by many to be an effective non-surgical treatment for the alleviation of snoring and obstructive sleep apnea, patients complain about discomfort caused by the mask and hoses, including bloating, nasal drying, and dry eyes. As a result, patient compliance for CPAP is only about 40%. 
         [0010]    Surgical treatments have also been used to treat OSA. One such treatment is referred to as uvulopalatopharyngoplasty, which involves removing about 2 cm of the trailing edge of the soft palate to reduce the soft palate&#39;s ability to flutter between the tongue and the pharyngeal wall. Another procedure uses a surgical laser to create scar tissue on the surface of the soft palate, which reduces the flexibility of the soft palate for reducing snoring and/or closing of the air passage. Yet another procedure, commonly referred to as cautery-assisted palatal stiffening operation (CAPSO), is an office-based procedure performed under local anesthesia whereby a midline strip of soft palate mucosa is removed, and the wound is allowed to heal whereupon the flaccid palate is stiffened. 
         [0011]    Surgical procedures such as those mentioned above continue to have problems. More specifically, the area of tissue that is surgically treated (i.e., removal of palatal tissue or scarring of palatal tissue) is often larger than is necessary to treat the patient&#39;s condition. In addition, the above-mentioned surgical procedures are often painful with extended, uncomfortable healing periods. For example, scar tissue on the soft palate may present a continuing irritant to the patient. Furthermore, the above procedures are not reversible in the event of adverse side effects. 
         [0012]    Surgical implants have also been used to treat OSA. One such implant system, sold under the name AIRvance by Medtronic, Inc. of Minneapolis, Minn., uses a titanium screw that is inserted into the posterior aspect of the mandible at the floor of the mouth. A loop of suture is passed through the tongue base and attached to the mandibular bone screw. The procedure achieves a suspension or hammock of the tongue base making it less likely for the base of the tongue to prolapse during sleep. Due to the high activity of the tongue during wakefulness, however, the suture component of this device may act as a cutting element within the tongue, causing device trans-location and ultimately a loss of efficacy of the procedure thereby requiring subsequent removal. 
         [0013]    Another known tongue suspension device similarly utilizes a bone screw in the mandible, but has the advantage of being adjustable. The device utilizes a flexible shape memory anchor within the tongue that is shaped similar to a grappling hook to engage the tissue within the tongue base. It is placed through a small incision in the sub-mental region and the suture is attached to a spool-like component attached to the mandible. Two to four weeks after healing, a small incision is made under the chin and a screw is turned to tighten the suture, thus pulling the device forward. While the device provides a simplified installation technique from within the sterile space, the anchors suffered from a high rate of device fracture and failure due to loading within the tongue musculature. Additionally, the risk of damage to the teeth or the nerve roots for the teeth is similar in both devices. 
         [0014]    U.S. Pat. No. 7,367,340 describes the use of an element that is anchored to the mandible and is capable of applying force within the tongue to prevent the tongue from collapsing during sleep. In the embodiments described, the device consists of an element that is attached to the mandible though drilling of the mandible to provide a rigid point of fixation. The method of attachment produces essentially the same risk to the dental anatomy and nerve structures within the mandible. 
         [0015]    A system is disclosed in US 2008/0208265, Frazier, et al., titled “system and method for percutaneous palate remodeling” discloses a looped tether element with one or more regions of an expanded diameter to reduce the risk of cutting through the tongue. This region is created to provide a flexible implant with a fixed expanded region, a balloon region or an in-situ expanding region. This method provides a large bearing surface on limited regions of the fiber. Additionally, this method requires the addition of an element to create the expanded region on the fiber. It is anticipated that this type of device will also be difficult to extract from the tongue tissues after healing has occurred since the portion buried on the tongue base is larger in cross section than the tracks remaining from the trailing ends of the looped tether. 
         [0016]    Given the disadvantages described above, there remains a need for a tongue suspension device that provides a high degree of flexibility, a large load bearing surface and the option of multi-point fixation. 
       SUMMARY OF THE INVENTION 
       [0017]    The present invention provides an implantable tissue suspension device including first and second filamentary elements bonded together only at a central connection region such that first and second leading and trailing legs of the respective first and second filamentary elements extend outwardly from the central connection region. In one embodiment, the central connection region is adapted to be implanted laterally within and across a portion of a patient&#39;s tongue, with the first and second leading and trailing legs of the respective first and second filamentary elements having a length sufficient to extend through the tongue and into the submetal space. 
         [0018]    The first and second filamentary elements may be made of a biocompatible, polymeric material, such as polypropylene, Poly(hexafluoropropylene-VDF), ePTFE, or Polyester. In another embodiment, the first and second filamentary elements may be made of an absorbable material, such as polydioxanone or polyglactin. In yet another embodiment, the first and second filamentary elements may be made of a combination of absorbable and non-absorbable materials. 
         [0019]    In yet further alternate embodiments, the first and second filamentary elements may be bonded together using ultrasonic welding, compression thermal welding, RF welding, or shrink tube welding, or alternatively may be bonded together using chemical, solvent or adhesive based techniques. 
         [0020]    Also provided is a method for treating obstructive sleep apnea including the steps of obtaining an implantable tissue suspension device having first and second filamentary elements bonded together only at a central connection region such that first and second leading and trailing legs of the respective first and second filamentary elements extend outwardly from the central connection region; implanting the central connection region of the tissue suspension device laterally across a patient&#39;s tongue; and passing the first and second leading and trailing legs of the first and second filamentary elements through the tongue such that ends thereof are positioned within submental space. 
         [0021]    In one embodiment, the free ends of the filamentary elements are attached to a tissue anchor located within the submental tissues. 
         [0022]    In an alternate embodiment, the free ends of one filamentary element are attached to a tissue anchor element within the submental space, and the free ends of the second filamentary element are attached to a structure separate from the tissue anchor element. 
         [0023]    The first and second filamentary elements may be made of a biocompatible, polymeric material, such as polypropylene, Poly(hexafluoropropylene-VDF) , or nylon, or may be made of an absorbable material such as polydioxanone or polyglactin. In yet another embodiment, the first and second filamentary elements are made of a combination of absorbable and non-absorbable materials. 
         [0024]    These and other objects, features and advantages of the present invention will be apparent from the following detailed description of illustrative embodiments thereof, which is to be read in connection with the accompanying drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0025]      FIGS. 1-3  illustrate the human anatomy; 
           [0026]      FIG. 4  illustrates an exemplary tissue suspension device according to the present invention; 
           [0027]      FIGS. 5   a  and  5   b  illustrate steps of an exemplary method for producing a device according to the present invention; 
           [0028]      FIG. 6  illustrates an alternate method for producing a device according to the present invention; and 
           [0029]      FIGS. 7 and 8  illustrate various anchoring points for the device of the present invention; and 
           [0030]      FIGS. 9-20  illustrate steps of exemplary methods for implanting the devices of the present invention. 
       
    
    
     DETAILED DESCRIPTION 
       [0031]      FIG. 1  shows a cross-section of a human head with anatomical structures including the nasal cavity N, bone B of the hard palate HP, the soft palate SP, the mouth M, the tongue T, the trachea TR, the epiglottis EP, the esophagus ES, and the posterior pharyngeal wall PPW. In the human head, an air filled space between the nasal cavity N and the larynx LX is referred to as the upper airway. 
         [0032]    The most critical part of the upper airway associated with sleep disorders is the pharynx PX. Referring to  FIG. 2 , the pharynx has three different anatomical levels. The nasopharynx NP is the upper portion of the pharynx located in the back of the nasal cavity N. The oropharynx OP is the intermediate portion of the pharynx containing the soft palate SP, the epiglottis EP, and the curve at the back of the tongue T. The hypopharynx HP is the lower portion of the pharynx located below the soft tissue of the oropharynx OP. The oropharynx OP is the section of the pharynx that is most likely to collapse due to the high prevalence of soft tissue structure, which leaves less space for airflow. The hypopharynx HP lies below the aperture of the larynx and behind the larynx, and extends to the esophagus. 
         [0033]    As is well known to those skilled in the art, the soft palate and the tongue are both flexible structures. The soft palate SP provides a barrier between the nasal cavity N and the mouth M. In many instances, the soft palate SP is longer than necessary and extends a significant distance between the back of the tongue T and the posterior pharyngeal wall PPW. 
         [0034]    Although the muscles relax throughout the body during sleep, most of the muscles of the respiratory system remain active. During inhalation, the diaphragm contracts and causes negative pressure to draw air A into the nasal cavity N and the mouth M. The air then flows past the pharynx PX, through the trachea TR and into the lungs. The negative pressure causes the tissue of the upper airway to deform slightly, which narrows the airway passage. In apneic patients, the soft palate SP, the tongue T, and/or the epiglottis EP collapse against the posterior pharyngeal wall PPW to block airflow into the trachea. As the airway narrows, airflow through the pharynx becomes turbulent which causes the soft palate SP to vibrate, generating a sound commonly known as snoring. 
         [0035]    During sleep, humans typically experience brief obstructions of airflow and/or small decreases in the amount of airflow into the trachea and lungs. An obstruction of airflow for more than ten seconds is referred to as apnea. A decrease in airflow by more than fifty percent is referred to as hypopnea. The severity of sleep disorders is measured by the number of apneas and hypopneas that occur during every hour of sleep. 
         [0036]    If apnea or hypopnea occurs more than five times per hour, most medical personnel diagnose the individual as having an upper airway resistance problem. Many of these patients often exhibit symptoms related to sleep disorders including sleepiness during the day, depression, and difficulty concentrating. Individuals having ten or more episodes of apnea or hypopnea during every hour of sleep are officially classified as having obstructive sleep apnea syndrome. As the airway is obstructed, the individual makes repeated attempts to force inhalation. Many of these episodes are silent and are characterized by movements of the abdomen and chest wall as the individual strains to draw air into the lungs. Typically, episodes of apnea may last a minute or more. During this time, oxygen levels in the blood will decrease. Ultimately, the obstruction may be overcome by the individual generating a loud snore or awakening with a choking feeling. 
         [0037]    Referring to  FIG. 2 , when an individual is awake, the back of the tongue T and the soft palate SP maintain their shape and tone due to their respective internal muscles. As a result, the airway A through the pharynx remains open and unobstructed. During sleep, however, the muscle tone decreases and the posterior surface of the tongue and the soft palate become more flexible and distensible. 
         [0038]    Referring to  FIG. 3 , without normal muscle tone to keep their shape and to keep them in place either alone or as a group, the posterior surface of the tongue T, the epiglottis EP, and the soft palate SP tend to easily collapse to block the airway A. 
         [0039]    It is well known that thermoplastic fibers or filamentary elements can be produced by extrusion and subsequent drawing to increase the straight tensile strength of the material. The draw ratio is a measure of the degree of stretching during orientation of a fiber or filament, and is expressed as the ratio of the cross-sectional area of the undrawn material to that of the drawn material. Typically, the use of higher draw ratios will produce fibers with great axial strength, but the flexibility of the fiber tends to be reduced. In order to produce fibers that have large surface areas for load bearing purposes, the draw ratio is reduced to increase the diameter of the fiber. Although the flexibility of the fiber when compared to high draw ratio fibers of the same diameter may increase as the draw ratio is reduced, elongation of these fibers due to tensile loading increases significantly. As the fiber yield strength is decreased due to reducing the draw ratio, the overall fiber diameter must be increased with low draw fibers to produce materials with similar overall yield force (not stress) for tissue loading without premature yielding. For the purposes of medical implants for tongue suspension, however, it is desirable to produce high yield strength fibers with reduced diameters that can provide a large load bearing surface. Thus, the requirements (high yield strength, low diameter) for an ideal fiber for a medical implant for tongue suspension are conflicting. 
         [0040]    The present invention, however, overcomes these limitations and achieves a fiber based medical implant for tongue suspension that has a high degree of flexibility while providing a large load bearing surface in one or more specific locations. 
         [0041]      FIG. 4  illustrates one embodiment of a tissue suspension device  100  according to the present invention. The tissue suspension device  100  includes at least first  102  and second  104  fiber or filamentary (used interchangeably) elements bonded together at one or more discrete connection regions  106 . The first and second filamentary elements may be produced as standard solid form extrusions from a variety of biocompatible, polymeric materials, such as non-absorbable thermo-set polymers such as polypropylene, Polyesters, Fluoropolymers, Polyvinylidene fluoride(PVDF), Poly(hexafluoropropylene-VDF) nylon etc. In the embodiments that utilize mechanical connections such as adhesive or crimp type connectors, materials such as rubbers, silicones, urethanes, thermoset polymers and metallic wire may be considered for use, Alternatively, the first and second filamentary elements may be produced through multi-stage extrusion and sintering as is done in the fabrication of ePTFE. In addition, the first and second filamentary elements may be produced from absorbable materials such as polydioxanone, polyglactin etc, or any suitable combination of absorbable and non-absorbable materials. For example, fibers may include absorbable coverings through processing such as coating and co-extrusion. Further, the fibers may have a fully round cross-section, or any suitable non-round cross sectional geometry such as elliptical or rectangular. 
         [0042]    The discrete connection region(s)  106  may be produced through typical bonding methods that are energy based or chemical, mechanical or solvent or adhesive based. For example,  FIGS. 5   a  and  5   b  illustrate a method of bonding the fibers together through the use of ultrasonic welding. The fibers  104 ,  102  are placed within a welding nest  120 , one on top of the other. An ultrasonic horn  122  is utilized to contact the material and apply vibrational energy to the stacked fibers. In the case of cylindrical fibers, the abutting edges of the cylinders serve as natural energy directors and the vibrational energy is transformed into frictional thermal energy which produces a localized weld without significant damage to the fibers. 
         [0043]    Alternatively, the fibers may be subjected to other forms of welding energy including compression thermal welding with heated dies, RF welding to provide very local welding at the interface of the two fibers or shrink tube lap welding. While the first three methods of welding provide welded joints, the use of the shrink tube welding may be preferable as it produces a solid, seamless welded region. Shrink tube welding is depicted in  FIG. 6 , and includes a shrink tube  130  that has a transition temperature (shrink temperature) that is greater than the melt temperature of the first and second fibers  102 ,  104 . Thus, as the shrink tube collapses/compresses at the transition temperature and exerts a compaction force on the fibers, the molten fiber polymer flows together and effectively welds. The shrink tube is subsequently removed, leaving the welded fibers. Additionally, the shape of the welded zone of material may be adapted to preferred geometries through the use of a non-uniform shrink tube or by confinement of the tube by horizontal compression. 
         [0044]    It may also be desirable to produce the tissue supporting device of the present invention through the use of adhesive or solvent along the interface of the first and second fiber in the discrete connection region. The adhesive may be curable/reactive, or it may be of the thermal melt type. 
         [0045]    When materials such as ePTFE are used, the discrete connection region(s) is created through the use of volume compaction and re-sintering of the material. ePTFE is formed as an expanded Teflon material with free volume located similar to a foam structure. The material is formed through a paste extrusion and is then subjected to a sintering process to cause bonding of the nodules of material to create a fiber with adequate strength and a high degree of suppleness. With ePTFE, the fiber is placed within compaction dies and is subjected to temperatures similar to those utilized in the sintering process, which enables fusion of the fibers at discrete locations. 
         [0046]    Particular applications of the devices of the present invention will now be described in detail with reference to  FIGS. 7 and 8 . As indicated previously, the devices described herein have particular application for tongue suspension for the treatment of OSA. Referring also back to  FIG. 4 , the first and second fibers  102 ,  104  are joined only at one or more discrete connection regions  106 . In the illustrated embodiment, the device includes a single discrete connection region centrally located between first  102   a,    104   a  and second  102   b,    104   b  ends of the first and second fibers respectively. As such, there remains a single fiber leading leg  105 ,  107  and trailing leg  109 ,  111  for each of the first and second filaments respectively on either side of the discrete connection region. The single fiber leading and trailing legs provide flexibility of typical monofilament fibers as they remain unaltered from the extruded condition. The volume of the combined fibers at the centrally located discrete connection region  106  provides an increased load bearing surface at the center of the tongue which also serves to minimize the risk of pull out.  FIG. 7  illustrates the tissue suspension device  100  implanted within the tongue T. The connection region  106  lies along an axis that is substantially perpendicular with an anterior-posterior axis of the tongue. The leading and trailing legs of the first and second fibers  105 ,  109 ;  107 ,  111  preferably extend toward to a substantially common fixation point  150  located within the posterior aspect of the mental tubercle, near the genio hyoid tubercle. The anchor may be either affixed to the soft tissues inferior to the mylohyoid muscle, or may be anchored directly to the mandible, slightly inferior to the genio hyoid tubercle. 
         [0047]    Referring now to  FIGS. 9-16 , the installation of the fiber element into the tongue with a common fixation point will be described in detail.  FIG. 9  provides an illustration of the human mandible  200  in a simplified form to enable clear visualization of the tongue T. The fiber element  100  with the needle  202  attached is provided for passage through the tongue T. Referring to  FIG. 10 , it can be seen that the needle is passed in a lateral direction with the punctures placed approximately one centimeter from the midline  204  of the tongue. Referring to  FIG. 11 , the needle  202  is passed entirely through the tongue until the bonded region of the fiber is located within the tissues of the tongue. The needle is then removed either by cutting the fiber or removing any other mechanical connection means that may be employed. As can be seen in  FIG. 12 , a lateral submental incision  206  is made to expose the musculature. A snare type trocar  210  is then utilized to create a pathway for the fiber to the pass through the tongue from the inferior incision, through the mylohyoid and genioglossus muscles and exiting through the mucosal surface of the tongue within the oral cavity. The snare type trocar consists of a shaft  208  mounted to the handle  214 . The shaft is produced with a tapered point  212  to enable passage without cutting the musculature. Additionally, the tip of the trocar preferably is produced with an eyelet feature  216  that is utilized to capture the fiber within the oral cavity. 
         [0048]    The snare is advanced through the tongue from the submental region to create a tunnel through the tissue. The tip of the snare is guided to the puncture site previously created in the lateral portion of the tongue mucosal surface. The snare tip is forced through the puncture and exits into the oral cavity alongside of the fiber element ends. In the case of the single point of fixation, the two free ends  104   a  and  102   a  are threaded through the eyelet portion  216  of the snare. The two ends are then pulled back through the mucosal puncture towards the point of fixation and preferably are passed through the anchor element  230  ( FIG. 15 ). Once the fiber ends from one side have been pulled through the tongue, the snare is advanced again from the submental incision through the tongue into the oral cavity through the second mucosal puncture as is illustrated in  FIG. 14 . The free ends of the fiber  102   b  and  104   b  are threaded through the eyelet and the free ends are again pulled through the mucosal puncture and through the tongue and associated anchor  230  as illustrated in  FIG. 15 . Tension is applied to the free ends of the fiber to advance the tongue base as is necessary and the free ends of the fiber are either tied in a knot  240 , clipped or clamped to the fixation anchor as illustrated in  FIG. 16 . 
         [0049]    Referring to  FIG. 8 , the first and second fibers may alternatively be anchored at more than one location or fixation point such as a soft anchor located as previously detailed and the hyoid bone. This enables creation of sling effects that are more stable and resist slippage relative to the location or original placement as the number of degrees of freedom of motion have been reduced. In this embodiment, the fiber is placed as previously described in the lateral passage illustrated in  FIGS. 9-11 . Incisions are then made in the submental region and also in the tissues that provide direct access to the hyoid bone. A larger submental incision made be created with increased tissue dissection to access the hyoid bone  250  or a separate incision made be made near the hyoid bone. The snare is advanced first from the submental incision near the anchor point and is passed into the oral cavity as previously disclosed through the mucosal punctures as is illustrated in  FIG. 17 . One free end of the fiber  102   a  is threaded through the snare and is pulled through the tissue to the anchor in the submental region. The snare is then passed though the tissues of the tongue from an origin point located near the hyoid bone. The tip is guided to the same puncture as was previously utilized for pulling free end  102   a.  Once the snare is within the oral cavity, the free end  104   a  is threaded through the eyelet as is shown in  FIG. 18 , and the free end  104   a  is pulled through the tissues of the tongue to the exit point near the hyoid bone. The procedure is repeated for free ends  102   b  and  104   b  resulting in fiber free end placement as illustrated in  FIG. 19 . 
         [0050]    Once the free ends have been passed through the tongue, the free ends  104   a  and  104   b  are attached to the hyoid bone either through the use of knots or through the use of bone anchors, hooks, clips, or adhesives. The remaining two free ends  102   a  and  102   b  are tensioned and the tongue base and hyoid bone are advanced to the desired position and the two ends are then attached to the anchor device  230 . The device may be knotted  240  directly as illustrated in  FIG. 20 , or alternative fixation devices including bone anchors, hooks, clips, adhesives or the like may be utilized to attach the free ends to the anchor. Unlike the single point of fixation, it can be seen that the tongue base and hyoid bone may be advanced simultaneously and the rotation of the tongue base may be altered favorably. 
         [0051]    Although illustrative embodiments of the present invention have been described herein with reference to the accompanying drawings, it is to be understood that the invention is not limited to those precise embodiments and that various other changes and modifications may be effected herein by one skilled in the art without departing from the scope or spirit of the invention.