Due to anatomical variations, a small percentage of the population will not be suitable for treatment with oral appliances. Most of these patients have severe sleep apnea, whereby, they stop breathing for more than 30 times per an hour. In these cases, a double jaw surgery is performed with both the upper jaw (maxilla) and lower jaw (mandible) moved forward a minimum of 10mm to permanently enlarge the airway to allow patients to breathe properly when they sleep . The recovery process for the surgery is about 2 weeks and the patient will need orthodontics treatment before, during and after surgery to make sure that the jaws fit together and the bite is comfortable. The jaw surgery procedure is usually performed on adults in a hospital surgery center such as Stanford under general anesthesia. The patient will need a consult with a sleep surgeon who does oral maxillofacial surgery and who will work closely with the orthodontist to coordinate the surgery.
Other types of skeletal surgery include Distraction Osteogenesis for Maxillary Expansion (DOME), which helps with nasal breathing and provides more space for the tongue after the palate is widened. The purpose of the DOME procedure, is to transform a narrow palate that is associated with nasal obstruction and crowded teeth to a widened palate and so a widened base of the nasal cavity, which will reduce nasal obstruction and allow air to flow freely.
In the medical community, CPAP and soft tissue surgery have been the main methods of treatment. However, evidence has shown that any improvement gained from soft tissue surgery is not lasting with high chance of relapse and has only improvement for a limited period of time. Excessive soft palate tissue frequently causes airway obstruction leading to obstructive sleep apnea and this is most commonly treated with a uvulopalatopharyngoplasty.
This procedure removes tissue from the palate and/or the back of the throat to increase airway size. However, there are potential significant complications associated with uvulopalatopharyngoplasty, such as foreign body sensation — a feeling that something is in the back of the throat while swallowing — and velopharyngeal insufficiency — liquids or food escape into the nose while drinking or eating. Post-operative pain can be significant, especially when combined with a tonsillectomy.
Occasionally, turbinate reduction by radiofrequency may be performed in conjunction to enlarge the nasal airway. In general soft tissue surgeries is not as effective and will require combination therapies with oral appliances.
It is important to note that obstructive sleep apnea affects up to 10% of children.The primary soft tissue surgery treatment for children with obstructive sleep apnea is adenoidectomy and tonsillectomy. In children and young adults, a narrow maxilla may be expanded with customized expanders without surgery such as the DOME as the facial bone remains fairly soft. This will reduce sleep apnea in children and prevent other health problems from developing. Symptoms of obstructive sleep apnea in children may consist of restless sleep, sweating during sleep, snoring, night terror, sleepwalking, bed wetting, daytime fatigue, hyperactive behavior similar to ADHD and poor school performance due to an inability to concentrate. Growth hormones are secreted during sleep and it is extremely important for children to get enough deep sleep to allow proper growth and development . Hence, it is imperative to treat obstructive sleep apnea in Children so that surgery can be minimized or prevented in the future.