“Maxillomandibular advancement” (MMA) surgery is widely recognized to be a highly effective surgical intervention for the treatment and management of “obstructive sleep apnea syndrome” (OSAS) in patients where “continuous positive airway pressure” (CPAP) therapy is not applicable, is intolerant, or is unsuccessful.[1,2,3]
Currently, MMA is used routinely to treat OSAS in patients with either dentofacial deformities or abnormal facial morphology. The success rate fluctuates between 90% and 97%.[4,5]
The objective and subjective outcomes following MMA surgery for the treatment of patients with OSAS, indicate that surgery can be highly successful and can eliminate the use of CPAP, improving the subjective outcomes and considerably decreasing the Apnea–Hypopnea Index (AHI) score.[6]
As objective measurements can be considered the pre and post operative ‘PSGs’ (polysomnographs), the airway morphology (airway volume and minimal cross-sectional area), the linear changes to ‘Pas B- Pogonion’ and the ‘PNS’ length in lateral cephalograms, in OSAS patients. The subjective outcomes are suggested by the Epworth Sleepiness Scale ‘ESS’ before and after MMA.[6,7,8]
None of the reported studies include a detailed documentation of the subjective and objective measurements of all treated patients with MMA as well as the efficacy of mandibular repositioning device (MRD) as an index for future MMA surgery.
The therapeutic efficacy of MMA in a patient can be shown by comparing the preoperative with the postoperative AHI score. Surgical success is defined by the percentage of patients with >50% reduction of the AHI to fewer than 20 events/h after the MMA surgery, whereas surgical cure is defined after the MMA surgery with AHI fewer than 5 events/h.
Suspected patients – suffering from OSAS – underwent polysomnography test, lateral cephalography, three-dimensional cone-beam computed tomography, and nasopharyngeal endoscopy. Furthermore, they underwent clinical evaluation and answered a questionnaire regarding their symptoms.
In our 3-year study, a total of 88 patients underwent polysomnography test, from which, sixty were diagnosed with OSAS with AHI >5, and CPAP was proposed to 39 patients with AHI >15. MRDs were used in 37 patients out of the total 60 patients in the list as well as in 24 patients with AHI <5 but with severe clinical symptoms.
The MRDs have been used as an alternative to CPAP and as an index for future surgery.
Our team has surgically treated 14 patients (MMA) with an average mean AHI of 23.35/h and an ESS score of 13.28/24, preoperatively, resulting to AHI of 4.34/h and ESS of 1.71/24, respectively, postoperatively. Significant parameters such as airway volume (cm3) (minimal cross-sectional area [mm2]), PAS B-Pogonion, and PNS length were calculated, and the results are shown in Table 2. It is remarkable that the mean length of PAS B-Pogonion postoperatively is <+9 mm. Overall, our results conclude to 71.42% cure rate and 92.85% success rate. In addition, none of the patients had any clinical symptoms after surgery. There are four out of 14 cases in this list that did not show surgical cure; more specifically, two out of four of these patients were over 55 years old with central sleep apnea and the other two patients presented an increased body mass index pre- and postoperatively, but all of them did not have any clinical symptoms [Tables 1–4].
Table 1.
Patient demographic data
| Patient number | Age (year) | Gender | MRD Preoperative | Concomitant procedure |
|---|---|---|---|---|
| 1 | 41 | Male | - | - |
| 2 | 52 | Male | - | - |
| 3 | 34 | Male | Yes | - |
| 4 | 20 | Male | - | Genioplasty |
| 5 | 36 | Male | Yes | - |
| 6 | 46 | Male | - | - |
| 7 | 39 | Male | Yes | Turbinectomy |
| 8 | 26 | Male | Yes | Turbinectomy and genioplasty |
| 9 | 29 | Male | Yes | Genioplasty |
| 10 | 63 | Male | - | Genioplasty |
| 11 | 31 | Male | Yes | - |
| 12 | 55 | Male | Yes | Genioplasty |
| 13 | 20 | Male | - | Genioplasty |
| 14 | 29 | Female | - | Genioplasty |
| Mean | 37.21 |
MRD: Mandibular repositioning device
Table 4.
Pre- and postoperative sleep quality
| Patient number | AHI | ESS | Main symptoms | |||
|---|---|---|---|---|---|---|
| Preoperative | Postoperative | Preoperative | Postoperative | Preoperative | Postoperative | |
| 1 | 16 | 2 | 12/24 | 2/24 | Drowsiness and memory loss | None |
| 2 | 7 | 1 | 9/24 | 1/24 | Headache and disorder of concentration | None |
| 3 | 25 (4 MRD) | 0.68 | 12/24 | 3/24 | Headache, disorder of concentration, and memory loss | None |
| 4 | 45 | 10 | 19/24 | 1/24 | Drowsiness, headache, and disorder of concentration | None |
| 5 | 72 (16 MRD) | 1 | 14/24 | 0/24 | Drowsiness and disorder of concentration | None |
| 6 | 14 | 2 | 12/24 | 2/24 | Drowsiness and headache | None |
| 7 | 19 (6 MRD) | 2 | 9/24 | 2/24 | Headache | None |
| 8 | 52 (15 MRD) | 11 | 12/24 | 1/24 | Drowsiness and disorder of concentration | None |
| 9 | 15 (4 MRD) | 1 | 16/24 | 0/24 | Drowsiness and headache | None |
| 10 | 20 | 19 | 17/24 | 5/24 | Drowsiness and disorder of concentration | None |
| 11 | 9 (3 MRD) | 1 | 14/24 | 1 | Headache and disorder of concentration | None |
| 12 | 22 (11 MRD) | 9 | 12/24 | 2/24 | Drowsiness and memory loss | None |
| 13 | 2 | 0 | 13/24 | 1/24 | Disorder of concentration | None |
| 14 | 9 | 1 | 15/24 | 3/24 | Drowsiness and headache | None |
| Mean | 23.35 | 4.34 | 13.28/24 | 1.71/24 | ||
AHI: Apnea–Hypopnea Index, ESS: Epworth Sleepiness Scale, MRD: Mandibular repositioning device
Table 2.
Pre- and postoperative airway morphology parameters
| Patient number | Airway volume (cm3) | MinCSA (mm2) | PAS B-Pogonion (mm) | PNS length (airway height) (mm) | ||||
|---|---|---|---|---|---|---|---|---|
| Preoperative | Postoperative | Preoperative | Postoperative | Preoperative | Postoperative | Preoperative | Postoperative | |
| 1 | 5.958 | 8.662 | 46 | 143 | 6 | 11 | 73 | 62 |
| 2 | 11.768 | 15.282 | 166 | 264 | 6 | 9 | 53 | 49 |
| 3 | 9.609 | 12.320 | 32 | 107 | 8 | 12 | 64 | 59 |
| 4 | - | - | - | - | 4 | 14 | 77 | 69 |
| 5 | - | 7.097 | - | 198 | 7 | 16 | 62 | 57 |
| 6 | - | 22.245 | - | 470 | 8 | 13 | 84 | 73 |
| 7 | 11.216 | 21.451 | 141 | 750 | 7 | 16 | 50 | 48 |
| 8 | 14.903 | 18.877 | 287 | 401 | 7 | 16 | 65 | 62 |
| 9 | 5.720 | 9.012 | 70 | 164 | 4 | 9 | 51 | 48 |
| 10 | 19.434 | 24.107 | 343 | 553 | 4 | 9 | 63 | 59 |
| 11 | 6.704 | 10.857 | 171 | 452 | 5 | 10 | 55 | 52 |
| 12 | 9.309 | 20.737 | 81 | 183 | 4 | 11 | 55 | 53 |
| 13 | 11.969 | 15.162 | 230 | 388 | 9 | 16 | 67 | 60 |
| 14 | 4.167 | 6.975 | 25 | 154 | 3 | 10 | 44 | 39 |
| Mean | 10.068 | 14.829 | 144.7 | 325.15 | 5.85 | 12.28 | 61.64 | 56.42 |
MinCSA: Minimal cross-sectional area, PAS: Posterior airway space, PNS: Posterior nasal spine
Table 3.
Surgical treatment plan
| Patient number | Maxilla advancement (mm) | Mandible advancement (mm) |
|---|---|---|
| 1 | 7 | 10 |
| 2 | 9 | 9 |
| 3 | 8 | 9 |
| 4 | - | 8 |
| 5 | 10 | 12 |
| 6 | 7 | 11 |
| 7 | 9 | 11 |
| 8 | 9 | 11 |
| 9 | 8 | 8 |
| 10 | 10 | 11 |
| 11 | 9 | 9 |
| 12 | 9 | 10 |
| 13 | 9 | 8 |
| 14 | 6 | 14 |
Our findings reflect the results of the study mentioned above. MMA surgery for the treatment of OSAS can be a highly successful surgery which may result in total healing of the syndrome. The MRDs may be used as an index for future surgery especially in cases with normal facial appearance, and the full documentation of the cases before and after surgery is vital.
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