Surgical Maxillomandibular Advancement

Technique
Kok Weng Lye and Joseph R. Deatherage
Some of the most severe forms of obstructive sleep apnea are attributed to
anatomic abnormalities in the facial skeleton. With the use of conventional orthognathic surgical techniques, it is possible to expand the posterior airway. In fact,
there is strong evidence in the literature to support maxillomandibular advancement as one of the most efficacious surgical procedures for the treatment of
obstructive sleep apnea (OSA). There are complications associated with this procedure but these are minor when compared with the risk of inadequately treated
OSA. (Semin Orthod 2009;15:99-104.) 2009 Elsevier Inc. All rights reserved.

ard tissue surgery for obstructive sleep apnea (OSA) treatment includes genioglossus advancement (GGA) and maxillomandibular
advancement (MMA). Genioglossus advancement
surgery initially was described as a rectangular
osteotomy at the chin, which contains the genial
tubercles.1 GGA has been a frequently performed procedure, but not as an isolated one, to
treat OSA. GGA often is performed together
with uvulopharyngopalatoplasty, with an acceptable success rate of 80% for moderate OSA
(respiratory distress index [RDI] 21 to 40), 64%
for moderately severe OSA (RDI 41 60), and
only 15% for severe OSA (RDI 61).2 Other
techniques following the same principle of advancing the genial tubercles along with the genial glossal muscles are the inferior horizontal
geniotomy and the mortized geniotomy.
Kuo et al3 initiated the use of orthognathic
surgery for the treatment of OSA in 1979. The
treatment involved the advancement of the maxilla and mandible via traditional orthognathic
surgery, which was then called MMA. The rationale for this treatment is the advancement of the

Department of Oral and Maxillofacial Surgery, National Dental

Centre, Singapore; Department of Oral and Maxillofacial Surgery,
University of Alabama School of Dentistry, Birmingham, AL.
Address correspondence to Kok Weng Lye, Department of Oral
and Maxillofacial Surgery, National Dental Centre, 5 Second Hospital Avenue, Singapore, 168938. Phone: 65-6324 8890; E-mail:
kokwenglye@yahoo.com
2009 Elsevier Inc. All rights reserved.
1073-8746/09/1502-0$30.00/0
doi:10.1053/j.sodo.2009.01.004

skeletal attachment of the suprahyoid and velopharyngeal muscles and tendons and an increase
in volume of the nasopharynx, oropharynx, and
hypopharynx. Together, this advancement leads
to the anterior movement of the soft palate,
tongue, and anterior pharyngeal tissues. Subsequently, an enlargement of the posterior airway
and a decrease in laxity of the pharyngeal tissues
ensues and results in a decrease in the obstruction of the posterior airway space. Since 1979,
there have been several publications that
showed overall success rates of 96%,4 97%,5
98%,6 and 100%.7 There is also strong evidence
of the long-term efficacy of the MMA approach,
as Li et al8 showed a 90% success rate for a group
of 40 patients with a mean follow-up period
exceeding 50 months. These results are further
supported by a study examining the surgical stability of MMA, which found that the large horizontal advancement of the maxilla and mandible is stable and without significant relapse.9
However, there are 2 philosophies regarding
the use of MMA. Some groups believed in a
2-stage protocol where MMA is the stage 2 procedure if stage 1, which consists of uvulopharyngopalatoplasty, GGA, and hyoid suspension,
fails.6,10 This latter protocol was developed to
reduce the use and complications of the more
invasive MMA procedure for patients who would
have responded to the first-stage procedures. In
the landmark study6 from which this protocol
was developed, the authors found that the success rate was 60% for stage 1 surgery and 97%
for stage 2 surgery. However, only 25% of the

Seminars in Orthodontics, Vol 15, No 2 (June), 2009: pp 99-104

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Lee and Deatherage

stage 1 nonresponders went on to stage 2 surgery. This failure to proceed with the stage 2
surgery was probably a result of the trauma experienced from the first surgery and being discouraged by the failure of improvement after
the stage 1 surgery.
For these reasons, other groups of clinicians
believe in using the most efficacious technique
from the start and proceeding directly with
MMA.4,5 Waite et al,4 in a key study, evaluated 23
patients who had had MMA surgery together
with septoplasty and inferior turbinectomies.
They achieved a success rate of 96%. Based on
the criteria of a 50% reduction in the RDI and a
final RDI of less than 20,4 Hochban et al5 and
Prinsell7 also used MMA as the primary procedure for 38 and 50 OSA patients, achieving 97%
and 100% success rate, respectively.

Indications and Contraindications

for MMA
To be a suitable patient for MMA treatment, a
few prerequisites are necessary.11 The patients
apnea-hyponea index or RDI must be greater
than 15, with a lowest desaturation 90% and
subjective excessive daytime sleepiness. In addition, conservative treatments, such as weight
loss, mandibular repositioning devices, and/or
continuous positive airway pressure, must have
been unsuccessful or intolerable for the patient.
The patient must also be medically fit to undergo the surgery. If, in addition, the following 2
clinical conditions also are present, then MMA
should be the procedure of choice. First, there
should be obstruction at multiple sites or obstruction could not be distinguished, as it was
diffuse. Second, the patient should present with
a dentofacial skeletal deformity and malocclusion, most often a Class II relationship, and the
MMA surgery should be able to provide an opportunity to obtain multiple benefits. Obviously,
patients who do not meet the criteria for the
MMA procedure or who are unwilling and/or
unable to undergo MMA surgery should be excluded.

Surgical Planning and Technique

MMA is primarily orthognathic surgery in which
the maxilla and mandible are advanced through
osteotomies. Thus, MMA surgery requires all the

relevant preoperative records and planning, such

as facial examination, radiographs, cephalometric
analysis, nasopharyngoscopy and model surgery.
Ideally, preoperative orthodontic treatment should
be used to ensure a good postoperative occlusion
as well as correcting any pre-existing malalignment of the teeth to enhance the cosmetic appearance of the patients. However, many OSA
patients are older and are unwilling to undergo
the recommended orthodontic phase of the
treatment, or they may not wish to delay the
treatment of their OSA condition. In addition,
some OSA patients may have multiple missing
teeth, active advanced periodontal disease, or
complex fixed prosthodontic restorations, which
may complicate orthodontic treatment. Furthermore, the patients problem is often a functional
one, and they may be less concerned with the
esthetic improvement of any treatment. Those patients who, for whatever reason, elect or are
advised not to undergo presurgical orthodontic
treatment should clearly understand their possible and potential need for postsurgical orthodontic and/or restorative dental treatment.

Orthodontics
The objectives of presurgical orthodontic treatment for MMA patients is different from those of
routine orthognathic surgery for patients who
have dentofacial deformities. For the MMA patients, the purpose of the presurgical orthodontic treatment is to assist in maximizing the anterior positioning of the maxilla and mandible
while attempting to obtain a reasonable occlusion. In Class II patients, it is advisable to retract
the lower incisor teeth and procline the upper
incisor teeth to maximize the amount of mandibular advancement. This step will provide the
greatest amount of airway improvement.

Cephalometric Analysis
In general, a lateral cephalogram is a standardized and repeatable radiograph that presents the
profile view of the viscerocranium. It is a routine
tool for the diagnostic workup of all OSA patients and the technique has been previously
described.12 Cephalometric analysis helps to
confirm the clinical and nasopharyngoscopy
findings. The values of different parameters in
the analysis can be compared to normal values

Surgical Maxillomandibular Advancement Technique

to characterize the craniofacial relationship and

the posterior airway status.
Cephalometric analysis reveals the severity of
any craniofacial dysmorphy or abnormalities.
Studies have referred to the retro-positioning of
the jaws, a short mandibular length, a long anterior face height, clockwise rotation of the facial structure, short cranial base, and decreased
craniofacial flexure angle as common abnormalities found in OSA patients.4,13-17 The underlying
principle is that when the craniofacial structure is
retropositioned through either underdevelopment
in the horizontal plane or a clockwise rotational
growth pattern, the structures that form the anterior and lateral boundaries of the posterior
airway, such as the palate, tongue, and pharyngeal tissues are displaced posteriorly. The tissues
are also lax and more liable to collapse in the
presence of negative pressure. This results in the
constriction of the posterior airway, increased airway resistance and obstructions. Moreover, the restriction generates turbulence of the airflow and
vibration of the redundant tissues, causing snoring. Interestingly, significant craniofacial abnormalities are found in about 40% of these patients.18 In terms of treatment planning, it is an
important tool to help identify the patients who
have severe craniofacial deficiency (SNB angle
75), as they should be directly offered MMA
surgery instead of soft tissue procedures.10
Although there are more advanced imaging
techniques to study the posterior airway, cephalometric analysis still offers considerable advantages, including low cost, ease of use and minimal radiation exposure. It is also able to analyze
the craniofacial morphology, airway status, head
position and hyoid position simultaneously. In
addition, its acceptable reproducibility enables
easy comparisons longitudinally, before and after procedures and between populations.

Technique
The MMA is achieved by use of the standard
bilateral sagittal split osteotomy technique for
the mandible and the Le Fort I level maxillary
osteotomy. The mandible is cut and a sagittal
split is carried out bilaterally in the posterior
body, angle and lower ramus region. The proximal segments with the condyles are kept in the
same position while the distal segment; the body
of mandible, alveolus and teeth, are advanced

101

according to the prefabricated occlusal splint

into a Class III relationship. The occlusal splint
is made during the presurgical model surgery.
The inferior alveolar nerve is kept intact but
sustains some tension during the surgical advancement procedure. The distal segment is
then fixated with bicortical screws or titanium
miniplates and screws. Performing the mandibular advancement first creates a more stable occlusal platform. The advancement of the mandible
pulls the geniohyoid, genioglossus, mylohyoid and
the digastric muscles anteriorly. This in turn
brings the base of tongue and hyoid bone forwards and upwards. In addition, the advancement of the mandible creates a larger volume
for the tongue and floor of mouth. These two
effects result in the enlargement of the posterior
airway space at the retroglossal and hypopharyngeal region level.
The maxilla is then cut and mobilized at the
Le Fort I level. The advancement is then
achieved with the aid of a final occlusal splint or
a stable final occlusion. The maxilla is then fixated with 4 titanium plates and screws. There are
prebent OSA advancement plates19 that are designed for this purpose and have been shown to
be more resistant to relapse.20 Because there is
very often a large gap and minimal bony contact
between the upper and lower segments of the
maxilla, bone grafting is necessary to ensure
good bony healing, better stability, and the minimization of relapse.21 Nasal septal defects and
enlarged inferior turbinates can be treated via
the Le Fort approach after down-fracturing of
the maxilla. The generally accepted magnitude
of advancement was 10 mm. The 10-mm quantum is not evidenced based, and the authors of
the present paper have achieved good success
despite surgical advancement of a lesser degree.
This is because the change in airway resistance is
inversely proportional to the radius of the airway
raised to the power of four. The movement of
the maxilla and mandible will be the same only
in cases in which there is no change in occlusion. Equal maxillary and mandibular advancement also occurs in patients who do not undergo preoperative orthodontic treatment.
Patients who have dysgnathia usually are scheduled for orthodontic treatment and improvement of their malocclusion. In patients with dysgnathia who undergo orthodontic treatment the

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Lee and Deatherage

maxilla and mandible will obviously not be advanced equal amounts.

An additional procedure to complement the
MMA is the GGA. This could be done via the
rectangular osteotomy technique popularized by
Riley et al22 or an inferior horizontal geniotomy;
the standard chin osteotomy used in orthognathic surgery. This technique increases the
magnitude of repositioning of the genioglossus,
geniohyoid and digastric muscles.23
Simultaneous adjunctive soft-tissue procedures can be considered during the MMA procedure. However, any pharyngeal soft-tissue procedures performed simultaneously with MMA
may result in airway compromise secondary to
bleeding and swelling. These procedures include surgery to the soft palate, tonsils, and the
tongue. These cases may need surgical tracheostomy,4 prolonged endotracheal intubation or
continuous positive airway pressure use for the
period of postoperative edema. In addition, any
tension on the soft-tissue closure from the skeletal advancement may lead to poor healing or
even fibrosis and scarring.7 Nonpharyngeal procedures, such as nasal procedures, cervicofacial
liposuction, or lipectomy can be done simultaneously with MMA because there is no potential
airway compromise in these procedures.7

Complications
There are no major complications reported for
the MMA procedure. Various authors have mentioned some minor complications. As the advancement of the mandible is often 10 mm or
greater, the incidence of permanent hypesthesia
of the lower lip is one of the commonest problems. Studies have shown long term hypesthesia
to be in the range of 13%6 and 20%.10 If there is
no concurrent orthodontic treatment, postoperative occlusal changes, such as malocclusion and
open bites, are relatively common. This could
result in the need for reoperation, postoperative
orthodontic treatment, or postoperative prosthodontic rehabilitation. When there has been
previous or concurrent soft palate surgery to
stiffen or shorten the palate, velopharyngeal insufficiency can occur.24 Velopharyngeal insufficiency results in a lack of palatal closure and
allows air escape during speech and swallowing
difficulty. This problem is usually temporary and

can be improved with the assistance of speech

therapy. Sometimes, speech difficulties from the
change in lip position also may require speech
therapy.
Esthetic alterations, especially widening of
the alar base of the nose and superior movement
of the nasal tip and a more acute nasolabial
angle, are problems that should be discussed
with the patient preoperatively. However, many
studies have indicated that the facial changes were
generally viewed favorably by the patients.25 This
change in facial appearance is more of a concern
among the Asians population because of the
common presentation of bimaxillary protrusion
in this group of patients.26 Another complication that may arise is temporo-mandibular disorder (TMD). The TMD is caused by the alteration
in the condylar position and increased joint
pressure from the large mandibular advancement. Pre-existing TMD is a risk factor that may
drastically increase the likelihood of postoperative TMD.
Additional reported concerns that may arise
are limited range of motion, sinus dysfunction
and decreased bite force. These complications
have been observed more frequently in older
patients. Bettega et al10 encountered some other
minor complications, such as local infection, an
oro-nasal perforation that healed spontaneously,
and maxillary pseudo-union resulting in instability and that required bone grafting. Prinsell11
reported minimal postoperative difficulties with
a mean hospital stay of 1.6 days, no significant
impairment from the hypesthesia, and good patient acceptance of their facial changes. Waite
et al4 also showed 95% patient satisfaction despite the minor complaints.1

Advances in MMA
In the presence of modern technology, researchers and clinicians have started using computed
tomography (CT) and magnetic resonance (MR)
scans to evaluate the posterior airway 3-dimensionally. This is superior to the widely used 2
dimensional cephalograms. However, cephalometric analysis of the airway has been well
established and permits measurements at key
anatomical locations. Although CT and MR provide extremely accurate distance and area measurements of the airway in all dimensions, there

Surgical Maxillomandibular Advancement Technique

are no recognized normal ranges. Furthermore,

there is no standardization in the thickness, direction and precise location of the sections as
yet.27 In a recent study, 20 patients who underwent MMA had CT scans preoperatively and
following surgery to analyze the morphologic
changes of the airway.28 The results demonstrated significant increase in both the anteroposterior and lateral airway dimensions after
MMA surgery.
Another area of interest is the emergence of
the quality-of-life dimension. This represents
the functional effect of an illness and its consequent therapy upon a patient, as perceived by
the patient.29 It has been a neglected dimension
as clinicians have been treating patients based
on results of objective investigation. Nowadays,
quality of life is increasingly valued as an important aspect of patient care. There have been
very few studies that examined the changes in
the quality of life after surgical procedures for
OSA.30,31 Lye32 recently reported on MMA having equally high success in achieving significant
improvement in the area of quality of life.
In conclusion, there is strong evidence to support MMA as one of the most efficacious surgical procedure for the treatment of OSA. It is
a safe procedure and the more commonly noted
complications are relatively minor as compared
to the risk of inadequately treated OSA. There
have been some modifications to the technique
and inclusion of some adjunctive procedures
over the years. There is also essential research
being done to provide the latest information on
this treatment which will help in our understanding and improve our management of the
OSA patient.

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