ORIGINAL ARTICLE

Follow-up observation of patients with

obstructive sleep apnea treated by
maxillomandibular advancement
Ghaddy AlSaty,a Jun Xiang,b Mary Burns,c Manhal Eliliwi,d Juan Martin Palomo,d Chris Martin,a Bryan Weaver,e
and Peter Ngana
Morgantown, WVa, and New Hope, Pa, and Cleveland, Ohio

Introduction: This study aimed to evaluate the follow-up observation of patients with obstructive sleep apnea
treated with maxillomandibular advancement (MMA) procedure with or without genial tubercle advancement
(GTA). Methods: A total of 25 patients (mean age 37.1 6 17.3 years) were included in the study. Cone-
beam computed tomography scans were taken before treatment; after presurgical orthodontic treatment;
immediately after MMA procedure; and follow-up visit. All Digital Imaging and Communications in Medicine
files were analyzed using the Dolphin 3D Imaging software program (Dolphin Imaging and Management
Solutions, Chatsworth, Calif) to determine the total airway volume (TAV), airway area (AA), and minimal
cross-sectional area (MCA). Dolphin 3D voxel-based superimposition was used to determine the amount of
skeletal advancement with MMA and changes after surgery. Results: Significant increase in TAV, AA, and
MCA was found with MMA treatment (40.6%, 28.8%, and 56.4%, respectively, P \0.0001). Smaller but signif-
icant decrease in TAV, AA, and MCA was found during a follow-up visit (20.0%, 9.7%, and 26.8%, respectively,
P \0.0001) giving a net increase of TAV, AA and MCA (35.8%, 27.1%, and 45.9%, respectively). No significant
differences were found in any of the airway measurements with or without the GTA procedure. The average
forward movements of the maxilla, mandible, and chin were 6.6 mm, 8.2 mm, and 11.4 mm, respectively. A
relapse of less than 1 mm was found in each of the variables during the follow-up period. No correlation was
found between the magnitudes of skeletal advancement and the change in oropharyngeal airway space
(OPAS). Conclusions: Significant increase in OPAS can be expected with MMA surgery with or without GTA
procedure in patients diagnosed with obstructive sleep apnea. A partial loss in OPAS was found during the
follow-up visit. The surgical movements were found to be stable, with less than 1 mm of relapse during the
follow-up period, which was not clinically significant. (Am J Orthod Dentofacial Orthop 2020;158:527-34)

O
bstructive sleep apnea syndrome (OSAS) is a Successfully treating patients with OSAS remains a
sleep-related breathing disorder, characterized challenge among all dental and medical specialists.
by disrupted snoring and repetitive upper airway Continuous positive airway pressure is considered the
obstructions.1 It results in a continuum of changes in therapeutic mainstay for OSAS.3 However, more than
upper airway resistance, reduced blood oxygen levels, 50% of patients are intolerant and reject the therapy
fragmentation of sleep, snoring, daytime fatigue, and within the first few months after initiation.4 Other treat-
hypersomnia which often lead to occupational disability ments for OSAS aimed at enlarging the upper airway
and behavioral changes.2 while decreasing airway collapsibility include mandib-
a
Department of Orthodontics, West Virginia University, Morgantown, WVa. ular positioning devices and surgical reduction of the
b
c
Department of Family Medicine, West Virginia University, Morgantown, WVa.
pharyngeal soft tissues.5,6 However, mandibular posi-
Private practice, New Hope, Pa.
d
Department of Orthodontics, Case Western Reserve University, Cleveland, Ohio. tioning devices are removable appliances and have
e
Department of Oral and Maxillofacial Surgery, West Virginia University, Mor- compliance limitations, and patients still seek alternative
gantown, WVa.
treatment options, including upper airway surgery.7
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. The severity of OSAS is not the only determinant of
Address correspondence to: Peter Ngan, Department of Orthodontics, West Vir- candidacy for maxillomandibular advancement (MMA);
ginia University, 1073 Health Science Center N, Morgantown, WV 26506; e-mail,
these patients often require detailed evaluation and
pngan@hsc.wvu.edu.
Submitted, July 2019; revised and accepted, September 2019. counseling before MMA is selected as a treatment op-
0889-5406/$36.00 tion.8 Waite et al9 first described the MMA technique
Ó 2020.
was a procedure for the treatment of patients with
https://doi.org/10.1016/j.ajodo.2019.09.016

527
528
OSAS. It was performed by a combination of LeFort I and
bilateral sagittal split osteotomies procedures, which
moved both jaws anteriorly. This procedure leads to
the anterior repositioning of the soft palate, tongue,
and pharyngeal tissues. MMA is currently considered
to be the most effective craniofacial surgical technique
for treating OSAS in adults.10 It is beneficial in terms
of the increased total volume of the upper airway size,
improved oximetry indicators, and better quality of life
measured on the Epworth sleepiness scale.11 Genial
tubercle advancement (GTA) is often performed
concomitantly with MMA for esthetic purposes.12 Body
mass index (BMI), age, severity of OSAS, airway space,
amount of skeletal advancement and relapse of MMA
have been reported as clinical factors predictive of surgi-
cal success for treatment of patients with OSAS.13
Cephalometric imaging has been commonly used to
assess the anatomy of the facial skeleton and upper
airway. However, it is limited in its representation of
3-dimensional (3D) structures. Cone-beam computed
tomography (CBCT) provides the ability to visualize the
upper airway and perform 3D reconstructions.14 Howev-
er, it should not be used to diagnose sleep apnea,
because such imaging currently does not represent a
proper risk assessment technique or screening method.
When available, it may be used for monitoring or treat-
ment planning.8 Three-dimensional imaging exposes
patients to a lower radiation dose than conventional
computed tomography and is a faster procedure.14
CBCT is a noninvasive, effective, and reliable technique
for airway evaluation.15-17 CBCT can as well produce
more accurate images without distortion and can be
used to evaluate 3D skeletal changes via
superimposition with the cranial base structure, which
is not affected by surgery.18
Although CBCT is the preferred method for evalu-
ating oropharyngeal airway space (OPAS), few studies
have compared the use of lateral cephalogram and
CBCT in evaluating airway space.19 Moreover, there are
few follow-up studies evaluating airway changes and
skeletal stability of MMA for patients with OSAS.20-23
This study aimed to determine the follow-up airway
changes in patients with OSAS treated with MMA
procedure with or without GTA. In addition, this study
attempted to determine if there is a relationship between
skeletal and airway changes in order to gain a better
understanding of the stability after the MMA procedure.
MATERIAL AND METHODS
This study was carried out on 25 subjects. The sample
size for the study was predetermined using G*Power
(version 3.1, Faul, Erdfelder, Lang, & Buchner,
October 2020  Vol 158  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
AlSaty et al
D€usseldorf, Germany) for the repeated measures analysis
of variance to detect a medium effect (d 5 0.25) with
statistical power at 0.80 and a 5 0.05 significance level
(actual power was 0.99).24
This study was approved by the West Virginia Univer-
sity Institutional Review Board (protocol no.
1704532922). This was a retrospective study using exist-
ing scans selected from the database of 1 of the investi-
gator's (M.B.) orthodontics office, and permission was
obtained from the office to use the records for the study.
The following criteria were considered in the selec-
tion of the subjects: patients who were 15 years or older,
patients who were diagnosed with OSAS with polysom-
nography or airway constriction at 1 or more levels along
with the posterior airway space, and patients with
adequate radiographic documentation. Patients with a
previous history of orthognathic or maxillofacial surgery
and/or with craniofacial abnormalities were excluded
from the study.
All patients underwent presurgical orthodontic phase
for an average of 18 months. All patients received MMA
surgery, but 15 (10 females and 5 males) of these
patients underwent MMA with GTA. After surgery, all
patients were followed for an average of 10 months.
The CBCT scans were taken before treatment (T1), af-
ter presurgical orthodontic treatment (T2), immediately
after MMA procedure (T3), and follow-up visit (T4).
Thus, T2 T1 represented changes due to orthodontic
treatment only, T3 T2 represented changes due to
MMA procedure, and T4 T3 represented changes
10 months follow-up after surgery. Each patient served
as his or her own control. During image acquisition, the
patient was in a natural head posture and in a maximum
interception position. All CBCT scans were taken using
Kodak 9500 Cone Beam 3D System (Carestream Health,
Rochester, NY) with the following settings: 10 mA,
90 kV, exposure time of 10.8 seconds, voxel size of
300 mm, axial slice thickness of 0.2 mm, and scanning
area of 18 3 20.6 cm. All files were originated and
kept as Digital Imaging and Communications in Medi-
cine format files.
For measurements of OPAS, Dolphin (version 11.95,
Dolphin Imaging and Management Solutions, Chats-
worth, Calif) software was used to calculate the total
airway volume (TAV), airway area (AA) and the minimal
cross-sectional area (MCA) selected from predefined
structures. The borders of OPAS were identified, similar
as described in El and Palomo,25 between the palatal
plane (ANS-PNS) superiorly extending to the posterior
wall of the pharynx and the plane parallel to the palatal
plane that passes from the most anterior-inferior point
of the third cervical vertebrae and the base of the
epiglottis inferiorly (Fig 1). TAV, AA, and MCA
AlSaty et al 529

Fig 1. The borders of oropharyngeal airway space between the palatal plane (ANS-PNS) superiorly to
the plane that passes from the most anteroinferior point of the third cervical vertebrae (CV3): A, sagittal
view; B, coronal view.

Fig 2. Airway measurements with Dolphin software: A, AA; B, TAV and MCA.

measurements of the airway were then calculated by us-
ing a specific analysis tool in Dolphin (Fig 2) for each pa-
tient at all time points (Fig 3).
For skeletal measurements, Dolphin 3D voxel-based
superimposition method proposed by Bazina et al,26
was adopted to assess the skeletal changes and relapse
after MMA. Dolphin, ITK-SNAP, an open-source soft-
ware (version 3.2; http://www.itksnap.org) and 3D Slicer
(version 4.8; http://www.slicer.org) imaging software
programs were used. Three areas were selected to mea-
sure the differences between the 2 models at the
T3 T2 surgical period. The 3 areas were A-point,
B-point, and Pogonion point (Fig 4). After defining these
areas, the absolute differences in millimeters between
the 2 3D surfaces were then calculated by using the
Mesh Statistics tool in 3D Slicer. Quantification of the
differences was done by measuring the distance between
the 2 surface models using closest-point color maps as
well (Fig 5). This process was performed and repeated
for each patient at the T4 T3 period as well to assess
the relapse after the surgery.
Statistical analysis
The data collected were compiled in an Excel spread-
sheet (Microsoft, Redmond, Wash) and transferred to
SAS software (version 9.4, SAS Institute, Cary, NC) for
statistical analysis. Descriptive analyses were conducted
to get a basic understanding of the study sample. To
determine the change in airway measurements between
different time points, we used repeated measures anal-
ysis of variance analysis. Tukey's test was followed to
compare individual measurement means. The significant
cutoff value for the Bonferroni correction test was set to
0.008 (0.05 per 6). We incorporated a paired t test to
examine the significance of the advancement and
relapse in skeletal change. We used Pearson correlation
tests to evaluate the relationship between airway change
and skeletal change. Intraclass correlation coefficients

American Journal of Orthodontics and Dentofacial Orthopedics October 2020  Vol 158  Issue 4
530 AlSaty et al

Fig 3. A schematic example of typical changes in the TAV in a patient at different time points.

Fig 5. Three-dimensional color map of the registered T3

Fig 4. The 3 fiducial areas that were selected using the
Pick 'n Paint tool in 3D Slicer to measure the skeletal
changes.
(ICC) were calculated to evaluate the reliability of the
repeated measurements. All statistical tests were
2-sided, and P \0.05 was considered statistically signif-
icant.
RESULTS
For error measurements, 15 subjects were analyzed
by the same researcher a second time with a 2-week
interval in between. ICC values were calculated to
models showing the differences in millimeters at
(T4 T3) period.
determine the reliability of measurements. The ICC
values ranged from 0.94 to 0.98, indicating a high level
of agreement between the 2 measurements.
A total of 25 Caucasians (18 females and 7 males)
who were evaluated for OSAS and underwent MMA
surgical treatment were included in the final study.
The average age at the time of surgery was 37.1 years
(range 15-62 years). Fifteen of these patients underwent
MMA with GTA procedures.
For the subjects who completed the OSAS diagnosis
with preoperative polysomnography (PSG), the

October 2020  Vol 158  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
AlSaty et al 531

Table I. TAV, AA, and MCA of oropharyngeal airway space

P value Mean change Percentage change, %

Variable Time point Mean SD T2 T1 T3 T2 T4 T3 T2 T1 T3 T2 T4 T3 T2 T1 T3 T2 T4 T3

TAV, mm3 T1 11886.1 976.4 0.34 \0.0001* \0.0001* 1305.1 9019.7 3699.2 9.9 40.6 20.0
T2 13191.2 962.7
T3 22210.9 1198.4
T4 18511.7 1344.2
AA, mm2 T1 521.1 27.7 0.40 \0.0001* 0.020 37.8 225.7 69.5 6.8 28.8 9.7
T2 558.8 28.1
T3 784.5 31.2
T4 715.0 32.1
MCA, mm2 T1 122.2 14.6 0.99 \0.0001* 0.002* 2.6 161.5 60.5 2.1 56.4 26.8
T2 124.8 13.1
T3 286.4 17.6
T4 225.9 20.9
Note: P values from Tukey honest significant difference test after significant results (P \0.0001) of the repeated measures analysis of variance test.
SD, standard deviation; MCA, minimal cross-sectional area.
*Significant results after comparing to cutoff point 0.008 (0.05 per 6) for Bonferroni correction test.

preoperative average of the apnea-hypopnea index was

22.6 (range 5.0-72.9), and peripheral oxygen saturation Table II. Skeletal movements and relapse
was 87.4% (range 82%-95%). The preoperative BMI was T3 T2 T3 T4
30.6 kg/m2 (range 25.4-35.8).
Mean Mean
The results showed no significant increase in TAV Variable change SD P value change SD P value
with a mean of 1305.08 mm3 after the presurgical ortho- Maxillary 6.6 2.0 \0.0001* 0.6 0.6 0.0002***
dontic phase. After the MMA procedure, TAV was advancement,
increased by 9019.7 mm3 in the T3 T2 period, which mm
represents a gain of 40.6% (P \0.0001). During the Mandibular 8.2 3.2 \0.0001* 0.4 0.8 0.01*
advancement,
follow-up period, a reduction of 3699.2 mm3, or a loss
mm
of 20.0%, was found after surgery (T4 T3, Chin advancement, 11.4 4.1 \0.0001* 0.6 0.8 0.002**
P \ 0.0001) (Table I). mm
No significant increase or decrease in AA was found
Note. P values from paired t test.
after the presurgical orthodontic phase T2 T1 and SD, standard deviation.
during the observation period T4 T3. There was a sig- *P \0.05; **P \0.01; ***P \0.001.
nificant increase of 225.7 mm2 (28.8%) in AA after the
MMA procedure (T3 T2, P \0.0001) (Table I). correlations were found between the amount of skeletal
An increase in MCA by 161.5 mm2 (56.4%) was found relapse and the OPAS changes at the follow-up period.
after the MMA procedure (T3 T2, P \0.0001), and
DISCUSSION
there was also a decrease of 60.5 mm2 (26.8%) during
the observation period (T4 T3, P 5 0.002) (Table I). This study evaluated the stability of changes in skel-
The mean and range of maxillary, mandibular, and etal and OPAS dimensions over an average of
chin advancements were 6.6 mm (range 3.5-11.2 mm), 10 months follow-up period for patients with OSAS
8.2 mm (range 3.7-19.4 mm), and 11.4 mm (range undergoing MMA with or without GTA procedure. A
3.5-16.3 mm), respectively. The P values show a signif- significant increase was obtained with MMA procedure
icant difference in the comparison between T2 and T3 at in TAV (40.6%), AA (28.8%), and MCA (56.4%) during
all measured points. During the observation period (T4), the T3 T2 period. The significant 3D increase in
the mean relapse at Point A, Point B, and Point Pogon- OPAS after MMA agreed with previous studies. Raffini
ion were 0.6 mm, 0.4 mm, and 0.6 mm, respectively. The et al27 found a significant increase in the OPAS with
P values also showed a statistically significant difference TAV (56%), AA (34%), and MCA (112%) immediately
for this period (T4 T3; Table II) at all measured points. after MMA surgery in 10 patients with skeletal Class
There were no significant correlations found between II skeletal malocclusions. Goncalves et al21 also re-
the amount of skeletal advancement and the OPAS ported a significant increase in 3D airway space in 30
changes immediately after surgery. No significant patients after MMA with counterclockwise rotation in

American Journal of Orthodontics and Dentofacial Orthopedics October 2020  Vol 158  Issue 4
532
patients who required temporomandibular joint
concept total joint prostheses. The MMA procedure
has a higher efficacy for lowering the apnea-
hypopnea index, which enlarges the OPAS and de-
creases upper airway collapsibility by forward-fixing
both the maxilla and mandible.28 However, there is
no direct link between any radiographic measures of
airway size or shape and PSG results. Therefore, imag-
ing values should be interpreted cautiously and in
conjunction with other clinical signs and symptoms.8
During the follow-up observation period (T4 T3), a
decrease in pharyngeal airway space (TAV 20.0% and
MCA 26.8%) was found. This finding is consistent with
a study by Carvalho et al,22 who studied 20 patients
treated with MMA and followed them for 6 months, af-
firmed that the MMA procedure allowed linear area and
volume increase in OPAS in the immediate and late post-
operative periods, but there was partial loss of the
increased space after 6 months. Edema is an important
factor in the evaluation of airway space, particularly in
the immediate postoperative period of MMA. Edema in
airways may have masked the real gain in airway space
in the immediate period (T3 T2), and it became
more perceptible in the late period (T4 T3) after edema
regressed. Although edema and hypopharyngeal hema-
toma may occur in the immediate postoperative period
after MMA, there appears to be minimal risk for airway
compromise or postoperative exacerbation of OSAS.28
According to Riley et al,29 additional data analysis
showed that after the initial enlargement of the OPAS,
soft tissue relapse would occur during the first 12 months
and then stabilize. A similar finding was noted by Yao
et al.30 Possible explanations include the concept that
lateral pharyngeal wall collapse is a significant contrib-
utor to hypopharyngeal obstruction in patients with
OSAS, and skeletal surgery gives support to the lateral
pharyngeal through the constrictor muscles.29 Kochar
et al31 in a postsurgical evaluation study of airway space
after mandibular advancement for 16 patients with Class
II malocclusions performed by acoustic pharyngometry,
found a significant increase 2 months after surgery in
minimum cross-sectional area, mean cross-sectional
area, and mean volume. Relapse was also observed
1 year after surgery in the previous airway measurements
12.6%, 7.9%, and 3.9%, respectively.
In the current study, 15 patients had MMA together
with the GTA procedure. There were no significant
differences in airway measurements with or without
the GTA procedure. This finding is in agreement with
a 2-dimensional (2D) study by Torres et al,12 which
found that MMA surgery, with and without advance-
ment genioplasty, can promote immediate gains to
the OPAS.
October 2020  Vol 158  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
AlSaty et al
Maxillary rigid fixation was achieved with miniplates,
and the mandible and the chin were fixed with bicortical
screws. At the T3 T2 period, the mean maxillary,
mandibular, and chin advancements were 6.6 mm,
8.2 mm, and 11.4 mm, respectively. Gonçalves et al21
performed a mean maxillary advancement of 3.5 mm,
and mandibular advancement of 9.65 mm, whereas Car-
valho et al,22 reported a mean maxillary advancement of
3.6 mm, and mandibular advancement of 12.5 mm. The
magnitude of skeletal movements completed in this
study was comparable with other studies.22 According
to Holty and Guilleminault,16 maxillary advancement
of approximately 8.4 6 2.8 mm led to a success rate
of less than 80%, whereas maxillary advancement of
approximately 9.9 6 1.3 mm increased the success
rate to more than 80%.29 At T4, the mean relapse at
Point A, Point B, and Point Pogonion were 0.6 mm,
0.4 mm, and 0.6 mm, respectively. These results suggest
that there is a very minimum clinical loss for advance-
ment at all time points. A change of less than a 1 mm
was statistically significant but not clinically significant.
Proffit et al32 considered changes of \ 2 mm within the
range of method error and clinically insignificant. The
surgical movements (T3 T2) remained stable during
the follow-up period (T4 T3) agreeing with the results
in previous studies.21,33-35 Furthermore, Nojan et al36
found that there was no significant relapse after genio-
plasty and bilateral sagittal split osteotomy or genio-
plasty alone after 12 months when rigid internal
fixation is used. The changes were minimal and hard
to detect clinically.
When correlating the amount of skeletal advance-
ment with the OPAS measurements immediately after
surgery, there was no significant correlation found,
which agreed with Butterfield et al37 and Riley et al29
who found that there is no direct relationship between
the amount of skeletal advancement and change in
OPAS as well. A similar finding was noted by Yao
et al.30 Possible explanations include the concept that
lateral pharyngeal wall collapse is a significant contrib-
utor to hypopharyngeal obstruction in patients with
OSAS, and skeletal surgery gives support to the lateral
pharyngeal through the constrictor muscles.29 Another
2D study by Susarla et al38 stated that
[W]ith regard to the lack of a dose-response relation
between the magnitude of jaw advancement and
changes in cephalometric parameters, it is likely that
anatomic changes in the airway are the result of a
complex interplay between demographic factors
(age, gender, BMI) and surgical factors (magnitude
of advancement). Given the small sample evaluated,
a dose-response relation could not be appropriately
evaluated using a multiple regression model.
AlSaty et al
This is the same case in this study. In contrast,
Gonçalves et al21 found a positive correlation between
the amount of mandibular advancement and increases
in airway surface area, airway volume, lateral dimension
of the retroglossal airway, and anteroposterior dimen-
sion of the retroglossal airway. Thus, the greater the
mandibular advancement, the greater the dimensional
airway increase.
When correlating the amount of skeletal relapse with
the airway changes at the follow-up period, there was no
significant correlation found. This finding is in agree-
ment with a 2D study by Tiner et al,23 who found that
there was no significant correlation between the amount
of surgical advancement and the amount of postsurgical
instability. Moreover, Nojan et al36 found that the
relapse rate for genioplasty was not statistically related
to the amount of advancement. However, the skeletal
relapse in the current study was clinically insignificant
that led to no effect of the amount of skeletal relapse
on the OPAS measurements.
There are several limitations to the current study,
including relatively small sample size, wide age distribu-
tion, and dissimilar sex distribution, which limited the
ability to use these findings to predict the surgical out-
comes according to patient age and sex. Moreover, there
was variation in medical history, age, sex, BMI, severity of
malocclusion, and OSAS among the patients. Although
CBCT is a tremendous tool in evaluating airway parame-
ters, it is a static evaluation of a dynamic structure. Future
studies using a larger sample, longer follow-up period,
and a dynamic imaging of the airway are recommended.
CONCLUSIONS
1. A significant increase in oropharyngeal space can be
expected with MMA surgery with or without GTA
procedure in patients diagnosed with OSAS.
2. Significant forward movement of the maxilla,
mandible, and chin positions can be obtained with
the MMA procedure.
3. A partial loss in the increase in oropharyngeal space
(TAV 20.0%, AA 9.7%, and MCA 26.8%) was found
during an average of 10 months follow-up period.
4. The surgical movements were found to be stable
with less than 1 mm of relapse during an average
of 10 months follow-up period, which was not clin-
ically significant.
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