Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-016-4015-4
REVIEW ARTICLE
Efficiency of bimaxillary advancement surgery in increasing
the volume of the upper airways: a systematic review
of observational studies and meta-analysis
Henrique Damian Rosário1 • Gustavo Mussi Stefan Oliveira2 • Irlan Almeida Freires3
Felipe de Souza Matos4 • Luiz Renato Paranhos5,6
Received: 9 February 2016 / Accepted: 23 March 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract Postsurgical changes of the airways have
become a great point of interest because it has been
reported that maxillomandibular advancement surgery can
improve or eliminate obstructive sleep apnea; however, its
treatment effectiveness is still controversial. The purpose
of this systematic review and meta-analysis was to assess
the effectiveness of maxillomandibular advancement sur-
gery to increase upper airway volume in adults, comparing
before and after treatment. Bibliographic searches of
observational studies with no restriction of year or lan-
guage were performed in the electronic databases PubMed,
Scopus, ScienceDirect and SciELO for articles published
up to April 2015. After verification of duplicate records,
1860 articles were examined. Of these, ten met the eligi-
bility criteria, of which three were excluded for having
poor methodological quality. The other seven articles were
included in the systematic review and six in the meta-
analysis, representing 83 patients. One study whose data
were not given in absolute values was excluded from the
& Luiz Renato Paranhos
paranhos@ortodontista.com.br
1
Department of Orthodontics, Faculdades Integradas do Norte
de Minas-FUNORTE, Florianópolis, SC, Brazil
2
University of Louisville School of Dentistry, Louisville, KY,
USA
3
Department of Physiological Sciences, Piracicaba Dental
School, University of Campinas, Piracicaba, SP, Brazil
4
Postgraduate Program in Dentistry, Federal University of
Sergipe, Aracaju, SE, Brazil
5
Department of Dentistry, Federal University of Sergipe,
Lagarto, SE, Brazil
6
Residencial Vista do Atlântico, Ap. 1402, Jordão de Oliveira
St., 996, Atalaia, Aracaju, SE 49037-330, Brazil
•
meta-analysis. The meta-analysis showed a statistically
significant difference between the averages of upper airway
volume before and after surgery {7.86 cm3 [95 % CI (6.22,
9.49), p = 1.00)}. Clinical evidence suggests that the
upper airway volume is increased after maxillomandibular
advancement surgery.
Keywords Orthognathic surgery
Airway obstruction

Sleep apnea syndrome
Meta-analysis
Introduction
Obstructive sleep apnea (OSA) is a respiratory condition
that directly affects the individuals’ quality of life, expos-
ing them to accidents [1], diabetes and hypertension [2],
renal disorders and chronic fatigue [3], hepatic disorders
[4], obesity [5], depression [6], among others [7]. These
problems may be associated with decreased hemoglobin
levels during sleep [2]. Reduced upper airway volume, or
the presence of constrictions that increase the resistance to
the airflow, is considered a risk factor for the development
of this disorder [8].
Conservative measures such as healthy diet [5], changes
of body position during the sleep [9], propulsive devices
[10], and continuous positive airway pressure devices [10,
11], have preferably been used in lieu of corrective surgery
[11]. However, in more severe cases, surgery may be the
treatment of choice [12].
Bimaxillary advancement surgery has been reported as
an effective method to treat or reduce the severity of OSA
[13–16]. Radiographic examinations are successfully used
to visualize the changes obtained with the surgery [17].
The cone beam computerized tomography (CBCT) method
is considered the most effective, fast and with low radiation
123

dose currently available [18]. This radiographic technique
permits to find constriction areas that would hardly be seen
in two-dimensional images. In addition, this method is also
useful for post-operative follow-up [19].
The purpose of this systematic review and meta-analysis
was to assess the effectiveness of maxillomandibular
advancement surgery to increase upper airway volume,
comparing before and after treatment.
Materials and methods
Protocol and registration
This systematic review and meta-analysis were performed
following the instructions of the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA—
http://www.prisma-statement.org) [20]. The systematic
review was recorded in PROSPERO database (http://www.
crd.york.ac.uk/PROSPERO) with registration number
CRD42015016465.
Eligibility criteria
Guiding question
The present research aimed to answer the following
focused question: is the maxillomandibular advancement
surgery effective to increase upper airway volume in
adults, when compared before and after treatment? The
strategy ‘‘PICO’’, meaning population (population/partici-
pants), intervention (intervention/exposure for observa-
tional studies), comparator (comparison), and outcomes
(outcome), was used for the research question.
Inclusion criteria
Clinical controlled trials reporting on the volumetric
changes in the upper airways seen through CT upon
maxillomandibular advancement surgery were selected,
without restriction of year, publication status, or language.
Exclusion criteria
Articles that used bidimensional examinations; literature
reviews, case reports, editorials and/or letters to the editor
were excluded, as well as articles with participants who
were less than 17 years.
Information sources
Systematic searches were conducted in the electronic
databases PubMed, Scopus, ScienceDirect and SciELO, to
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identify all potentially relevant studies. In specific cases,
the authors of potentially eligible articles were contacted
by e-mail and asked for missing information. The refer-
ences of eligible studies were also identified and analyzed
by means of a manual search, to verify possible studies that
were not retrieved from the databases, but could potentially
be included in this study. This systematic review covers all
data in the international literature published up to April 16,
2015.
Search
The MeSH resource was used to select the controlled
descriptors ‘‘airway obstruction’’, ‘‘sleep apnea syndrome’’
and ‘‘orthognathic surgery’’, to retrieve the articles from
the databases. Non-controlled descriptors were also used:
‘‘airway’’ ‘‘obstruction’’, ‘‘maxillomandibular’’, ‘‘ad-
vancement’’, ‘‘orthognathic’’, ‘‘surgery’’, ‘‘sleep’’ and
‘‘apnea’’. Boolean operators (‘OR’ and ‘AND’) were used
to join terms (thesaurus or words) related the topic. Table 1
shows the search strategy used in this systematic review.
The records obtained were exported to Mendeley Desktop
1.13.3 software (Mendeley Ltd, London, England), to
check the existence of duplicity.
Study selection
Subsequently, the titles and abstracts were systematically
examined by two non-blind examiners through title and
abstract reading. The studies not selected at this stage or at
subsequent stages were recorded in an exclusion table to-
gether with the reasons for the exclusion. In cases when the
study seemed to be eligible, but there were insufficient data
in the title and abstract to make a clear decision, the full
text was obtained and evaluated to determine whether it
would meet the inclusion criteria.
Data collection process
Two examiners performed the evaluation of the risk of bias
and the quality assessment in individual studies (H. D. R.
and L. R. P.). In case of disagreement, a third examiner (G.
M. S. O.) was consulted. At this step, the review was
blindly performed, masking the names of authors and the
journals, avoiding any potential bias and conflicts of
interests during the sample selection.
Data items
After the screening for methodological quality, the full
texts of selected articles were reanalyzed using a stan-
dardized data extraction sheet. The following information
were extracted from the studies: authors; year of
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Table 1 Search strategy for identification of studies in primary electronic databases

Database Search strategy

PubMed (‘‘airway obstruction’’[MeSH Terms] OR (‘‘airway’’[All Fields] AND ‘‘obstruction’’[All Fields]) OR ‘‘airway
http://www.ncbi.nlm.nih. obstruction’’[All Fields]) AND ‘‘maxillomandibular’’[All Fields] AND ‘‘advancement’’[All Fields]
gov/pubmed (‘‘airway obstruction’’[MeSH Terms] OR (‘‘airway’’[All Fields] AND ‘‘obstruction’’[All Fields]) OR ‘‘airway
obstruction’’[All Fields]) AND (‘‘orthognathic surgery’’[MeSH Terms] OR (‘‘orthognathic’’[All Fields] AND
‘‘surgery’’[All Fields]) OR ‘‘orthognathic surgery’’[All Fields])
(‘‘sleep apnoea’’[All Fields] OR ‘‘sleep apnea syndromes’’[MeSH Terms] OR (‘‘sleep’’[All Fields] AND
‘‘apnea’’[All Fields] AND ‘‘syndromes’’[All Fields]) OR ‘‘sleep apnea syndromes’’[All Fields] OR
(‘‘sleep’’[All Fields] AND ‘‘apnea’’[All Fields]) OR ‘‘sleep apnea’’[All Fields]) AND (‘‘orthognathic
surgery’’[MeSH Terms] OR (‘‘orthognathic’’[All Fields] AND ‘‘surgery’’[All Fields]) OR ‘‘orthognathic
surgery’’[All Fields])
(‘‘sleep apnoea’’[All Fields] OR ‘‘sleep apnea syndromes’’[MeSH Terms] OR (‘‘sleep’’[All Fields] AND
‘‘apnea’’[All Fields] AND ‘‘syndromes’’[All Fields]) OR ‘‘sleep apnea syndromes’’[All Fields] OR
(‘‘sleep’’[All Fields] AND ‘‘apnea’’[All Fields]) OR ‘‘sleep apnea’’[All Fields]) AND maxillomandibular[All
Fields] AND advancement[All Fields]
Scopus ‘‘airway obstruction’’ OR airway AND obstruction AND maxillomandibular AND advancement
http://www.scopus.com ‘‘airway obstruction’’ OR airway AND obstruction AND orthognathic AND surgery
‘‘sleep apnea’’ OR sleep AND apnea AND orthognathic AND surgery
‘‘sleep apnea’’ OR sleep AND apnea AND maxillomandibular AND advancement
ScienceDirect ‘‘airway obstruction’’ OR airway AND obstruction AND maxillomandibular AND advancement
http://www.sciencedirect. ‘‘airway obstruction’’ OR airway AND obstruction AND orthognathic AND surgery
com ‘‘sleep apnea’’ OR sleep AND apnea AND orthognathic AND surgery
‘‘sleep apnea’’ OR sleep AND apnea AND maxillomandibular AND advancement
SciELO sleep OR apnea AND maxillomandibular
http://www.scielo.br airway OR obstruction AND maxillomandibular
sleep OR apnea AND orthognathic
airway OR obstruction AND orthognathic
sleep OR apnea AND advancement
airway OR obstruction AND advancement
sleep OR apnea AND surgery
airway OR obstruction AND surgery

publication; sample size and profile; age; body mass index
and apnea index; presence or absence of obstructive sleep
apnea; presence of control groups; assessment checkpoints;
extension of maxillomandibular advancement; anatomical
limits; segmentation method; average and percentage of the
volumetric difference; and clinical outcome. When
required, authors were contacted by e-mail to identify
unpublished or unclear pertinent information.
Risk of bias in individual studies
The risk of bias and quality in selected individual studies
were evaluated using the checklist adapted [21]. Each study
received a score that is considered of low quality (0–6
points), medium quality (7–9 points) and high quality
(10–2 points).
Synthesis of results
At a final stage, a meta-analysis was carried out to quan-
titatively analyze the means obtained in the selected stud-
ies. Calculations were performed in Review Manager
version 5.3 (Rev Man, Copenhagen, Denmark). Exact
binomial 95 % confidence intervals (CI) were calculated
for each study before and after surgery. Heterogeneity
between studies was assessed using the Chi-square statistic
and I2. Statistical tests were two sided, and p values lower
than 0.10 were regarded as significant.
Risk of bias across studies
As the data were homogeneous, a meta-analysis was pos-
sible and the risk of bias was assessed.

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Results
Study selection
The searches in the electronic databases resulted in 2906
records. Of these, 1046 were excluded due to duplicity and
the remaining 1860 were analyzed, as shown in Fig. 1. A
total of 1850 studies were excluded after analysis, and the
main reasons for exclusion are described in Fig. 1. The
references of the remaining studies were checked manually
to find other potentially relevant studies, but no further
inclusions were done.
Study characteristics
Among the selected studies, one was conducted in the US,
one in Brazil, two in Canada, one in Spain, one in Italy and
one in Germany. All studies were conducted between 2007
and 2014 and published in English.
Fig. 1 Flow diagram of the
strategies used for identification,
screening, and inclusion of
studies in the systematic review
and meta-analysis
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Table 2 shows the characteristics of the samples
included in the different studies. The research by
Abramson et al. [22], Butterfield et al. [23, 24] included
samples mostly composed of men, while there was a
predominance of women in the studies by Raffaini and
Pisani [25], Valladares-Neto et al. [26] and Brunetto et al.
[27].
Although the number of individuals has been mentioned
in the study by Hernández-Alfaro et al. [28], the authors
failed to describe the distribution by gender, the average
age and physical characteristics, such as the apnea index
(AHI) and body mass index (BMI). Furthermore, they
failed to describe the size of the surgical advancement, and
the presence of patients with OSA.
In the studies in which the individuals were not diag-
nosed with OSA [25–27], there was no report of body mass
index and, obviously, AHI.
Although most of post-operative CT scans were per-
formed within the first year, there is no standardization of
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Table 2 Characteristics of the studies selected for qualitative analysis

Authors (year) Sample size Age BMIa AHIb Individual with Control Assessment Extension of
Geographical (no. of (years) OSAc group checkpoints advancement
location individuals) (max/mand) in mm

Abramson 9# 38.9 28.7 48.8/Not Yes Yes Not reported 9.2/10.1

et al. (2011) 2$ (21–55) reported
[22]
USA
Hernández- 10 (does not Not Not Not Yes, but did not No 146.3 days Not reported
Alfaro et al. specify) reported reported reported provide exact (average)
(2011) [28] description
Spain
Raffaini and 0# 22 – – No No Between 6 and Not reported/10–18
Pisani (2013) 10 $ 12 months
[25]
Italy
Valladares- 7# 35.5 – – No No 6.3 months 0–4/4–10
Neto et al. 18 $ (17–57.5) (2–26 months)
(2013) [26]
Germany
Brunetto et al. 8# 24.77 – – No No Between 5 and 4.74/6.34
(2014) [27] 12 $ (18–30) 8 months
Brazil
Butterfield 10 # 42.75 30.35/ 47.7/7.57 Yes Yes Between 3 and 8/11
et al. (2015a) 2$ 29.44 10 months
[23]
Canada
Butterfield 13 # 42.4 30.33/ 45.5/7.7 Yes No Between 2 and 8.07/10.08
et al. (2015b) 2$ (19–61) 30.05 49 months
[24]
Canada
a
Body Mass Index
b
Apnea Index (AHI) before/after. Normal = 5
c
Obstructive Sleep Apnea

the evaluation period. The study by Butterfield et al. [24]
showed a great variation in the evaluation period ranging
from 2 to 49 months. Abramson et al. [22] did not describe
how long it took for individuals to undergo a second
examination, and Hernández-Alfaro et al. [28], despite
showing an average, did not mention the evaluation
periods.
Divergences were also found in all studies concerning
the extension of the bone base advancements achieved.
However, Abramson et al. [22], Butterfield et al. [23] and
Butterfield et al. [24] showed similar levels of bimaxillary
advancements. The lowest maxillary advancement was
described by Valladares-Neto et al. [26] (0–4 mm) and the
lowest mandibular advancement was reported by Brunetto
et al. [27] (6.34 mm).
Risk of bias within studies
The methodological assessment is shown in Table 3. Three
studies [13, 14, 29] did not meet acceptable inclusion cri-
teria and hence were excluded from the meta-analysis. The
authors failed to describe how the sample size was calcu-
lated and/or, most importantly, lacked a control group. In
addition, these studies scored only one point (out of three
maximum) on the section appropriate study design. The
studies by Carvalho et al. [29] and Bianchi et al. [13] did
not mention the study shortcomings, and Schendel et al.
[14] made no reference to the statistical method with
declared p value.
With regard to the eligible studies [22–28], only the
study by Raffaini and Pisani [25] failed to mention the

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Table 3 Analysis of the potential risk for bias in the eligible articles
Authors (year) Q.1 (1 Q.2 (1 Q.3 (1 Q.4 (3 Q.5 (2 Q.6 (1 Q.7 (1 Q.8 (1 Q.9 (1 Total Overall
point) point) point) points) points) point) point) point) point) quality

Abramson et al. Yes Yes Yes 1/0/1 No Yes Yes Yes Yes 9 Moderate
(2011) [22] points
Carvalho et al. (2012) Yes Yes Yes 0/0/1 No No Yes Yes No 6 Low
[29] points
Hernández-Alfaro Yes Yes Yes 1/0/0 No No Yes Yes Yes 7 Moderate
et al. (2011) [28] points
Raffaini and Pisani Yes Yes No 1/0/1 No No Yes Yes Yes 7 Moderate
(2013) [25] points
Valladares-Neto et al. Yes Yes Yes 1/0/0 No No Yes Yes Yes 7 Moderate
(2013) [26] points
Bianchi et al. (2014) No Yes Yes 1/0/0 No No Yes Yes No 5 Low
[13] points
Brunetto et al. et al. Yes Yes Yes 1/0/1 Yes No Yes Yes Yes 10 High
(2014) [27] points
Schendel et al. (2014) Yes Yes Yes 0/0/1 No No No Yes Yes 6 Low
[14] points
Butterfield et al. Yes Yes Yes 1/0/1 No No Yes Yes Yes 8 Moderate
(2015a) [23] points
Butterfield et al. Yes Yes Yes 1/0/1 No No Yes Yes Yes 8 Moderate
(2015b) [24] points
Q.1—The abstract clearly presents the study objective, methodology, results and conclusion. Q.2—The study exposes the objective clear and
precisely. Q.3—The ethical aspects of the research are cited in the text. Q.4—The research design is adequate (randomization and blinding).
Q.5—The sample size calculation is reported. Q.6—Control groups are used. Q.7—The statistical methods are cited and p values are described.
Q.8—The study exposes the results clearly and precisely. Q.9—The study limitations are discussed. Checklist adapted from Cericato et al. [21]

ethical issues involved in the research, and Brunetto et al.
[27] were the only authors that described how sample size
was calculated. Only the study by Brunetto et al. [27] was
considered of high methodological quality based on the
criteria adapted from Cericato et al. [21].
Results of individual studies
The anatomical limits and the segmentation method used
(manual or automated) can be seen in Table 4, as well as
the effects of intervention.
Synthesis of results
In all studies [22–28], there was a statistically significant
increase in the upper airway volume; however, there is no
report on the mean deviation of the changes.
The study by Brunetto et al. [27] was excluded from the
meta-analysis for not presenting the difference in pre- and
post-surgery volumes in absolute values, but percentage.
Finally, the six studies included accounted for 83
patients. The results of the meta-analysis (Fig. 2) showed
that, in all selected articles, there was an increase in the
upper airway volume upon bimaxillary advancement sur-
gery. The mean increase was 7.86 cm3 [95 % CI (6.22,
9.49), p = 1.00].
Risk of bias across studies
This systematic review shows that there is no standard-
ization in the literature about the anatomical limits evalu-
ated. In this respect, the most common upper reference was
the projection of palatal plane towards the posterior limit of
the pharynx. The lower limits ranged among soft tissue
structures, such as epiglottis and uvula, and hard tissues,
such as the vertebrae edges.
Discussion
There has been an increasing interest on upper airways on
the part of surgeons and orthodontists, as these constitute
anatomical structures with great influence on health and
quality of life of the population [1–11]. This interest is
given by the direct relationship with the syndrome of
obstructive sleep apnea (OSA) [16]. Hence, we carried out
this systematic review of the literature with meta-analysis
to verify the influence of maxillomandibular advancement
surgery on upper airway volume.
The choice for observational studies to respond to the
objective of this study was done by the difficulty of finding
feasible clinical trials in the literature. The random allo-
cation of patients in need of surgical treatment for OSA is

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Table 4 Anatomical limits, results and clinical outcome of the studies included in the qualitative analysis
Authors (year) Anatomical limits Segmentation Average of Change Clinical outcome
method differences in (%)
volume (mm3)

Abramson Upper limit: projection of palatal plane Not reported 7800 67.47 Statistically
et al. (2011) Lower limit: base of the epiglottis significant
[22] increase in
volume
Hernández- No description was given. Based on the figure, it seems that Semi- 9267 68.4 Statistically
Alfaro et al. the upper limit is the projection of palatal plane, and the automatized significant
(2011) [28] lower limits if the lowest edge of the third vertebra increase in
volume
Raffaini and Upper limit: projection of Frankfurt plan passing through Automatized 7367 56 Statistically
Pisani the soft palate floor significant
(2013) [25] Lower limit: projection of Frankfurt plane passing through increase in
the tip of the epiglottis volume
Valladares- Upper limit: projection of palatal plane Automatized 7770 54.5 Statistically
Neto et al. Lower limit: tip of the uvula significant
(2013) [26] increase in
volume
Brunetto et al. Anterior limit: in a vertical plane through the posterior Not reported Not reported 28.5 Statistically
(2014) [27] nasal spine perpendicular to the sagittal plane on the significant
lower edge of the vomer increase in
Lower limit: a plane tangential to the medial caudal volume
projection of the third cervical vertebra perpendicular to
the sagittal plane
Upper limit: the highest point of the nasopharynx,
coinciding with the posterior choanae and coincident with
the anterior limit
Butterfield Upper limit: projection of palatal plane Not reported 7720 79.65 Statistically
et al. (2015a) Lower limit: tip of the epiglottis significant
[23] increase in
volume
Butterfield Upper limit: projection of palatal plane Not reported 7818 80.43 Statistically
et al. Lower limit: tip of the epiglottis significant
(2015b) [24] increase in
volume

Fig. 2 Averages of the upper airway volumes before and after maxillomandibular advancement surgery reported in the studies selected for
quantitative analysis (meta-analysis)

123

not ethically acceptable, and the design of this type of
research could lead to selection biases.
Cone beam computed tomography is a complementary
exam commonly ordered for the analysis of craniofacial
structures. Due to its high accuracy, ease of obtaining and
managing images, as well as lower level of radiation
emission—when compared to conventional tomography—
CBCT has also been used in post-operative follow-up [8].
Studies approaching such diagnostic method rather than
two-dimensional images were selected in this meta-analy-
sis, given the ability to view, segment and measure com-
plex anatomical structures such as the airways [30].
Moreover, CBCT is specific to dentofacial imaging and
thus facilitates the standardization of exams [31]. In addi-
tion, the reduced time necessary to obtain the images
prevents changes caused by breathing movements and
swallowing, hence providing more accurate scans [14].
For quantitative selection of articles, we used an adap-
tation of the methodological evaluation criteria proposed
by Cericato et al. [21]. Only studies describing and pre-
senting their findings accurately with an appropriate
methodological design could provide a reliable response in
the meta-analysis.
Small sample size was a common shortcoming in the
studies, which was mentioned by some authors [22, 23, 25,
27]. Abramson et al. [22] pointed out that despite this
limitation, the results were statistically significant and
demonstrate that the treatment effect was large enough to
be perceived on a small sample.
The dissimilarity in the distribution of gender and the
wide age range of the samples limit the accuracy of the
extension of changes caused by the surgical procedure.
These issues were addressed by Butterfield et al. [23].
However, Valladares-Neto et al. [26] and Brunetto et al.
[27] found no relationship between the extension of
increase of the volume and the variables gender and age.
As Raffaini and Pisani [25] carried out a study including
only women, no correlation related to gender could be
established. The other studies [22–24, 28] did not correlate
the increased volume observed with the variables gender
and age.
The outcome of interest in this meta-analysis was the
modification of the upper airway volume, which is of great
importance particularly because of the relationship of the
upper airways with OSA. Therefore, the body mass index,
apnea index, and the positive diagnosis of OSA were
recorded during the data collection. Only the studies by
Butterfield et al. [23, 24] showed a comparison between the
baseline and final averages of the apnea index. Abramson
et al. [22] pointed out that patients submitted to surgery
tend to be uncompliant to undergo new polysomnography
imaging, because of cessation or reduction of the symp-
toms, leading to lack of interest. In the studies in which the
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individuals were not diagnosed with OSA [25–27], there
was no record of this index. Although having referred to
the existence of patients with OSA, Hernández-Alfaro et al.
[28] did not describe the number of OSA individuals or the
index value. It is important to highlight that although some
patients do not have symptoms of OSA, it does not mean
that they do not have the disease, given that diagnosis is
determined by polysomnography [22, 23].
The average body mass index was recorded at two dif-
ferent periods in two studies [23, 24]. This information is
important as the improvement in the symptoms of apnea may
be somehow related to a loss of weight after surgery [8, 28].
Another limitation of the study is the assessment
checkpoints. There is no consensus in the literature
regarding the most appropriate moment to make follow-up
assessments. Although the follow-up in these studies was
performed on average within the first year [23, 25–28], CT
scans obtained up to 49 months after surgery were also
used. Butterfield et al. [23] commented that the lack of
uniformity of checkpoints could lead to different results for
the same patient. In addition, no long-term follow-up has
been reported in the literature, but there is a concern about
the stability of the upper airway volume increase after a
long period of time. Usually, this type of evaluation is not
carried out due to ethical issues involved in exposing
patients to unnecessary radiation.
Our study indicates that the direct relationship between
the extension of maxillomandibular advancement and an
increased volume in the upper airways is well established
[24, 27]. Bimaxillary advancements greater than 10 mm
are considered effective to improve OSA [26, 27]. Despite
the fact that all selected studies [22–28] have shown a
significant increase in volume, the advancement averages
found ranged from 0 to 9.2 mm. Therefore, no studies
showed maxillary advancement greater than or equal to
10 mm. On the other hand, mandibular advancements
greater than 10 mm were achieved, with the exception of
two studies [27, 28].
A great concern was raised on the validity of the airway
measurements via CBCT and the reproducibility of this
method. Among the seven articles included in this review,
six [22–25, 27, 28] did not perform statistical tests to check
inter- and intra-examiner agreement. Nonetheless, one
study found significant intra-examiner agreement [26].
The tomographic scanning time ranged between 7 and
40 s. Some studies [22–24] did not mention the time
elapsed to obtain images. The CT scan may vary according
to the breathing movements of patients [23, 27, 28]. If the
patient breathes deeply, speaks, swallows, or coughs, the
formed image may appear deformed or result in the com-
position of multiple images.
There is a difference between the scanning position of
the patient and the sleeping position, which may raise
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questions about the morphology and size of the airways for
each of these two positions [14, 32]. Butterfield et al. [24]
pointed out that one should be careful when comparing the
morphology of the static airways (patient awake in vertical
position), with its dynamic counterpart (supine position
during REM sleep). According to Abramson et al. [22], the
muscle tone of the upper airways is loose during sleep,
which could potentially exacerbate any constrictions of the
airways during wakefulness. Thus, despite the anatomical
differences between the two states of consciousness, the
measurements performed in the supine position can be
correlated with the presence and severity of OSA.
The determination of anatomical limits varied among
the selected studies, making it difficult to measure the
real gain in volume resulting from the surgery. However,
as a statistically significant increase in volume was
observed in all studies [22–28], small variations in the
anatomical limits did not seem to have great influence on
the results. According to Brunetto et al. [27], the cali-
bration and training of examiners, and the determination
of a threshold value, are critical for the reliability of the
method.
Conclusions
Based on the results of this systematic review, there is clear
evidence that the bimaxillary advancement surgery can
effectively increase the volume of the upper airways.
Nevertheless, the standardization of anatomical limits and
methods for determination of area remains to be estab-
lished to elucidate the actual benefits of this type of
surgery.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict
of interest.
Ethical approval This article does not contain any studies with
human participants or animals performed by any of the authors.
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