J Oral Maxillofac Surg

69:e165-e176, 2011

Maxillomandibular Advancement for

Treatment of Obstructive Sleep Apnea
Syndrome: A Systematic Review
Katharina Pirklbauer, MD, DMD,*
Guenter Russmueller, MD, DMD,†
Leopold Stiebellehner, MD, PhD,‡ Christina Nell, MD, DMD,§
Klaus Sinko, MD, DMD,储 Gabriele Millesi, MD, DMD,¶ and
Clemens Klug, MD, DMD, PhD#

Purpose: To perform a systematic review of the published data concerning maxillomandibular ad-
vancement for the treatment of obstructive sleep apnea syndrome.
Materials and Methods: A systematic literature search was performed in the PubMed database.
Original articles in the English language were reviewed to obtain information about patient data, success
rates, and outcome measures.
Results: The systematic literature search yielded 1,113 citations, of which 101 articles met our
inclusion criteria. After a review of the full text, 39 studies were included in the analysis. Most
articles were classified as evidence level 4, and 5 met the inclusion criteria for level 2b. The only
prospective randomized controlled study had been published in January 2010 and was assigned level
1b.
Conclusions: A recommendation grade of A to B was achieved with regard to the levels of evidence-
based medicine. Our results have shown that maxillomandibular advancement is the most successful
surgical therapy, and the postoperative polysomnography results are comparable to those under venti-
lation therapy.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:e165-e176, 2011

Obstructive sleep apnea syndrome (OSAS) is a com-
mon disorder caused by upper airway collapsibility
during sleep. The common symptoms are snoring and
excessive daytime sleepiness because of a disturbed
sleep pattern and less restorative sleep owing to the
recurrent hypoxia events.
The increased risk of accidents and cardiovascular
complications such as myocardial infarction and
stroke are life-threatening sequelae.1-5 In addition, pa-
tients have depression, intellectual and physical im-
pairment, headache, and erectile dysfunction.
Ventilation therapy, such as continuous positive
airway pressure (CPAP), is the reference standard of
treatment; however, many patients are unable to tol-
erate lifelong therapy with a ventilation device.6-9
Maxillomandibular advancement (MMA) has been
reported to be the most successful surgical treatment.
The procedure is routinely performed to correct dys-

*Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Austria.
†Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Austria.
‡Department of Internal Medicine IV, Medical University of Vi-
enna, Austria.
§Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Austria.
储Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Austria.
¶Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Austria.
#Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Austria.
Address correspondence and reprint requests to Dr Pirklbauer:
Department of Oral and Maxillofacial Surgery, Medical Univer-
sity of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria;
e-mail: katharina.pirklbauer@meduniwien.ac.at
© 2011 American Association of Oral and Maxillofacial Surgeons
0278-2391/11/6906-0070$36.00/0
doi:10.1016/j.joms.2011.01.038

e165
e166 MMA FOR TREATMENT OF OSAS

gnathia. It results in widening of the pharynx and Table 2. GRADES OF RECOMMENDATION AND
enhances the tension of the soft tissues, reducing the LEVELS OF EVIDENCE
collapsibility and obstruction of the pharynx.10-13 The
surgical technique and pre- and postoperative care in Recommendation Evidence
Grade Level Study Type
the treatment of OSAS have been extensively de-
scribed in previous studies.14,15 A 1a Systematic review of
The objective of the present study was to review randomized controlled
the published English-language data and evaluate the trials
1b Individual randomized
effectiveness of MMA for the treatment of OSAS. controlled trial
B 2a Systematic review of cohort
studies
Materials and Methods 2b Individual cohort study
A multistep search of the Web-based PubMed data- 3a Systematic review of case
control studies
base was performed using the following key words: 3b Individual case control
sleep apnea, MMA, cephalometry, osteotomy, orthog- studies
nathic surgery, phase I and II surgery, and maxilloman- C 4 Case series/case report
dibular advancement. The linked search terms and num- D 5 Expert opinion, bench
ber of obtained citations are summarized in Table 1. research
The inclusion criteria were as follows: 1) original Data adapted from Oxford Centre of Evidence-Based
articles in the English language; 2) publication be- Medicine.16
tween 1985 and January 2010; 3) patient age between Pirklbauer et al. MMA for Treatment of OSAS. J Oral Maxillofac
20 and 65 years; 4) diagnosis of OSAS using polysom- Surg 2011.
nography (PSG); 5) the absence of acromegaly,
craniofacial syndromes, or temporomandibular joint
disorders; and 6) MMA as the principal treatment. The studies and case-control studies and their reviews,
sample size was not an inclusion criterion. respectively. Case series reach level 4, and expert
The reference sections of the studies identified by opinions are classified as level 5, the lowest level of
this procedure were searched for additional articles. evidence. These evidence levels give rise to the rec-
Single case reports, letters, reviews, exclusive de- ommendation grades A to D.
scriptions of surgical technique, and redundant pa- A meta-analysis was not performed.
tient data were excluded.
The quality of the studies was assessed according to
Results
the criteria defined by the Oxford Centre of evidence-
based medicine. Each article was assigned to a desig- We generated 1,113 hits and identified 101 poten-
nated level of evidence (Table 2).16 Level 1 refers to tially relevant articles. After a review of the full text,
randomized controlled trials or the systematic re- 42 reviews, 11 case reports, 1 letter to the editor, and
views of such studies. Levels 2 and 3 include cohort 8 articles containing data that had appeared else-
where were excluded (Fig 1).
A total of 39 articles were reviewed and divided
Table 1. PUBMED SEARCH TERMS AND RESULTING into 2 groups. Group A consisted of 28 articles de-
CITATIONS scribing the pre- and postoperative PSG results (Table
3). The subjects had undergone MMA as treatment of
Search Hits
OSAS. Additional surgical interventions were listed.
Sleep apnea ⫹ MMA 23 The numbers of reported cases, patient data, and
Sleep apnea ⫹ cephalometry 527 follow-up period were given. The success rates
Sleep apnea ⫹ osteotomy 187
Sleep apnea ⫹ orthognathic surgery 44
ranged from 52% to 100%, depending on the criteria
Sleep apnea ⫹ phase surgery 51 defined by the investigators. In no study was MMA
Sleep apnea ⫹ maxillomandibular advancement 78 found to be ineffective.
Maxillomandibular advancement ⫹ MMA 21 In terms of quality, 22 articles were graded as level
Maxillomandibular advancement ⫹ cephalometry 69 4, 5 were graded level 2b, and 1 as level 1b. The
Maxillomandibular advancement ⫹ osteotomy 87
Maxillomandibular advancement ⫹ orthognathic
number of subjects included in the articles ranged
surgery 20 from 3 to 175. The mean duration of follow-up was 6
Maxillomandibular advancement ⫹ phase surgery 6 months (range 6 weeks to 50.7 ⫾ 31.9 months).
Total 1,113 Adjunctive surgical interventions were mentioned
Pirklbauer et al. MMA for Treatment of OSAS. J Oral Maxillofac in 18 articles. Subjective measures such as the Ep-
Surg 2011. worth sleepiness scale (ESS) score, questionnaires
PIRKLBAUER ET AL
FIGURE 1. Flow diagram of lit-
erature search (n ⫽ excluded
citations).
Pirklbauer et al. MMA for
Treatment of OSAS. J Oral Max-
illofac Surg 2011.
about esthetic concerns, and the patient’s percep-
tion or objective findings such as reaction time tests
or imaging results were mentioned under additional
findings.
Three studies reported on esthetic changes using
nonvalidated questionnaires.17-19 In 2 studies, a visual
analog scale was used to show the patients’ percep-
tion and satisfaction.20,21 Nonvalidated questionnaires
were also used to register subjective symptoms.11,22 The
ESS was used to obtain information about improvement
of daytime sleepiness in 3 articles.21,23-25 The Functional
Outcomes of Sleep Questionnaire was used to measure
changes in quality of life in 1 article.26,27 A reaction time
test was used to quantify the objective improvement of
vigilance in an additional article.22 Computed tomogra-
phy scans and nasopharyngoscopy were mentioned in
one study each.28,29 Widening of the pharynx, quanti-
fied at the level of posterior airway space, was described
in 9 studies.12,13,18,19,24,29-32 The PSG results after MMA
and for patients receiving ventilation therapy were com-
pared in 6 articles.12,22,32-35 When reported in the stud-
ies, the average quantity of MMA was listed.
e167
Group B consisted of 11 heterogeneous articles
without PSG results, which provided additional in-
formation such as long-term skeletal stability, post-
operative endoscopic findings, soft tissue changes,
or the need for bone grafting. All articles were
graded as level 4 and are summarized in Table 4,
including the sample size, objective, and principal
findings.
Discussion
We performed a systematic review of the published
data concerning MMA for the treatment of OSAS. To
our knowledge this is the most extensive review on
the subject.
A meta-analysis was not performed for the follow-
ing reasons. First, it was difficult to quantify the entire
reviewed sample size because different outcome mea-
sures were used. The PSG findings were presented as
the respiratory disturbance index (RDI) in 17 studies,
and the apnea-hypopnea index (AHI) was used in 11
studies. Second, an overlap of patients could not be
ruled out in some articles.
 e168
Table 3. PRIMARY ARTICLES REPORTING PRE- AND POSTOPERATIVE PSG RESULTS

Patients (n); Mean Age

PSG Findings
Investigator, (yr); Men (%); BMI Success
Year LOE (kg/m2) Additional Surgery (n) Preoperative Postoperative Follow-Up Success Criteria Rate Additional Findings

Bettega et 4 20; 45; 90%; 26.9 ⫾ 4.3 Before MMA: phase I: 13 AHI 59.3 ⫾ 29.0/h AHI 11.1 ⫾ 8.9/h 6 mo AHI ⬍15/h and reduction 75% Advancement: 11.8 ⫾ 0.5 mm
al,47 2000 of AHI ⬎50% Complications
Blumen et 4 50; 46.4 ⫾ 9.0; 98%; Before MMA: UPPP, 11; AHI 65.5 ⫾ 26.7/h AHI 14.4 ⫾ 14.5/h 11.6 ⫾ 13.7 mo AHI ⬍20/h and reduction 80%/52% Complications/adverse effects
al,17 2009 28.9 ⫾ 4.6 UPPP ⫹ septoplasty ⫹ of AHI ⬎50%/AHI Functional and cosmetic changes
partial turbinectomy, 7; ⬍10/h Advancement (maxilla/mandible):
UPPP ⫹ genioglossus 7.4 ⫾ 1.6 mm/11.2 ⫾ 1.4 mm
advancement, 1;
septoplasty, 1;
septoplasty ⫹
tonsillectomy, 1
Conradt et 4 15; 44 ⫾ 12; 93.3%; None AHI 51.4 ⫾ 16.9/h AHI 5.0 ⫾ 5.8/h 6-12 wk AHI ⬍10/h 80% Long-term results
al,33 1997 28.3 ⫾ 3.4 AHI 8.5 ⫾ 9.4/h Minimum 2 yr CPAP: AHI 3.9 ⫾ 5.3/h
Conradt et 2b 24; 42.7 ⫾ 10.7; 100%; None RDI 59.3 ⫾ 24.1/h RDI 5.6 ⫾ 9.6/h 3 mo CPAP: RDI 5.3 ⫾ 6.0/h
al,22 1998 26.7 ⫾ 2.9 Reaction time test
Preoperative: 0.96 s
CPAP: 0.77 s
Postoperative: 0.73 s
Questionnaire subjective symptoms
Dattilo et al,23 4 15; 44.2; 80%; NA None RDI 69.4/h RDI 10.6/h Min 8 wk RDI ⬍15/h or reduction 95% ESS
2004 of RDI ⬎50% Preoperative: 17.8
Postoperative: 4.7
Fairburn et 4 20; 47.55; 65%; 33.85 Before MMA: UPPP and/or AHI 69.22/h AHI 18.57/h 3-6 mo Preoperative ⫹ postoperative CT scan:
al,28 2007 septoplasty, 15 enlargement of lateral diameter
greater than anteroposterior
diameter of pharynx
Goh et al,53 4 11; 42.8; 100%; 29.4 Before MMA: phase I, 3; AHI 70.7 ⫾ 15.9/h AHI 11.4 ⫾ 7.4/h 7.7 mo AHI ⬍20/h and reduction 82%
2003 tracheotomy, 1 of AHI ⬎50%
Gregg et al,38 4 35; 41; 88.6%; NA None RDI 50.5/h RDI 17.2/h 3-6 mo RDI ⬍10/h/reduction of 89%/94%
2000 RDI ⬎50%
Guilleminault 4 18; 41.0 ⫾ 13.5; 88.9%; Before MMA: UPPP ⫹ RDI 65.5 ⫾ 20.1/h RDI 8.5 ⫾ 5.6/h 6 mo
et al,34 31 ⫾ 7.4 hyoid myotomy, 18
1989
Hendler et 4 7; 47.0 ⫾ 6.22; 86%; Before MMA: tracheotomy, RDI 90.0 ⫾ 31.5/h RDI 16.5 ⫾ 23.62/h 6 mo RDI ⬍20/h and reduction 86% Advancement (maxilla/mandible):
al,58 2001 36.3 4; genioglossus of RDI ⬎50% 7.4 ⫾ 1.7/10.2 ⫾ 2.3 mm
advancement, 2;
simultaneous:
genioglossus

MMA FOR TREATMENT OF OSAS

advancement, 5
Hochban et 4 38; 42.76; 94.7%; NA After MMA: UPPP ⫹ AHI 45.16/h AHI 2.29/h 2 mo AHI ⬍10/h 97% Advancement (maxilla/mandible):
al,10 1997 genioplasty ⫹ palatal mandible: 9.5/10.8 mm
advancement, 2 Postoperative PSG results comparable
with CPAP results
Hoekema et 4 4; 50.3 ⫾ 4.9; 100%; Reconstruction of nasal AHI 49.5 ⫾ 20.7/h AHI 1.5 ⫾ 1.1/h 4-8 mo Advancement (maxilla/mandible):
al,24 2006 29.5 ⫾ 3.6 septum plus UPPP, 1; 8.9/8.5 mm
reconstruction of nasal PAS
septum, 1 Preoperative: 9.3 mm
Postoperative: 15.8 mm
ESS
Preoperative: 9.25
Oral appliance: 4.25
Postoperative: 1.25
 PIRKLBAUER ET AL
Table 3. PRIMARY ARTICLES REPORTING PRE- AND POSTOPERATIVE PSG RESULTS (cont’d)

Patients (n); Mean Age

PSG Findings
Investigator, (yr); Men (%); BMI Success
Year LOE (kg/m2) Additional Surgery (n) Preoperative Postoperative Follow-Up Success Criteria Rate Additional Findings

Lee et al,59
4 3; 42.7; NA; NA Before MMA: phase I, 3 RDI 74.0 ⫾ 24.2/h RDI 5.0 ⫾ 2.4/h 4-6 mo RDI ⬍20/h and oxygen 100%
1999 saturation ⬎95%
Li et al,36 2b 175; 43.5; NA; NA Before MMA: phase I, 86; RDI 72.3 ⫾ 26.7/h RDI 7.2 ⫾ 7.5/h 6 mo AHI ⬍20/h and reduction 95% CPAP: RDI 8.2/h
1999 UPPP, 78 of AHI ⬎50%
Li et al,30 4 40; 45.6 ⫾ 20.7; 82.5%; Before MMA: phase I, 40 RDI 71.2 ⫾ 27.0/h RDI 9.3 ⫾ 5.4/h 6 mo AHI ⬍20/h and reduction 90% Long-term results
2000 31.4 ⫾ 6.7 RDI 7.6 ⫾ 5.1/h 50.7 ⫾ 31.9 mo of AHI ⬎50% PAS
Preoperative: 3.7 ⫾ 1.6 mm
Postoperative: 10.1 ⫾ 2.1 mm
Long-term: 6.7 ⫾ 1.9 mm
Advancement: 10.8 ⫾ 2.7 mm
Li et al,20 4 42; 46.3 ⫾ 6.6; 86%; Before MMA: phase I, 42; RDI 58.7 ⫾ 21.5/h RDI 10.0 ⫾ 8.6/h 6 mo RDI ⬍20/h and reduction 88% Questionnaire (VAS) about patient
2000 32.1 ⫾ 6.0 tracheotomy, 4 of RDI ⬎50% acceptance: 95% would have
surgery again
Li et al,18 4 19; 45.3 ⫾ 6.6; 78.9%; Before MMA: phase I, 19 RDI 63.3 ⫾ 20.8/h RDI 8.1 ⫾ 5.9/h 6-12 mo Questionnaire about esthetic
2000 33.1 ⫾ 7.1 concerns (VAS) of patients
without mandible deficiency: 10
felt more attractive, 8 neutral
response, 1 less attractive
PAS
Preoperative: 5.1 ⫾ 2.4 mm
Postoperative: 9.7 ⫾ 3.1 mm
Li et al,31 4 21; 42.6 ⫾ 7.9; 61.9%; Before MMA: tracheotomy, RDI 83 ⫾ 30.1/h RDI 10.6 ⫾ 10.8/h 6 mo (21.8 ⫾ RDI ⬍20/h and minimal 81% Obese patients
2000 45 ⫾ 5.4 11; phase I, 16; UPPP, 5 15.4 mo) desaturation ⬍90% PAS
Preoperative: 7.0 ⫾ 4.6 mm
Postoperative: 11.2 ⫾ 3.8 mm
Advancement: 11.7 ⫾ 2.3 mm
Li et al,49 4 52; 46.6 ⫾ 6.7; 83%; Before MMA: UPPP, 52 RDI 61.6 ⫾ 23.9/h RDI 9.2 ⫾ 8.0/h 6-12 mo Questionnaire about velopharyngeal
2001 32.0 ⫾ 6.0 insufficiency (VAS)
Advancement: 10.5 ⫾ 1.5 mm
Li et al,19 4 44; 46.5 ⫾ 6.5; 88.6%; NA RDI 60.3 ⫾ 22.2/h RDI 10.8 ⫾ 9.4/h 6-12 mo Questionnaire about esthetic
2001 32.4 ⫾ 6.2 concerns (VAS): 24 felt more
attractive; 14, neutral response;
4, less attractive
PAS
Preoperative: 5.1 ⫾ 2.2 mm
Postoperative: 9.5 ⫾ 2.9 mm
Li et al,29 4 12; 47.3 ⫾ 9.8; 75%; NA RDI 75.3 ⫾ 26.4/h RDI 10.4 ⫾ 10.8/h PAS
2002 33.5 ⫾ 6.2 Preoperative: 6.0 ⫾ 2.0 mm
Postoperative: 10.4 ⫾ 3.6 mm
Advancement: 10.5 ⫾ 1.2 mm
Nasopharyngoscopy performed
6 mo after MMA showed less
obstruction in 11 patients
Lye et al,27 4 15; 47.93; 86.7%; 32.1 UPPP, genioplasty, or AHI 69.12/h AHI 13.87/h 4-6 mo AHI ⬍20/h and reduction 87% FOSQ
2008 septorhinoplasty, 12 of AHI ⬎50% Preoperative: 14.4
Postoperative: 18.9
Advancement (maxilla/mandible):
8.59/8.96 mm

e169
 e170
Table 3. PRIMARY ARTICLES REPORTING PRE- AND POSTOPERATIVE PSG RESULTS (cont’d)

Patients (n); Mean Age

PSG Findings
Investigator, (yr); Men (%); BMI Success
Year LOE (kg/m2) Additional Surgery (n) Preoperative Postoperative Follow-Up Success Criteria Rate Additional Findings

Prinsell,32 2b 50; 42.7 ⫾ 9.3; 88%; Before MMA: tonsillectomy, AHI 59.2 ⫾ 28.4/h AHI 4.7 ⫾ 5.9/h 5.2 mo AHI ⬍15/h, AI ⬍5/h, or 100% CPAP: AHI: 5.4 ⫾ 6.8/h
1999 30.7 ⫾ 4.5 26; UPPP, 10; reduction in AHI ⬎60% PAS
tracheotomy, 2; Preoperative: 5.1 ⫾ 2.4 mm
simultaneous: Postoperative: 11.6 ⫾ 3.4 mm
genioplasty, 50; Questionnaire about subjective
turbinectomy, 26; symptoms
septorhinoplasty, 28;
lipectomy, 26
Riley et al,35 2b 30; 44.8 ⫾ 10.4; 76.7%; Before MMA: UPPP, 25; RDI 72.0 ⫾ 25.8/h RDI 8.8 ⫾ 1.0/h Min 6 mo CPAP: RDI 8.6 ⫾ 4.3/h
1990 32.6 ⫾ 6.0 simultaneous: hyoid
advancement, 30
Riley et al,12 2b 91; 43.5 ⫾ 11.5; 31.1 ⫾ Before MMA: phase I, 24; RDI 68.3 ⫾ 23.3/h RDI 8.4 ⫾ 5.9/h 6 mo AHI ⬍20/h and reduction 98% CPAP: RDI 7.6 ⫾ 5.9/h
1993 6.3 UPPP, 60 of AHI ⬎50% PAS
Preoperative: 4.3 ⫾ 1.8 mm
Postoperative: 9.4 ⫾ 2.2 mm
Smatt et al,60 4 18; 46.6 ⫾ 6.06; 83.3%; Simultaneous: UPPP ⫹ AHI 54.0 ⫾ 20.7/h AHI 9.65 ⫾ 6.7/h 6 mo AHI ⬍15/h and reduction 84% Advancement (maxilla/mandible):
2005 29.23 ⫾ 4.14 glossoplasty ⫹ of AHI ⬎50% mandible: 5.24 ⫾ 1.8 mm/
genioplasty, 18 10.66 ⫾ 2.82 mm
Vicini et al,21 1b 25; 49.1 ⫾ 9.1; 92%; None AHI 56.8 ⫾ 16.5/h AHI 8.1 ⫾ 7.0/h 12 mo ESS
2010 32.7 ⫾ 5.8 Preoperative: 11.6 ⫾ 2.8
Postoperative: 7.7 ⫾ 1.3
Subjective overall satisfaction (VAS)
Waite et al,13 4 23; 45; 91.3%; NA Before MMA: UPPP, 5; RDI 63/h RDI 15/h 6 mo RDI ⬍10/h 65% Advancement (maxilla/mandible):
1989 simultaneous: Reduction of AHI ⬎50% 86% 7.3/12.5 mm
turbinectomy, PAS: ⫹7 mm
septorhinoplasty, 23;
after MMA: genioplasty,
15; glossectomy, 8;

MMA FOR TREATMENT OF OSAS

UPPP, 2

Abbreviations: LOE, level of evidence; BMI, body mass index; PSG, polysomnography; MMA, maxillomandibular advancement; AHI, apnea-hypopnea index; RDI, respiratory
disturbance index; NA, data not available; CPAP, continuous positive airway pressure; UPPP, uvulopalatopharyngoplasty; ESS, Epworth Sleepiness Scale; VAS, visual analog
scale.
Pirklbauer et al. MMA for Treatment of OSAS. J Oral Maxillofac Surg 2011.
PIRKLBAUER ET AL e171

Table 4. PRIMARY ARTICLES REPORTING ADDITIONAL FINDINGS TO MMA IN THERAPY FOR OSAS

Investigator, Patients (n); Mean Age (yr);

Year Men (%); BMI (kg/m2) Objective Main Findings
52
Carlo et al, 4; 45; NA; NA Demonstration of MMA with Modification led to improvement of
2008 modified genioplasty esthetic results without
compromising clinical efficacy
Conley et 31; 45 ⫾ 8.1; 87%; 29.8 ⫾ 4.1 Evaluation of soft tissue changes after MMA resulted in soft tissue
al,51 2007 MMA movements, producing soft/hard
tissue ratio of 0.9:1
Gilon et al,48 17; 50; 94%; ⬎30 OSAS treated with maxillomandibular More complications in OSAS group
2001 osteotomy compared with patients owing to substantial size of
who underwent surgery for skeletal advancement and older
correction of dentofacial patient age
disharmonies
Li et al,45 98; NA; NA; NA Evaluation of upper airway In MMA patients, minimal edema of
2000 characteristics in early soft palate and base of tongue,
postoperative period after OSAS and diffuse lateral pharyngeal wall
surgery with nasopharyngoscopy edema identified; hypopharyngeal
hematoma occurred in 4 patients
Louis et al,56 20; 44; 90%; NA Evaluation of long-term stability and No statistically significant difference
1993 relapse comparing large and small in measured relapse according to
maxillary advancements with 4- quantity of advancement
plate rigid fixation without bone
grafting
Louis et al,50 15; NA; NA; NA Evaluation of soft tissue changes in Soft/hard tissue ratio of labrale
2001 upper lip associated with maxillary superius: upper incisor, 0.8:1;
advancement in OSAS nasolabial angle did not change
significantly
Lye et al,61 36; 47.3; 75%; NA Evaluation of predictability when Size of prebent plate did not
2008 using prebent advancement plates predictably correlate with
in maxillary osteotomies for MMA quantity of advancement achieved
and frequently underestimated it;
accurate model surgeries still
required in most cases
Miles et al,54 32; 47; 100%; NA Examination of pre- and Surgery resulted in significantly
1995 postoperative mandibular longer mandible, larger gonion
morphology in OSAS patients angle, and reduced mandibular
undergoing MMA and assessment plane-hyoid distance; surgical
of stability of observed changes changes in mandibular length
stable in long-term
Nimkarn et 19; NA; NA; NA Examination of long-term skeletal Maxillary and mandibular
al,55 1995 stability of relatively large advancement appeared to be
maxillomandibular advancement stable in horizontal and vertical
surgery for treatment of OSAS planes for long-term; no
significant correlation between
quantity of surgical advancement
and relapse, except for gonion in
vertical plane
Waite et al,57 22; 43; 86.4%; NA To determine whether better stability Stability in genial bone graft group
1996 achieved with genial bone grafts better than that in nongrafted
and 4-plate rigid fixation for large group
Le Fort I advancements than with
nongrafted osteotomies
Yu et al,62 2; 36.5; 100%; 28.9 Results of computational fluid Results showed less constricted
2009 dynamic study on OSAS treated airway with fewer changes in
with MMA velocity and reduced pressure
gradient; less breathing effort
expected to achieve equivalent
ventilation after MMA
Abbreviations: OSAS, obstructive sleep apnea syndrome; other abbreviations as in Table 3.
Pirklbauer et al. MMA for Treatment of OSAS. J Oral Maxillofac Surg 2011.
e172
STUDY QUALITY
According to the criteria defined by the Oxford
Centre of evidence-based medicine (Table 2), most of
the studies were assigned to evidence level 4, with 5
assigned to level 2b and 1 to level 1b.
In the latter prospective randomized controlled
trial, 50 consecutive patients were randomized to a
conservative ventilation treatment group and an MMA
group. At 1 year after surgery or ventilation therapy,
both groups showed remarkable improvement on the
PSG and ESS, and no statistically significant difference
was found in the degree of improvement between the
2 groups.21 MMA yielded results similar to those with
ventilation therapy, which appears to be the refer-
ence standard of treatment.
All 5 level 2b articles reported good results. Four
articles were graded level 2b because they provided
comparisons of postoperative PSG and PSG during
CPAP therapy without randomization.12,22,32,35 In
these studies, patients had undergone CPAP therapy
before MMA, and the postoperative PSG results were
similar to the reference standard of CPAP.
One article was graded level 2b because of its large
sample size of 175 patients.36
Most case series, all assigned level 4, were highly
consistent with respect to the effectiveness of MMA.
All the investigators confirmed the success of MMA
and considered bimaxillary osteotomy the most suc-
cessful surgical intervention for the treatment of
OSAS.
We have concluded that MMA is an alternative
treatment modality that spares patients the need for
lifelong therapy with a ventilation device. Grade A
appears to be unwarranted as a general recommenda-
tion because only a single level 1b article was found.
Given the large number of 2b studies, grade B would
appear justified. We believe that the available evi-
dence in the published data can be assigned to grade
A or B.
SUCCESS
In all the investigated studies, the pre- and postop-
erative PSG results—in particular, the AHI and RDI—
were compared to determine the surgical outcomes.
Owing to the extremely diverse outcome criteria
used, the success rates range from 65% to 100%.
Li et al30,36 and Riley et al12,37 used a decrease in the
AHI to less than 20/hour and a reduction greater than
50% in the AHI to define success, respectively. The
corresponding success rates were 95% and 98%, and
the long-term success rate registered by this research
group was about 90%.12,30,36,37
Other research groups distinguished between the
terms “cure” and “success.” Strictly speaking, the cure
achieved by surgery refers to postoperative findings
in the sleep laboratory that are equivalent to those of
MMA FOR TREATMENT OF OSAS
a healthy individual (AHI ⬍5/hour).13,38 Waite et al13
and Hochban et al10 defined success as an RDI and
AHI of less than 10/hour; they achieved a success rate
of 65% and 97%, respectively.
Prinsell32 defined success as the lowest arterial oxy-
hemoglobin desaturation level greater than 80%, an
AHI less than 15/hour, an Apnea Index of less than
5/hour or a 60% reduction in the AHI or Apnea Index
and achieved a success rate of 100%.
We concur with the investigators who adhered to
strict success rates, because a satisfactory postopera-
tive outcome should result in a PSG examination sim-
ilar to that of an individual without OSAS. A major
reduction in the AHI is undoubtedly indicative of
improvement and can be used as an index of success
or failure, but strict follow-up investigations are re-
quired in all cases.
ADJUNCTIVE PROCEDURES
In 21 studies, the following adjunctive procedures
were performed before, in conjunction with, or after
MMA in some patients: uvulopalatopharyngoplasty
(UPPP), genioglossus advancement, genioplasty, sep-
torhinoplasty, turbinectomy, tonsillectomy, hyoid sus-
pension, tracheotomy, lipectomy, and glossectomy
(Table 3).
Depending on the chronologic sequence of the
surgical procedures, the investigators of the Stanford
group considered MMA as phase II surgery after phase
I procedures such as UPPP or genioglossus advance-
ment had failed.12,30,34,39-41 The choice of the phase I
treatment modality was made after investigating the
site of obstruction, which was classified into Fujita
levels.42 Velopharyngeal obstruction and hypopha-
ryngeal obstruction led to UPPP and genioglossus
advancement, respectively. Obstruction at all levels
was treated by UPPP and genioglossus advancement
performed simultaneously in phase I surgery.
The rationale of this stepwise approach is to per-
form less-invasive surgery before bimaxillary osteot-
omy. Li et al20 investigated patients’ perception of
MMA and found that most patients were willing to
undergo the procedure again. MMA was less harmful
than phase I surgery.20,34
Because additional surgeries could render patients
unwilling to undergo an eventually effective proce-
dure, many investigators recommend MMA as the first
surgical intervention in selected patients.10,11,13,43
Furthermore, the resultant palatal scarring could limit
the extent of bimaxillary advancement and increase
the risk of velopharyngeal insufficiency.11 Prinsell et
al32 reported on 50 consecutive patients undergoing
MMA combined with genioplasty and, occasionally,
simultaneous nonpharyngeal adjunctive procedures,
such as cervicofacial lipectomy, turbinectomy, septo-
rhinoplasty, or sinus curettage. Simultaneous pharyn-
PIRKLBAUER ET AL
geal procedures such as UPPP or tonsillectomy should
not be performed because of the risk of bleeding and
reduction of the size of the oral orifice.15
Waite et al13 reported improvement in 22 of 23
patients who had undergone adjunctive surgical pro-
cedures such as genioplasty, glossectomy, or UPPP—
in some cases after failure of MMA. Because the pos-
terior airway space changes were not correlated with
clinical success, they consider the posterior airway
space an important factor of OSAS but not the only
region of obstruction. Waite et al13 recommend a
staging procedure or a combination of procedures
but, in contrast to the Stanford group, support the
view that MMA can be used as the primary surgical
procedure.
Hochban et al10 reported a success rate of 97%
using MMA as the primary procedure. Adjunctive pro-
cedures after MMA were performed in 2 patients. The
investigators considered a stepwise procedure unjus-
tified in patients selected according to the cephalom-
etry findings.10
Li44 modified the stepwise approach of the Stanford
group and used MMA as the primary surgical proce-
dure in patients with severe OSAS and specific skele-
tal deformities.
The advantage of MMA compared with other OSAS
procedures is the possibility of expanding the phar-
ynx from the level of the soft palate to the base of the
tongue. Furthermore, the results of surgery based on
skeletal advancement appear to be much more stable
than interventions in the soft tissue.
Reviewing the existing data, we found that MMA
was used as a primary intervention by more investi-
gators in the past few years than had been done in the
past. We conclude that OSAS patients with skeletal
deficiency could benefit from MMA as a primary sur-
gical intervention and should not be subjected to less
successful surgical procedures.
COMPLICATIONS
Bimaxillary osteotomies are routinely performed to
correct dentofacial dysgnathia. Because the same sur-
gical techniques are used for the treatment of OSAS,
similar complications can be anticipated. The com-
mon minor complications after bimaxillary osteoto-
mies include hypesthesia of the lower lip, local infec-
tion, malocclusion, and temporomandibular joint
disorders. Major complications include bleeding and
problems associated with general anesthesia.
To assess the risk of perioperative obstruction after
MMA, Li et al45 performed nasopharyngoscopy 24 and
72 hours after MMA in 98 patients. None of these
patients had postoperative airway obstruction, but 4
had a hypopharyngeal hematoma. Surgeons should be
aware of these rare, but life-threatening, complica-
tions because intubation can be very difficult after
e173
MMA. Under no circumstances should MMA be per-
formed in conjunction with UPPP because of the risk
of postoperative airway edema involving all areas of
the upper airway.45
Goodday46 investigated the radiographic changes
during the period of maximal postoperative edema.
Postoperative edema did not affect the anteroposterior
dimensions of the pharyngeal airway. An additional in-
vestigation performed by the same investigators showed
a general reduction in oxygen desaturation within 48
hours after MMA.46
Postoperative complications have been reported in
just a few studies. Blumen et al17 observed adverse
effects of MMA in patients with OSAS. The most
common minor complications were hypesthesia of
the lower lip, bleeding, and wound infection.17 Bet-
tega et al47 reported local infection, perforation of the
osteosynthesis plate, and pseudarthrosis occurring af-
ter 3 years.
In the randomized controlled trial, Vicini et al21
observed minor complications, such as hypesthesia of
cheek and chin and light malocclusion. A comparison
of the complication rates between those undergoing
MMA and those who received CPAP treatment is ren-
dered impossible by the basic difference in the ap-
proach of these treatment modalities.21
Waite et al13 reported postoperative cardiac prob-
lems with no lethal outcome in 2 patients.
A comparison of the complication rates between
the patients with OSAS treated with MMA and those
undergoing bimaxillary osteotomy for dysgnathia
showed more numerous complications in those with
OSAS. This might have been because of greater ad-
vancement, patient age, and poorer medical condi-
tions in the OSAS group.48
Li et al49 found no persistent velopharyngeal insuf-
ficiency in patients treated with MMA after UPPP had
failed. In a questionnaire survey, 5 of 52 patients
reported regurgitation of fluids but no hypernasal
speech or regurgitation of food. The velopharyngeal
insufficiency resolved without additional intervention
within 1 year.
In view of the severe cardiovascular sequelae, the
increased risk of accidents, and impairment of quality
of life, the minor surgical complications of this pro-
cedure appear to be of secondary importance for
patients with OSAS.
ESTHETIC CONCERNS
All investigators agree that a minimal advancement
of 10 mm is required for successful treatment of
OSAS. Adverse esthetic effects could be anticipated in
conjunction with this degree of skeletal modification.
However, in all the relevant studies, most of the
patients were satisfied with the postoperative out-
come, including those with no preoperative skeletal
e174
deficiency. The advancement of the jaws causes ten-
sion in the soft tissue of the face, resulting in a more
youthful appearance.18,19 Only a small number of
patients believed they were less attractive after
MMA.17-19
The investigators of 2 studies reported on the soft
tissue changes after MMA in patients with sleep ap-
nea. Louis et al50 investigated the soft tissue changes
in the upper lip after MMA and registered a slight
decrease of the nasolabial angle, although the lip
length did not change significantly. Conley and
Boyd51 found a soft/hard tissue ratio of 0.9:1 for most
anatomic sites after MMA in patients with sleep ap-
nea.
Some investigators have tried to modify surgical
techniques to achieve greater advancement with min-
imal adverse esthetic effects. Bruno-Carlo et al52 de-
scribed monocortical genioplasty and Goh et al53 per-
formed segmentosteomy after premolar extraction in
both jaws.
LONG-TERM RESULTS
Skeletal relapse is a well-known problem in orthog-
nathic surgery and is even more relevant in patients
with OSAS because of the large degree of skeletal
advancement used in this setting. During an observa-
tion period of 48 and 12 months, respectively, Miles
and Nimkarn54 and Nimkarn et al55 observed rela-
tively stable skeletal conditions in both jaws after
large surgical advancement.
Louis et al56 found no significant correlation be-
tween the quantity of the advancement and the inci-
dence of skeletal relapse. They investigated cephalo-
metric analysis at 1 week and at least 6 months
postoperatively in 20 patients.56
Waite et al57 recommend interposition of bone
grafts to reduce skeletal relapse and enhance long-
term stability. The study included 22 patients, all of
whom underwent MMA: 11 with bone grafts from the
chin and 11 without bone grafts. Both groups
achieved similar advancement, but the mean relapse
rate was 7% in the grafted group and 18% in the
nongrafted group.57
Concerning the long-term PSG results, notable find-
ings have been reported in 2 studies. Conradt et al33
reported long-term success rates of 80% during an
observation period of 24 months. No significant
changes were registered when the 6- to 12-week post-
operative outcomes were compared with long-term
results.33
To our knowledge, Li et al performed the longest
follow-up investigations spanning a period of 50.7 ⫾
31.9 months, and achieved a success rate of 90%.30
All investigators agree that longer follow-up periods
are required to obtain data about the incidence of
potential relapse or aggravation of OSAS. However,
MMA FOR TREATMENT OF OSAS
only 2 studies with small patient populations have
investigated long-term results. The existing data are
promising in that MMA has proved to be a stable
treatment modality in the long-term.
SUBJECTIVE AND OBJECTIVE OUTCOMES
Questionnaires containing questions about daytime
fatigue or vigilance and the ESS were used to quantify
subjective improvement. Three investigators used the
ESS, which was reduced after MMA in all studies.21,23,24
Individual questionnaires concerning subjective out-
comes also revealed improvement.21,22,30,32
The Functional Outcomes of Sleep Questionnaire
was used by Lye et al27 and showed improvement in
quality of life in patients with OSAS treated with
MMA. Of 15 patients, 93% achieved a positive change
in their quality of life. The change in the AHI corre-
lated with the degree of Le Fort I advancement. How-
ever, the PSG and Functional Outcomes of Sleep
Questionnaire parameters do not coincide.27
Conradt et al22 used a reaction time test to quantify
the increase in daytime vigilance and registered pos-
itive effects on sleep patterns and wakefulness, simi-
lar to those seen after CPAP therapy. According to
their study, daytime vigilance— one of the principal
symptoms of OSAS—is improved by MMA.
OSAS is associated with severe cardiovascular se-
quelae. To assess arterial hypertension, Prinsell32
looked for a potential decrease in systolic and dia-
stolic blood pressure after MMA. It remains unclear
whether the reduction was achieved by curing the
OSAS or by the weight loss resulting from a strict
postoperative diet.32 The effect of the postoperative
body mass index on the general postoperative out-
come is also unclear in all studies.
In addition to improving the postoperative AHI/
RDI, relief from the symptoms of OSAS and a better
quality of life should be the primary aims of treating
this condition. Given the general improvement of
subjective symptoms and quality of life after MMA, it
can be regarded as a powerful treatment modality. No
data exist about the improvement of quality of life
after MMA compared with CPAP therapy.
The existing evidence in the published data sup-
ports the recommendation of grade A or B for the use
of MMA to treat OSAS.
More randomized controlled trials, long-term inves-
tigations, and larger sample sizes are needed to
achieve the recommendation of grade A. MMA is the
most successful surgical option for the treatment of
OSAS and an excellent alternative procedure for non-
responders or deniers of ventilation therapy.
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