Changes in the calibre of the upper airway and the surrounding structures after maxillomandibular advancement for obstructive sleep apnoea

doi:10.1016/j.bjoms.2014.02.006

British Journal of Oral and Maxillofacial Surgery

Volume 52, Issue 5, May 2014, Pages 445-451

https://doi.org/10.1016/j.bjoms.2014.02.006 Get rights and content

Abstract

Maxillomandibular advancement (MMA) is effective in the treatment of obstructive sleep apnoea. We aimed to assess changes in the calibre of the upper airway, facial skeleton, and surrounding structural position after MMA and their association with improvement in symptoms. Sixteen consecutive adults with moderate-to-severe apnoea were treated by primary MMA. Polysomnography and computed tomography (CT) of the head and neck were done before and at least 6 months after MMA. The calibre of the upper airway, the facial skeleton, and the surrounding structures were measured with image analysis software. After MMA, patients had a significant reduction in their apnoea-hypopnoea index (31.2 (18.8) number of events (n)/hour (h)). The mean (SD) volume of the airway increased significantly in the velopharynx (p < 0.01), oropharynx (p = 0.001), and hypopharynx (p < 0.001) (by 2.3 (2.4), 2.1 (2.6), and 1.7 (1.1) cm³, respectively) and the length of the airway was significantly decreased (by 3.1 (3.5) mm p < 0.01). The soft palate (p < 0.001), tongue (p < 0.001), and hyoid (p = 0.001) moved significantly anteriorly (by 4.4 (2.0), 7.5 (2.8), and 5.7 (5.0) mm, respectively), and these movements were related to the MMA (r = 0.6–0.8). The improvement in the apnoea-hypopnoea index was associated with both maxillary advancement and anterior movements of the soft palate and hyoid (r = 0.6–0.7). The results of this study suggest that MMA increases the volume in the upper airway and reduces its length. Improvement in obstructive sleep apnoea is associated with the extent of the anterior movements of the maxilla, soft palate, and hyoid.

Introduction

Maxillomandibular advancement (MMA) is used in the treatment of obstructive sleep apnoea as an effective alternative to continuous positive airway pressure (CPAP).¹ While CPAP remains the gold standard because it is highly efficacious, other options are needed because the clinical effectiveness of CPAP is often limited because patients find it difficult to tolerate.² MMA advances the maxilla and mandible to increase the calibre of the upper airway, thereby preventing its collapse during sleep. However, the mechanisms by which MMA improves sleep apnoea are not well understood.

Although MMA has been shown to improve the calibre of the upper airway,3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 these studies predominantly used cephalometric radiographs for assessment. Such measurements have the disadvantage that the images are usually taken with the patient upright (not a natural sleeping position), and a lateral cephalometric view of the airway limits its 3-dimensional form by not capturing the width of the airway. The surrounding structures (soft palate, tongue, and hyoid), the interaction between the upper airway and the surrounding structures, and the response to treatment, have never been systematically studied to our knowledge in patients treated by MMA.

Computed tomography (CT) is probably one of the best methods for assessment of the 3-dimensional structures of the upper airway, facial skeleton, and surroundings. In this study we aimed to evaluate the mechanism that underlies MMA in patients with obstructive sleep apnoea, and we used CT to assess the effects on the calibre of the upper airway and on the surrounding structures when the patient was awake.

Section snippets

Patients

We prospectively recruited adult patients with obstructive sleep apnoea from the Sleep Centre for primary treatment with MMA. Patients were included if they had at least 2 symptoms of sleep apnoea (snoring, witnessed apnoeas, fragmented sleep, or daytime sleepiness) and they had moderate-to-severe obstructive sleep apnoea on nocturnal polysomnography (apnoea-hypopnoea index (AHI) ≥ 15 n/h).15, 16 Patients were excluded if they had cleft palate, genetic syndromes, or were unable to comply with the

Results

The sample comprised 16 patients, 12 men and 4 women, mean (SD) age 33 (7.9) years (range 22–48) and mean (SD) body mass index (BMI) 22 (3.3) (range 17–28). All but one patient had skeletal Class II deformities. The mean duration of follow-up was 12 (8) months. Although most patients lost some weight postoperatively, their BMI had returned to baseline by the time of postoperative polysomnography (p = 0.4).

Discussion

We have challenged the traditional thinking that the primary mechanism of MMA is to increase the anteroposterior dimensions of the velopharynx and oropharynx by advancing the soft palate and tongue, thereby preventing collapse of the upper airway during sleep. One key finding was that MMA improves the calibre of the upper airway, as a result of increased volumes in the velopharynx, oropharynx, and hypopharynx and is mediated by increases in their anteroposterior and lateral dimensions. These

Acknowledgement

This study was supported by Chang Gung Memorial Hospital, Taiwan (CMRP390742).

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Cited by (47)

Modified maxillomandibular advancement surgery for the treatment of obstructive sleep apnoea: a scoping review
2024, International Journal of Oral and Maxillofacial Surgery
Modified maxillomandibular advancement (MMMA) has been proposed as an alternative to the classic maxillomandibular advancement (MMA) in East and Southeast Asian populations in which bimaxillary protrusion is a prevalent trait. The key difference between MMMA and MMA is the inclusion of anterior segmental osteotomies to reduce the protrusion of the perioral region. The aim of this scoping review was to identify the variations in MMMA and treatment outcomes. A search was conducted in the PubMed, Embase, and Cochrane electronic databases for articles published up to January 2023. Ten articles were included in this review. Three variations of MMMA have been reported in the literature. Treatment outcomes have mostly been favourable for all of these variations. Mandibular advancement of >10 mm and a greater than 50% reduction in the apnoea–hypopnoea index (AHI) have been well reported. Improvements in other outcome measures, such as enlargement of the airway dimension on computed tomography and the Epworth Sleepiness Scale score, have also been shown. Despite additional surgical procedures, complications have been uncommon and mostly minor in nature. It is necessary to be cognizant of MMMA and its variations when providing sleep surgery for East and Southeast Asian patients, tailoring this to the patient’s profile and needs.
Surgical Correction of Maxillofacial Skeletal Deformities
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Comparison of airway changes after maxillomandibular advancement with or without genial tubercle advancement in obstructive sleep apnea using cone-beam computed tomography
2022, American Journal of Orthodontics and Dentofacial Orthopedics
This study compared the airway changes of patients with obstructive sleep apnea (OSA) after maxillomandibular advancement (MMA) with or without genial tubercle advancement (GTA) using cone-beam computed tomography.
The authors retrospectively studied 26 patients with moderate to severe OSA who underwent MMA with or without GTA. Airway changes were determined from preoperative and postoperative 3-dimensional reconstructed cone-beam computed tomography images. The Wilcoxon signed rank test, Mann-Whitney U tests, and Spearman correlation coefficients were used in data analysis.
Airway was changed in all dimensions significantly after MMA with or without GTA. There was no significant difference in horizontal surgical changes between MMA and MMA with the GTA group. The mean increase in total airway volume was 66.8% for MMA alone and 74.7% for MMA with GTA (P = 0.39). Patients who underwent MMA had a larger percentage change of segmented upper airway volume than patients with MMA and GTA (106.6% vs 85.3%; P = 0.65). The group with MMA and GTA had a greater percentage change of segmented lower airway volume than the MMA alone group (80.1% vs 56.3%; P = 0.42).
Differences in airway changes between MMA alone and MMA with GTA were not statistically significant. Performing the GTA concomitantly with MMA may not cause greater improvement in the pharyngeal airway in patients with OSA compared with MMA alone.
The correlation of maxillomandibular advancement and airway volume change in obstructive sleep apnea using cone beam computed tomography
2021, International Journal of Oral and Maxillofacial Surgery
The purpose of this retrospective study was to evaluate the correlation of maxillomandibular advancement (MMA) and airway volume changes in patients with obstructive sleep apnea (OSA), and to determine the surgical skeletal movements necessary to achieve an increase in total airway volume (TAV) of ≥70%. Thirty patients with OSA treated by MMA were evaluated. Pre- and postoperative cone beam computed tomography images were used to determine the horizontal distance and angular changes in surgical parameters and linear, area, and volumetric airway parameters. Postoperatively, the horizontal distance of surgical parameters (A-point, UI, B-point, pogonion, and menton) and craniofacial angulation (SNA and SNB) increased significantly, similar to total surface area, TAV, and minimum cross-sectional area of the airway (p < 0.0001). The total airway length decreased significantly (p < 0.0001). The mean increase in TAV was 67.2%. There were positive correlations between linear surgical changes and the percentage change in TAV. All surgical parameters were predictive of a change in TAV ≥70%. The optimal surgical change was 6 mm for A-point, 7.9 mm for UI, 7.6 mm for B-point, 11.2 mm for pogonion, and 10 mm for menton. In conclusion, maxillary advancement of less than 10 mm was adequate in this study to obtain an increase in the TAV of at least 70%.
Upper airways after mandibular advancement orthognathic surgery: A 4-year follow-up
2021, American Journal of Orthodontics and Dentofacial Orthopedics
The purpose of this study was to assess the stability of changes in the upper airways 4 years after orthognathic surgery in patients with skeletal Class II malocclusion.
A retrospective clinical study was conducted including 33 cone-beam computed tomography images from 11 patients (average age of 35.91 years) followed up longitudinally for 4 years. The airways were measured with the help of the Dolphin Imaging software (Dolphin Imaging and Management Systems, Chatsworth, Calif) at 3 points: T1 (preoperative), T2 (6 months after surgery), and T3 (4 years after surgery). The parameters assessed were surface area (SA), minimum axial area, and volume (VOL) of the pharyngeal airway space. The times were compared using analysis of variance and Tukey’s test. Pearson’s analysis was performed to assess the correlation with surgical changes and age (P <0.05).
Four years after operating on the airway spaces, the means of SA and VOL were significantly higher than those observed before the surgery (P <0.05). The means at 6 months were intermediate, with no significant difference before the surgery and 4 years after it (P >0.05). There was no significant correlation of the changes in SA, VOL, and minimum axial area with the amount of mandibular advancement, counterclockwise rotation of the occlusal plane, and age of the patient (P >0.05).
Four years after mandibular advancement surgery in patients with skeletal Class II malocclusion, the increases in the airways remained stable.
Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis
2021, Sleep Medicine Reviews
Citation Excerpt :
The observed superiority of MMA over MLS in treating OSA is explained by enlargement of the entire retropalatal and retrolingual airway by expanding the skeletal framework, while MLS cannot. Currently, there are a few studies [25,31,40] reporting the significant increases in pharyngeal airway volume (PAV) in OSA patients treated with MMA, by 60.5%, 35.7% and 35.4%, respectively. However, to our knowledge, only Chiffer et al. [54] quantitatively measured the volumetric changes in upper airway before and after MLS for treating OSA.
Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which target different levels of airway obstruction. The objective of this review was to comparatively evaluate the clinical efficacy and safety of MMA and MLS in the treatment of OSA. MEDLINE and Embase databases were searched for studies on MMA and/or MLS in OSA patients. Twenty MMA studies and 39 MLS studies were identified. OSA patients who underwent MMA showed significant improvements in AHI, LSAT, ODI, and ESS by −46.2/h, 13.5%, −30.3/h, and −8.5, respectively. The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%, respectively. Patients who underwent MLS showed significant improvements in AHI, LSAT, ODI, and ESS by −24.7/h, 8.7%, −19.1/h, and −5.8, respectively. The pooled surgical success and cure rates for MLS were 65.1% and 28.1%, respectively. The rates of major complication of MMA and MLS were 3.2% and 1.1%, respectively, and the rate of minor complication of MMA was higher than that of MLS. We conclude that both MMA and MLS are effective treatment options for OSA. Compared to MLS, MMA may be more effective in improving OSA. However, the complication rate of MMA is higher.

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Changes in the calibre of the upper airway and the surrounding structures after maxillomandibular advancement for obstructive sleep apnoea

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgement

Sleep Med Rev

J Oral Maxillofac Surg

Chest

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Therapy with nCPAP: incomplete elimination of sleep related breathing disorder

Eur Respir J

Maxillofacial surgery and obstructive sleep apnea: a review of 80 patients

Otolaryngol Head Neck Surg

Maxillomandibular advancement surgery in 23 patients with obstructive sleep apnea syndrome

J Oral Maxillofac Surg