Clinical ReviewMaxillomandibular advancement for the treatment of obstructive sleep apnea: A systematic review and meta-analysis
Introduction
Obstructive sleep apnea (OSA) is characterized by repetitive episodes of pharyngeal collapse with increased airflow resistance during sleep.1 Risk factors include obesity, male gender, advancing age and an anatomically smaller upper-airway (i.e., maxillary or mandibular insufficiency).2 Up to 25% of adults have OSA (i.e., an apnea–hypopnea index (AHI) ≥5/h) and roughly 10% of all adults have moderate to severe disease (i.e., an AHI ≥15/h).3, 4 OSA is associated with higher rates of cardiovascular and cerebrovascular morbidity and mortality as well as excessive daytime sleepiness, fatigue and neurocognitive deficits.2 When left untreated, the mortality rate for severe OSA approaches 30% at 15 years.3
Conventional OSA therapy entails the use of indefinite nocturnal positive airway pressure (either continuous [CPAP] or bilevel) that pneumatically stents open the upper-airway.5 Unfortunately, adherence rates are poor with more than 50% of patients intolerant of CPAP, with many rejecting therapy within the first few months after initiation.6, 7 Patients who are nonadherent to CPAP therapy (compared with adherent subjects) have a 10% absolute increased mortality risk at 5 years.8 Several soft-tissue surgical procedures are now available to increase the posterior airspace and treat OSA in patients intolerant to CPAP. However, the reported surgical success rate for these procedures is approximately 40–60%.9, 10, 11 The limited efficacy for these procedures is primarily because clinically significant airflow restriction during sleep is due to multiple concurrent pharyngeal abnormalities.12, 13, 14 In the early 1980s several studies reported improvement in polysomnographic parameters in patients treated with mandibular osteotomy with advancement.15, 16, 17, 18 However, by the mid 1980s combined maxillomandibular advancement (MMA) was championed over mandibular osteotomy alone to treat nonsyndromic OSA patients in order to preserve the maxilla–mandibular relationship and due to the recognition that the physiologic etiology of OSA is often from concomitant mandibular and maxillary deficiency.19, 20
MMA enlarges the pharyngeal space by expanding the skeletal framework that the soft-tissue pharyngeal structures and tongue attach to resulting in reduced pharyngeal collapsibility during negative-pressure inspiration.14, 21 MMA is currently the most effective craniofacial surgical technique for the treatment of OSA in adults.*22, 23 However, some have questioned the widespread suitability of MMA because of a perceived lack of multicenter data and the potential for increased morbidity.24, 25, 26 Thus, we performed a systematic review of interventional studies of MMA to evaluate the polysomnographic effectiveness of MMA in treating OSA and alleviating daytime sleepiness, the effects of patient factors (e.g., age, gender) and therapeutic factors (e.g., degree of maxillary and mandibular advancement) on OSA improvement and the long-term effects and morbidity of MMA on OSA.
Section snippets
Methods
We used systematic methods to identify relevant studies, apply inclusion and exclusion criteria, and summarize the clinical efficacy of MMA for the treatment of OSA.
Results
We identified 914 titles of potentially relevant articles from our computerized search strategy and 97 additional references from our manual search of the bibliographies of retrieved articles. Of the 1011 potentially relevant articles, 59 reports met our inclusion criteria (Fig. 1). This included 53 reports (45 English14, 19, 21, *22, 23, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, *44, 45, 46, *47, *48, 49, *50, 51, 52, 53, 54, 55, *56, 57, 58, 59, 60, *61, 62, 63, 64, 65, 66, *67, 68, 69, 70, 71,
Discussion
Our systematic review and meta-analysis of 22 studies of MMA describing 627 adult OSA subjects revealed four key findings. First, we found that MMA is highly effective at treating OSA. The mean AHI decreased from 63.9/h to 9.5/h (p < 0.001) with a pooled surgical success rate of 86.0%. Overall, 43.2% of subjects were cured (AHI <5/h) with an increased cure rate (66.7%) for those with a preoperative AHI <30/h. Long-term surgical success was maintained at a mean follow-up of 44 months. Second,
Acknowledgements
We thank Eric Frenette, MD and Michael Hsu, MBA for their assistance in translating non-English articles.
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