lye surgical maxillomandibular advancement technique 2009

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Surgical Maxillomandibular AdvancementTechniqueKok Weng Lye and Joseph R. Deatherage

Some of the most severe forms of obstructive sleep apnea are attributed toanatomic abnormalities in the facial skeleton. With the use of conventional orthog-nathic surgical techniques, it is possible to expand the posterior airway. In fact,there is strong evidence in the literature to support maxillomandibular advance-ment as one of the most efficacious surgical procedures for the treatment ofobstructive sleep apnea (OSA). There are complications associated with this pro-

cedure but these are minor when compared with the risk of inadequately treatedOSA. (Semin Orthod 2009;15:99-104.) 2009 Elsevier Inc. All rights reserved.

Hard tissue surgery for obstructive sleep ap-nea (OSA) treatment includes genioglos-sus advancement (GGA) and maxillomandibularadvancement (MMA). Genioglossus advancementsurgery initially was described as a rectangularosteotomy at the chin, which contains the genialtubercles.1 GGA has been a frequently per-formed procedure, but not as an isolated one, totreat OSA. GGA often is performed togetherwith uvulopharyngopalatoplasty, with an accept-able success rate of 80% for moderate OSA(respiratory distress index [RDI] 21 to 40), 64%

for moderately severe OSA (RDI 4160), andonly 15% for severe OSA (RDI 61).2 Othertechniques following the same principle of ad-vancing the genial tubercles along with the ge-nial glossal muscles are the inferior horizontalgeniotomy and the mortized geniotomy.

Kuo et al3 initiated the use of orthognathicsurgery for the treatment of OSA in 1979. Thetreatment involved the advancement of the max-illa and mandible via traditional orthognathicsurgery, which was then called MMA. The ratio-nale for this treatment is the advancement of the

skeletal attachment of the suprahyoid and velo-pharyngeal muscles and tendons and an increasein volume of the nasopharynx, oropharynx, andhypopharynx. Together, this advancement leadsto the anterior movement of the soft palate,tongue, and anterior pharyngeal tissues. Subse-quently, an enlargement of the posterior airwayand a decrease in laxity of the pharyngeal tissuesensues and results in a decrease in the obstruc-tion of the posterior airway space. Since 1979,there have been several publications thatshowed overall success rates of 96%,4 97%,5

98%,6

and 100%.7

There is also strong evidenceof the long-term efficacy of the MMA approach,as Li et al8 showed a 90% success rate for a groupof 40 patients with a mean follow-up periodexceeding 50 months. These results are furthersupported by a study examining the surgical sta-bility of MMA, which found that the large hori-zontal advancement of the maxilla and mandi-ble is stable and without significant relapse.9

However, there are 2 philosophies regardingthe use of MMA. Some groups believed in a2-stage protocol where MMA is the stage 2 pro-

cedure if stage 1, which consists of uvulopharyn-gopalatoplasty, GGA, and hyoid suspension,fails.6,10 This latter protocol was developed toreduce the use and complications of the moreinvasive MMA procedure for patients who wouldhave responded to the first-stage procedures. Inthe landmark study6 from which this protocolwas developed, the authors found that the suc-cess rate was 60% for stage 1 surgery and 97%for stage 2 surgery. However, only 25% of the

Department of Oral and Maxillofacial Surgery, National DentalCentre, Singapore; Department of Oral and Maxillofacial Surgery,University of Alabama School of Dentistry, Birmingham, AL.

Address correspondence to Kok Weng Lye, Department of Oraland Maxillofacial Surgery, National Dental Centre, 5 Second Hos-pital Avenue, Singapore, 168938. Phone: 65-6324 8890; E-mail:[email protected]

2009 Elsevier Inc. All rights reserved.1073-8746/09/1502-0$30.00/0doi:10.1053/j.sodo.2009.01.004

99Seminars in Orthodontics, Vol 15, No 2 (June), 2009: pp 99-104
mailto:[email protected]:[email protected]


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stage 1 nonresponders went on to stage 2 sur-gery. This failure to proceed with the stage 2surgery was probably a result of the trauma ex-perienced from the first surgery and being dis-couraged by the failure of improvement after

the stage 1 surgery.For these reasons, other groups of clinicians

believe in using the most efficacious techniquefrom the start and proceeding directly withMMA.4,5Waite et al,4 in a key study, evaluated 23patients who had had MMA surgery togetherwith septoplasty and inferior turbinectomies.They achieved a success rate of 96%. Based onthe criteria of a 50% reduction in the RDIand afinal RDI of less than 20,4 Hochban et al5 andPrinsell7 also used MMA as the primary proce-dure for 38 and 50 OSA patients, achieving 97%and 100% success rate, respectively.

Indications and Contraindicationsfor MMA

To be a suitable patient for MMAtreatment, afew prerequisites are necessary.11 The patientsapnea-hyponea index or RDI must be greaterthan 15, with a lowest desaturation 90% andsubjective excessive daytime sleepiness. In addi-tion, conservative treatments, such as weightloss, mandibular repositioning devices, and/orcontinuous positive airway pressure, must have

been unsuccessful or intolerable for the patient.The patient must also be medically fit to un-dergo the surgery. If, in addition, the following 2clinical conditions also are present, then MMAshould be the procedure of choice. First, thereshould be obstruction at multiple sites or ob-struction could not be distinguished, as it wasdiffuse. Second, the patient should present witha dentofacial skeletal deformity and malocclu-sion, most often a Class II relationship, and theMMA surgery should be able to provide an op-portunity to obtain multiple benefits. Obviously,

patients who do not meet the criteria for theMMA procedure or who are unwilling and/orunable to undergo MMA surgery should be ex-cluded.

Surgical Planning and Technique

MMA is primarily orthognathic surgery in whichthe maxilla and mandible are advanced throughosteotomies. Thus, MMA surgery requires all the

relevant preoperative records and planning, suchas facial examination, radiographs, cephalometricanalysis, nasopharyngoscopy and model surgery.Ideally, preoperative orthodontic treatment shouldbe used to ensure a good postoperative occlusion

as well as correcting any pre-existing malalign-ment of the teeth to enhance the cosmetic ap-pearance of the patients. However, many OSApatients are older and are unwilling to undergothe recommended orthodontic phase of thetreatment, or they may not wish to delay thetreatment of their OSA condition. In addition,some OSA patients may have multiple missingteeth, active advanced periodontal disease, orcomplex fixed prosthodontic restorations, whichmay complicate orthodontic treatment. Further-more, the patients problem is often a functionalone, and they may be less concerned with theesthetic improvement of any treatment. Those pa-tients who, for whatever reason, elect or areadvised not to undergo presurgical orthodontictreatment should clearly understand their possi-ble and potential need for postsurgical orth-odontic and/or restorative dental treatment.

Orthodontics

The objectives of presurgical orthodontic treat-ment for MMA patients is different from those ofroutine orthognathic surgery for patients who

have dentofacial deformities. For the MMA pa-tients, the purpose of the presurgical orthodon-tic treatment is to assist in maximizing the ante-rior positioning of the maxilla and mandiblewhile attempting to obtain a reasonable occlu-sion. In Class II patients, it is advisable to retractthe lower incisor teeth and procline the upperincisor teeth to maximize the amount of man-dibular advancement. This step will provide thegreatest amount of airway improvement.

Cephalometric Analysis

In general, a lateral cephalogram is a standard-ized and repeatable radiograph that presents theprofile view of the viscerocranium. It is a routinetool for the diagnostic workup of all OSA pa-tients and the technique has been previouslydescribed.12 Cephalometric analysis helps toconfirm the clinical and nasopharyngoscopyfindings. The values of different parameters inthe analysis can be compared to normal values

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to characterize the craniofacial relationship andthe posterior airway status.

Cephalometric analysis reveals the severity ofany craniofacial dysmorphy or abnormalities.Studies have referred to the retro-positioning of

the jaws, a short mandibular length, a long an-terior face height, clockwise rotation of the fa-cial structure, short cranial base, and decreasedcraniofacial flexure angle as common abnormal-ities found in OSA patients.4,13-17 The underlyingprinciple is that when the craniofacial structure isretropositioned through either underdevelopmentin the horizontal plane or a clockwise rotationalgrowth pattern, the structures that form the an-terior and lateral boundaries of the posteriorairway, such as the palate, tongue, and pharyn-geal tissues are displaced posteriorly. The tissuesare also lax and more liable to collapse in thepresence of negative pressure. This results in theconstriction of the posterior airway, increased air-way resistance and obstructions. Moreover, the re-striction generates turbulence of the airflow andvibration of the redundant tissues, causing snor-ing. Interestingly, significant craniofacial abnor-malities are found in about 40% of these pa-tients.18 In terms of treatment planning, it is animportant tool to help identify the patients whohave severe craniofacial deficiency (SNB angle 75), as they should be directly offeredMMAsurgery instead of soft tissue procedures.10

Although there are more advanced imagingtechniques to study the posterior airway, cepha-lometric analysis still offers considerable advan-tages, including low cost, ease of use and mini-mal radiation exposure. It is also able to analyzethe craniofacial morphology, airway status, headposition and hyoid position simultaneously. Inaddition, its acceptable reproducibility enableseasy comparisons longitudinally, before and af-ter procedures and between populations.

Technique

The MMA is achieved by use of the standardbilateral sagittal split osteotomy technique forthe mandible and the Le Fort I level maxillaryosteotomy. The mandible is cut and a sagittalsplit is carried out bilaterally in the posteriorbody, angle and lower ramus region. The prox-imal segments with the condyles are kept in thesame position while the distal segment; the bodyof mandible, alveolus and teeth, are advanced

according to the prefabricated occlusal splintinto a Class III relationship. The occlusal splintis made during the presurgical model surgery.The inferior alveolar nerve is kept intact butsustains some tension during the surgical ad-

vancement procedure. The distal segment isthen fixated with bicortical screws or titaniumminiplates and screws. Performing the mandib-ular advancement first creates a more stable oc-clusal platform. The advancement of the mandiblepulls the geniohyoid, genioglossus, mylohyoid andthe digastric muscles anteriorly. This in turnbrings the base of tongue and hyoid bone for-wards and upwards. In addition, the advance-ment of the mandible creates a larger volumefor the tongue and floor of mouth. These twoeffects result in the enlargement of the posterior

airway space at the retroglossal and hypopharyn-geal region level.

The maxilla is then cut and mobilized at theLe Fort I level. The advancement is thenachieved with the aid of a final occlusal splint ora stable final occlusion. The maxilla is then fix-ated with 4 titanium plates and screws. There areprebent OSA advancement plates19 that are de-signed for this purpose and have been shown tobe more resistant to relapse.20 Because there isvery often a large gap and minimal bony contactbetween the upper and lower segments of the

maxilla, bone grafting is necessary to ensuregood bony healing, better stability, and the min-imization of relapse.21 Nasal septal defects andenlarged inferior turbinates can be treated viathe Le Fort approach after down-fracturing ofthe maxilla. The generally accepted magnitudeof advancement was 10 mm. The 10-mm quan-tum is not evidenced based, and the authors ofthe present paper have achieved good successdespite surgical advancement of a lesser degree.This is because the change in airway resistance isinversely proportional to the radius of the airway

raised to the power of four. The movement ofthe maxilla and mandible will be the same onlyin cases in which there is no change in occlu-sion. Equal maxillary and mandibular advance-ment also occurs in patients who do not un-dergo preoperative orthodontic treatment.Patients who have dysgnathiausually are sched-uled for orthodontic treatment and improve-ment of their malocclusion. In patients with dys-gnathiawho undergo orthodontic treatment the

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maxilla and mandible will obviously not be ad-vanced equal amounts.

An additional procedure to complement theMMA is the GGA. This could be done via therectangularosteotomy technique popularized by

Riley et al22

or an inferior horizontal geniotomy;the standard chin osteotomy used in orthog-nathic surgery. This technique increases themagnitude of repositioning of thegenioglossus,geniohyoid and digastric muscles.23

Simultaneous adjunctive soft-tissue proce-dures can be considered during the MMA pro-cedure. However, any pharyngeal soft-tissue pro-cedures performed simultaneously with MMAmay result in airway compromise secondary tobleeding and swelling. These procedures in-clude surgery to the soft palate, tonsils, and thetongue. These cases may need surgical tracheos-tomy,4 prolonged endotracheal intubation orcontinuous positive airway pressure use for theperiod of postoperative edema. In addition, anytension on the soft-tissue closure from the skel-etal advancement may lead to poor healing oreven fibrosis and scarring.7 Nonpharyngeal pro-cedures, such as nasal procedures, cervicofacialliposuction, or lipectomy can be done simulta-neously with MMA because there is no potentialairway compromise in these procedures.7

Complications

There are no major complications reported forthe MMA procedure. Various authors have men-tioned some minor complications. As the ad-vancement of the mandible is often 10 mm orgreater, the incidence of permanent hypesthesiaof the lower lip is one of the commonest prob-lems. Studies have shownlong termhypesthesiato be in the range of 13%6 and 20%.10 If there isno concurrent orthodontic treatment, postoper-ative occlusal changes, such as malocclusion and

open bites, are relatively common. This couldresult in the need for reoperation, postoperativeorthodontic treatment, or postoperative prosth-odontic rehabilitation. When there has beenprevious or concurrent soft palate surgery tostiffen or shorten thepalate, velopharyngeal in-sufficiency can occur.24 Velopharyngeal insuffi-ciency results in a lack of palatal closure andallows air escape during speech and swallowingdifficulty. This problem is usually temporary and

can be improved with the assistance of speechtherapy. Sometimes, speech difficulties from thechange in lip position also may require speechtherapy.

Esthetic alterations, especially widening of

the alar base of the nose and superior movementof the nasal tip and a more acute nasolabialangle, are problems that should be discussedwith the patient preoperatively. However, manystudies have indicated that the facial changesweregenerally viewed favorably by the patients.25 Thischange in facial appearance is more of a concernamong the Asians population because of thecommon presentation ofbimaxillary protrusionin this group of patients.26 Another complica-tion that may arise is temporo-mandibular disor-der (TMD). The TMD is caused by the alterationin the condylar position and increased jointpressure from the large mandibular advance-ment. Pre-existing TMD is a risk factor that maydrastically increase the likelihood of postopera-tive TMD.

Additional reported concerns that may ariseare limited range of motion, sinus dysfunctionand decreased bite force. These complicationshave been observed more frequently in olderpatients. Bettega et al10 encountered some otherminor complications, such as local infection, anoro-nasal perforation that healed spontaneously,and maxillary pseudo-union resulting in instabil-

ity and that required bone grafting. Prinsell11reported minimal postoperative difficulties witha mean hospital stay of 1.6 days, no significantimpairment from the hypesthesia, and good pa-tient acceptance of their facial changes. Waiteet al4 also showed 95% patient satisfaction de-spite the minor complaints.1

Advances in MMA

In the presence of modern technology, research-

ers and clinicians have started using computedtomography (CT) and magnetic resonance (MR)scans to evaluate the posterior airway 3-dimen-sionally. This is superior to the widely used 2dimensional cephalograms. However, cephalo-metric analysis of the airway has been wellestablished and permits measurements at keyanatomical locations. Although CT and MR pro-vide extremely accurate distance and area mea-surements of the airway in all dimensions, there



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are no recognized normal ranges. Furthermore,there is no standardization in the thickness, di-rection and precise location of the sections asyet.27 In a recent study, 20 patients who under-went MMA had CT scans preoperatively and

following surgery to analyze the morphologicchanges of the airway.28 The results demon-strated significant increase in both the antero-posterior and lateral airway dimensions afterMMA surgery.

Another area of interest is the emergence ofthe quality-of-life dimension. This representsthe functional effect of an illness and its conse-quent therapy upon a patient, as perceived bythe patient.29 It has been a neglected dimensionas clinicians have been treating patients basedon results of objective investigation. Nowadays,

quality of life is increasingly valued as an impor-tant aspect of patient care. There have beenvery few studies that examined the changes inthe quality of life after surgical procedures forOSA.30,31 Lye32 recently reported on MMA hav-ing equally high success in achieving significantimprovement in the area of quality of life.

In conclusion, there is strong evidence to sup-port MMA as one of the most efficacious sur-gical procedure for the treatment of OSA. It isa safe procedure and the more commonly notedcomplications are relatively minor as comparedto the risk of inadequately treated OSA. There

have been some modifications to the techniqueand inclusion of some adjunctive proceduresover the years. There is also essential researchbeing done to provide the latest information onthis treatment which will help in our under-standing and improve our management of theOSA patient.

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