Cillo 2019
Cillo 2019
Cillo 2019
Joseph E. Cillo Jr. DMD, MPH, PhD, FACS Associate Professor and Program Director ,
David J. Dattilo DDS Associate Professor and Division Director
PII: S1073-8746(19)30041-6
DOI: https://doi.org/10.1053/j.sodo.2019.08.003
Reference: YSODO 577
Please cite this article as: Joseph E. Cillo Jr. DMD, MPH, PhD, FACS Associate Professor and Program Director ,
David J. Dattilo DDS Associate Professor and Division Director , Orthognathic Surgery for Obstruc-
tive Sleep Apnea, Seminars in Orthodontics (2019), doi: https://doi.org/10.1053/j.sodo.2019.08.003
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service
to our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and
all legal disclaimers that apply to the journal pertain.
Pittsburgh, PA 15212
As the importance in the management of obstructive sleep apnea and other obstructive upper
airway disease continues to increase, the effect of orthognathic surgery on the upper airway in
correction of both dentofacial deformities and obstructive sleep apnea has become a prominent
component of treatment planning in recent decades. Applied correctly, orthognathic surgery can
have a dramatic and life-changing effect on decreasing nocturnal obstructions through expansion
of the upper airway. Large advancements of the maxillomandibular complex allows for three-
dimensional upper airway expansion to nocturnal obstruction that diminish the deleterious
effects of obstructive sleep apnea. This paper will discuss the orthognathic surgical techniques
that are essential in the treatment planning to achieve the desired results of relief of nocturnal
Introduction
Obstructive sleep apnea (OSA) is serious medical condition characterized by repeated collapse of
the upper airway during sleep which leads to airway resistance and obstruction, snoring, fatigue,
and daytime sleepiness1. This condition may have a significant impact on cognitive behavior,
cardiovascular disease.2 Prior to 1985, OSA was a disease researched and treated exclusively by
the medical specialties of otolaryngology and pulmonary medicine. Each passing year its
prevalence grew alarmingly swift as more patients were diagnosed and the effect of this
obstructive airway disease on the cardiovascular system, social issues associated with chronic
daytime sleepiness, increased mortality rates, such as nocturnal sudden death, made it a public
health threat that demanded immediate attention. At the time, through nocturnal and awake
endoscopic studies the airway collapse was known to occur at multiple areas along the upper
respiratory pathway. Continuous positive airway pressure (CPAP) is the recommended solution 1
but compliance has been a significant issue. Tracheostomy was the only procedure available and
was designed to bypass the entire upper airway but had its obvious social and physiologic
problems. The uvulopalatopharyngoplasty2 (UPPP) showed initial promise, but was eventually
found to have no more than a 40% successful and this only in mild obstructive cases. 3
Robert Riley and Nelson Powell, both dual otolaryngologists and oral and maxillofacial
surgeons from Stanford University, began using orthognathic surgical procedures designed for
the correction of craniofacial deformities for the treatment of OSA. 4 The mandible and its
attached anatomy, such as the genial tubercle attachment of the genioglossus muscle, were
advanced forward to help relieve base of the tongue obstruction from the posterior pharyngeal
wall. Along with Christian Guilleminault of the Stanford Sleep Disorders Clinic, these three
men developed a two-phase plan for the surgical treatment of OSA. 5 Phase 1 surgery consisted
of multiple procedures to address obstructive areas all along the upper respiratory tract; nasal and
palatal procedures for the nasopharynx, genioglossus advancement procedures for oropharynx ,
and hyoid suspension procedures for hypopharynx and Phase 2 surgery was maxillomandibular
advancement and became known as the Stanford Protocol of Surgical Management of OSA.
According to the Stanford Protocol, Phase I surgery was completed first and the patient re-
determined as an AHI/RDI reduction by 50% or less than 5, Phase 2 surgery would then be
recommended. Early clinical papers using reduction in the apnea-hypopnea index (AHI) or
respiratory disturbance index (RDI) and nadir (lowest) oxygen saturation (nO2) levels from
overnight sleep studies revealed a stunning success in the phase 2 with a greater than 90%
success 6,7,8. This was a game changing event that eventually resulted in maxillofacial surgeons,
orthodontist and the entire profession of dentistry becoming primary movers for the surgical
treatment of OSA.
It was apparent from the beginning that orthognathic surgery for dentofacial deformities and
OSA had only the technical procedures in common. Many of the earlier OSA surgical patients
reported in the literature had no orthodontic input at all for their surgery due to the urgency of the
situation and patient refusal to undergo such a time consuming and expensive procedure.
Maxillomandibular advancement (MMA) for these patients had no real guidelines except to
advance the maxillofacial complex as far forward as the enveloping musculature would permit
with a simple goal of returning the patient to his or her original functional occlusion as long as
Orthodontists who got involved with OSA patients found the following differences from
1. The extreme advancement of the lower facial skeleton (maxilla and mandible) tend to
experience more instability. This may be due to increase soft tissue stretch of the face
2. The importance of planning the final esthetic facial outcome becomes far less important
3. These patients not only represent a different age group on the average, but also tend to
have more missing teeth and periodontal problems. Therefore, coordination with
surgeons, periodontists, and restorative dentists is essential to successful treatment in
these patients.9
4. Due to the poor medical condition of these patients and the urgency of correction, surgery
first to advance and align the arches followed by post-surgical occlusal adjustment or
The orthodontist and the surgeon must understand that ideal treatment plans and esthetic
considerations that are a major part of conventional orthognathic surgery may have to take a
The soft tissue reaction to conventional orthognathic surgery, while very important and
predictable, remains secondary to the intended correction of the functional goals of occlusal and
hard tissue balance. In orthognathic surgery for the OSA the soft tissue reaction of the oro-
The following report will discuss the advances in technique, the long-term stability and the
present-day state of the art that have resulted from the last twenty years of applying these
Various dynamic and static methods have been used to determine the single or multi-level source
of upper airway in OSA. The primary challenge with radiograph interpretation of the upper
upright position. While providing important anatomical visualization and information, these
challenges are generally seen in static methods of upper airway radiographic interpretation such
such techniques as dynamic sleep magnetic resonance imaging (MRI) and drug-induced sleep
endoscopy (DISE). Sleep MRI allows for simultaneous evaluation of upper airway obstruction
and respiratory events in real time during natural sleep. This allows for respiratory and
desaturation events to be directly correlated with polysomnogram results and anatomic site of
obstruction. DISE is a combined endoscopic and anesthetic procedure that attempts to mimic
natural sleep through deepening of general anesthesia until a patient begins to obstruct in order to
Evaluation of the anatomical levels of upper airway sleep obstruction have been shown by
dynamic sleep MRI to be positively correlated with OSA severity. Specifically, severe OSA
patients have significantly more lateral pharyngeal wall collapse as compared to BMI-matched
mild OSA patients 10, 11. Airway obstructions visualized on sleep MRI during natural sleep
obstruction 12. DISE showed that obstruction may be observed in three dimensions:
anteroposterior, transverse and circumferential 13. DISE is able to visualize various anatomical
structures that can induce obstruction during sleep such as the retrovelar area (includes the soft
palate, mucosal velum, and uvula); the oropharyngeal area (includes the palatine tonsils and
pharyngeal walls); the hypopharyngeal area (includes the tongue base, lingual tonsils and lateral
pharyngeal walls); and the laryngeal area (includes the epiglottis and arytenoids). DISE findings
tend to indicate multiple levels of upper airway obstruction particularly in the retropalatal and
lateral pharyngeal walls. While individual anatomical obstruction during sleep will vary, findings
from dynamic upper airway observation in real time indicate that majority of nocturnal
obstruction are multilevel and occur primarily in the lateral pharyngeal wall, retropalatal and
retroglossal areas.
Static imaging of the upper airway such as static MRI, three-dimensional computed tomography
(3D-CT), and lateral cephalometry is a valuable screening tool for OSA. OSA patients,
include compromised total airway volume and minimum cross-sectional area 14. Upper airway
length has been shown to have a positive correlation and predictor to the OSA severity 11, 12,
while lateral/retroglossal anteroposterior dimension ratio shows an inverse correlation with the
OSA severity 15. These radiographic measures may be a good screening tool that will allow for
compared to the non-OSA population, reveals significant deviations in the OSA population that
may one or more of the following: shorter dimension of cranial base; shorter maxillary length;
despite normal angles of prognathism; mandibular retrognathia; increased anterior lower facial
height and mandibular plane angle; reduced size of bony pharynx; inferiorly positioned hyoid
Correction of dentofacial deformities (DFD), such as skeletal Class III malocclusion, have now
mandibular surgery affects the hyoid bone and tongue position which may influence pharyngeal
airway dimensions 9. A decrease in pharyngeal airway from this movement may cause the
development or worsening of OSA and must be taken into consideration in treatment planning 17.
Skeletal Class III dentofacial deformity generally may be treated with mandibular setback
procedures alone to correct the malocclusion without any consideration for the potential
deleterious effects on the upper airway. Single-jaw mandibular setback osteotomies have been
shown to reduce pharyngeal airway dimensions significantly due to posterior positioning of the
hyoid bone and decreased posterior airway space 18, 19. Compared to mandibular setback surgery
alone for the correction of skeletal Class III deformities, bimaxillary surgery to treat this
condition produces a less compromised post-surgical pharyngeal airway with significantly less
20 - 22
decreased cross-sectional area of the upper airway . However, while mandibular setback
procedures have been shown reduce pharyngeal airway dimensions, a possible predisposing
factor in the development of OSA, patients tend to adapt quickly and, while there are some initial
reduced respiratory parameters with some surgeries, there has not been much significant
23 - 25
evidence to confirm post-surgical OSA development . These studies, however, have been
performed on young and healthy adolescents and the effect of aging and changes in body habitus
are not taken into consideration. Many decades later the alteration in posterior airway may
contribute any alteration of the posterior airway space due to orthognathic surgery should be
orthognathic surgery treatment planning for correction of DFD should also seek to expand the
facial skeleton and thus the upper airway to alleviate, prevent, or decrease the risk of future
development of OSA.
Correction of skeletal Class II malocclusions with mandibular advancement surgery alone and
without genioplasty provides significant enlargement of the upper airway at the level of
26
oropharynx . The improvement is achieved through repositioning of the hyoid bone and
vallecula into a more superior and anterior position which has shown long term stability 27.
Maxillary only orthognathic surgery may also effect the upper airway and OSA. These tend to be
most effective when correcting maxillary hypoplasia through advancement and/or expansion in
28
individuals requiring this procedure to correct and existing DFD . However, correction of
vertical deficiencies does not appear to be as effective as correction of vertical maxillary excess
does not show a significant change in upper airway volume or subjective patient excessive
simultaneously advance both the upper and lower jaws specifically to treat OSA through
advancement and expansion of the facial skeleton. MMA has been successfully performed for
several decades and, other than tracheotomy, is the most effective and predictable surgical
procedure in the management of adult OSA 5, 7, 31 - 34. MMA advances the maxillomandibular
complex with a LeFort I maxillary and bilateral sagittal split mandibular ramus osteotomies, with
or without genioglossus advancement, and application of rigid internal fixation. Through the
subsequent expansion of the facial skeleton, the resultant increase in upper airway pharyngeal
volume is intended to decrease the risk of pharyngeal collapse from negative pressure inspiration
due to obstruction during sleep to ostensibly relieve or decrease the severity of OSA. In a multi-
center prospective study to comprehensively determine the effectiveness and safety of MMA for
the treatment of OSA, Boyd et al 35 found MMA to be a highly effective and safe treatment with
blood pressure. MMA is the only surgical procedure, outside the tracheotomy, that can
The purpose of MMA in the treatment of OSA is to relieve nocturnal obstruction and the
negative pressure effect that results. Decreasing the deleterious effects of the negative pressure
effect will decrease the breathing workload and improve the condition of OSA. The effect of
of this procedure. Numerous clinical and radiographic evaluations have been utilized to evaluate
the effect of orthognathic surgery and MMA on the upper airway. Two- and three-dimensional
evaluation of upper airway length, anterior-posterior multilevel width, vertical and horizontal
position of the hyoid bone, cephalometric measurements, upper airway volume, and minimum
improvements that are comparable to unoperated non-OSA patients 37. Post-operative MMA
changes result in significant decrease in laminar and turbulent air flow at every level of the upper
airway, specifically at the soft palate and base of tongue 38. This is due to expansion of the upper
airway in not only the anterior-posterior and lateral dimensions but also elevates the hyoid bone
39
. This all has an effect of decreasing the upper airway length as well 40.
Treatment planning for MMA is complex and more complicated than simply advancement of the
maxillomandibular complex as the occlusal plane and chin position need to be evaluated and
treated. Rotation of the occlusal plane, particularly counterclockwise (CCW) ration the of the
maxillomandibular complex. The purpose of CCW is to both improve esthetics as well as open
the upper airway. CCW rotation of the occlusal plane in MMA produces a significant increase in
minimal axial area and volume of the pharyngeal airway through increase in the volume and
minimum axial area. Retrogenic individuals may tend to have a significantly decrease posterior
airway space and may be more predisposed to OSA. Genioglossus advancement (GGA) is
intended to provide additional expansion of the upper airway at the hypopharyngeal level 41.
While MMA results in an increased overall anteroposterior posterior airway space, the addition
of GGA produces even greater expansion at the hypopharynx level and may further improve the
Evaluation methods in the effectiveness of MMA for OSA have included both subjective and
objective analyses 43, 44. Pre-operative OSA severity significantly influences outcome of MMA
with a strong positive correlation between pre-operative AHI/RDI and post-operative percent
change 45. In individuals with extremely severe OSA with an extremely high AHI of higher than
100, MMA an extremely highly successful one-stage surgery that eliminates positive pressure
treatment, improves subjective and objective outcomes 44. Traditionally, as described by Holty
and Guilleminault 5, objective surgical success is defined as a post-operative AHI of less than 20
and a 50% reduction in AHI with a „„cure rate‟‟ as a postoperative AHI less than 5. The success
rate commonly seen in the literature for MMA has consistently been greater than other OSA
46
surgical procedures and averages around 90% with a range between 71% and 100% 45, 47. The
surgical cure rates (AHI less than 5) range from 38% 47, 48 to 43% 5. Preoperative AHI of fewer
than 60 events per hour is strongly associated with the highest incidence of surgical cure.
Numerous meta-analyses of the effectiveness of MMA are clear that this procedure is highly
effective in the treatment of OSA 5, 8, 39, 45. The ubiquitous results from all of these studies have
shown that MMA significantly improves AHI/RDI between 64 to 80%. Improvements in nadir
oxygen saturation were between 70 to 87% and for up to 77% improvement in excessive daytime
sleepiness.
Timing of MMA
Traditionally, MMA was indicated for treatment of only severe OSA in patients who are
pressure or oral appliances 49. Additionally, as the Stanford Protocol advocates, MMA (Phase 2
surgery) should be performed once Phase 1 surgery has been proven to be ineffective in the
surgeries prior to having MMA, it has been advocated that MMA should be considered as a first-
line surgical therapy for moderate to severe OSA. Boyd et al 50 suggested that MMA should be
the initial surgical treatment choice for eligible patients who are recalcitrant to conservative
therapies for moderate to severe OSA. Their comparisons between three surgical groups, MMA
alone, UPPP followed by MMA, and UPPP alone, and after adjusting for differences in baseline
AHI, the mean post-operative change in AHI was significantly larger and more effective for
MMA alone compared with both UPPP and UPPP followed by MMA.
Skeletal stability of MMA in the treatment of OSA is an important aspect of long-term success.
obtain this intended result 5. This large amount of movement may result in craniofacial skeletal
instability with relapse and the undesirable possible recurrence or worsening of OSA. The large
advancements involved in MMA raise concerns for skeletal stability and relapse. Fortunately,
with the proper use of rigid fixation, short, medium, and long-term skeletal stability in MMA is
achievable. Clinically significant loss of skeletal stability, as described by Proffit et al, is a post-
medium (1 to 4 years) and long-term (greater than 4 years) MMA demonstrated minimal and
clinically insignificant skeletal relapse. Similarly, Lee 52 showed minor clinically insignificant
cephalometric skeletal changes with no development of malocclusion 2 years after MMA. Cillo
and Dattilo 53 showed that MMA in the treatment of severe OSA was a highly skeletally stable
long-term with no clinically significant loss of skeletal stability as far out as 8 to 13 years after
surgery independent of gender, age at the time of surgery, time to follow-up, and amount of
surgical movement.
The soft tissue response of orthognathic surgery is predictable and stable. Soft tissue responses to
orthognathic surgery for correction of DFD are generally intended to change to esthetic aspects
of the face. OSA patients may or may not have an acquired or congenital deformity that requires
surgical treatment. Soft tissue movements produced by MMA have a direct effect mostly on the
upper and lower lips, and chin in an almost one-to-one hard-tissue-to-soft-tissue ratio 54. The
unacceptable change in the esthetic aspects of the face. However, most of these individuals are
bi-maxillary retrusion and evaluation of patient perception of facial appearance after MMA
suggests that moderate changes are noticed by most patients but are met with a 90% positive or
Safety of MMA
Orthognathic surgery for DFD is considered a safe and effective procedure that is generally
performed on adolescent or young adults 55. The usually healthy DFD population tend to have
significantly fewer post-operative complications compared to OSA patients that undergo MMA
who are on average, older and have more comorbidities. OSA population tends to be morbidly
obese compared with the relatively healthier DFD population, the significantly less healthy OSA
population have a three times as great incidence of minor and major complications with no
mortality. However, despite this disparity the complication rate in MMA for OSA is no different
than other surgical procedures at between 1.0% to 3.1% 5. The overall frequency of early major
medical post-operative complications, defined as admission to the intensive care unit or death, is
low 56. Being that the rate of all complications in MMA is low and similar to other procedures
with similar level of risk with no impact on quality of life issues and it may be considered a safe
procedure.
Orthodontics in MMA
The main purpose to perform MMA is to correct a serious disease, OSA, and not to correct DFD.
Therefore, the use of orthodontics is not an absolute necessity. The advancement of the
maxillomandibular complex maintains the pre-surgical occlusion and, for the most part, does not
intentionally change the occlusion. There may be situations were a relative malocclusion may be
corrected without the need for orthodontics. Several studies that have evaluated MMA for OSA
have had a mix of patient that did and did not have pre- and post-operative orthodontic treatment
34, 35
. The utilization of orthodontic therapy certainly is advantageous in MMA surgery. The pre-
surgical orthodontic set-up for OSA is generally no different than in the treatment of DFD. It will
involve the same general needs to level and align the arches, remove dental compensations, place
teeth of basal bone, and coordinate the arches to position teeth into the appropriate post-operative
occlusion. In individuals who previously may have had orthodontic therapy and have no dental
compensations or other issues, the need for a pre-operative set up may be unnecessary. However,
individuals who have not previously had successful orthodontic therapy or have considerable
orthodontic issues would certainly benefit, but not absolutely require, pre-operative orthodontic
therapy. Pre-surgical orthodontic therapy in these situations will allow for an optimal surgical set
up and post-operative occlusal results. The need for pre-surgical orthodontic therapy is a decision
best made between the surgeon, orthodontist and patient to determine which would most benefit
Conclusion
In conclusion, MMA for the treatment of OSA has been established as a highly successful
procedure on many fronts. It is a highly skeletally stable long-term procedure that significantly
expands the upper airway and relieves nocturnal obstruction. It improves subjective outcomes of
OSA through decrease in excessive daytime sleepiness and improvement in quality of life issues.
in cardiovascular risk through a decrease in blood pressure. Given the high success that the
last resort” in the treatment of OSA but as a first line surgical option in individuals with
moderate, severe, very severe, and extremely severe OSA and recalcitrant to conservative
treatments.
References
1. White DP. Advanced Concepts in the Pathophysiology of Obstructive Sleep Apnea. Adv.
2. Dempsey JA, Xie A, Patz DS, Wang D. Physiology in medicine: obstructive sleep apnea
3. Costa E Sousa RA, dos Santos Gil NA. Craniofacial skeletal architecture and obstructive
10.1016/j.jcms.2012.12.010.
4. Riley RW, Powell NB, Li KK, et al. Surgery and obstructive sleep apnea: long-term
obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2010;
14:287.
abnormalities in non-obese and obese patients with obstructive sleep apnea. Eur Respir J.
1999;13(2):403-10.
7. Zaghi S, Holty JE, Certal V, Abdullatif J, Guilleminault C, Powell NB, Riley RW,
10.1001/jamaoto.2015.2678.
8. Agha B, Johal A. Facial phenotype in obstructive sleep apnea-hypopnea syndrome: a
10.1111/jsr.12485.
9. Mattos CT, Vilani GN, Sant'Anna EF, Ruellas AC, Maia LC. Effects of orthognathic
10. Huon LK, Liu SY, Shih TT, Chen YJ, Lo MT, Wang PC. Dynamic upper airway collapse
observed from sleep MRI: BMI-matched severe and mild OSA patients. Eur Arch
11. Liu SY, Huon LK, Lo MT, Chang YC, Capasso R, Chen YJ, Shih TT, Wang PC. Static
craniofacial measurements and dynamic airway collapse patterns associated with severe
obstructive sleep apnea: a sleep MRI study. Clin Otolaryngol. 2016 Dec;41(6):700-706.
doi: 10.1111/coa.12598.
12. Barrera JE. Sleep magnetic resonance imaging: dynamic characteristics of the airway
13. Kezirian EJ, Hohenhorst W, de Vries N. Drug-induced sleep endoscopy: the VOTE
doi:10.1007/s00405-011-1633-8.
14. Butterfield KJ, Marks PL, McLean L, Newton J. Quality of Life Assessment After
tomographic analysis of airway anatomy in patients with obstructive sleep apnea. J Oral
1995 Feb;17(1):45-56.
17. Rosario HD, Oliveira GMS, Freires IA, de Souza Matos F, Paranhos LR. Efficiency of
18. Hwang S, Chung CJ, Choi YJ, Huh JK, Kim KH. Changes of hyoid, tongue and
20. He J, Wang Y, Hu H, Liao Q, Zhang W, Xiang X, Fan X. Impact on the upper airway
space of different types of orthognathic surgery for the correction of skeletal class III
malocclusion: A systematic review and meta-analysis. Int J Surg. 2017; 38:31-40. doi:
10.1016/j.ijsu.2016.12.033.
21. Chen F, Terada K, Hua Y, Saito I. Effects of bimaxillary surgery and mandibular setback
bimaxillary surgery or mandibular setback surgery. Oral Surg Oral Med Oral Pathol Oral
mandibular setback surgery on oropharyngeal airway and arterial oxygen saturation. Int J
24. Lye KW. Effect of orthognathic surgery on the posterior airway space (PAS). Ann Acad
25. Tan SK, Leung WK, Tang ATH, Zwahlen RA. Effects of mandibular setback with or
10.1371/journal.pone.0185951.
26. Foltan R, Rybinova K. The impact of mandibular advancement on the upper airway
Advancement for Unilateral Crossbite in a Patient with Sleep Apnea Syndrome. Acta
29. Vijayakumar Jain S, Muthusekhar MR, Baig MF, Senthilnathan P, Loganathan S, Abdul
30. Waite PD, Wooten V, Lachner J, Guyette RF. Maxillomandibular advancement surgery
in 23 patients with obstructive sleep apnea syndrome. J Oral Maxillofac Surg. 1989
Dec;47(12):1256-61.
Dec;116(6):1519-29.
10.1016/j.coms.2009.09.001.
33. Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD.
Surgical modifications of the upper airway for obstructive sleep apnea in adults: a
34. Boyd SB, Walters AS, Waite P, Harding SM, Song Y. Long-Term Effectiveness and
35. Boyd SB, Chigurupati R, Cillo JE Jr, Eskes G, Goodday R, Meisami T, Viozzi CF, Waite
37. Butterfield KJ, Marks PL, McLean L, Newton J. Linear and volumetric airway changes
38. Sittitavornwong S, Waite PD, Shih AM, Cheng GC, Koomullil R, Ito Y, Cure JK,
Harding SM, Litaker M. Computational fluid dynamic analysis of the posterior airway
space after maxillomandibular advancement for obstructive sleep apnea syndrome. J Oral
39. Hsieh YJ, Liao YF. Effects of maxillomandibular advancement on the upper airway and
40. Susarla SM, Abramson ZR, Dodson TB, Kaban LB. Upper airway length decreases after
41. Maganzini AL, Alhussain IY. Treatment of obstructive sleep apnea with combined
42. Torres HM, Valladares-Neto J, Torres AM, Freitas RZ, Silva MA. Effect of Genioplasty
procedures for the treatment of sleep apnea: comparison of subjective and objective
44. Goodday RH, Bourque SE, Edwards PB. Objective and Subjective Outcomes Following
Severe Obstructive Sleep Apnea (Apnea-Hypopnea Index >100). J Oral Maxillofac Surg.
45. John CR, Gandhi S, Sakharia AR, James TT. Maxillomandibular advancement is a
successful treatment for obstructive sleep apnea: a systematic review and meta-analysis.
10.1016/j.ijom.2018.05.015.
46. de Ruiter MHT, Apperloo RC, Milstein DMJ, de Lange J. Assessment of obstructive
sleep apnea treatment success or failure after maxillomandibular advancement. Int J Oral
47. Giarda M, Brucoli M, Arcuri F, Benech R, Braghiroli A, Benech A. Efficacy and safety
48. Aurora RN, Casey KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, Karippot A,
Practice parameters for the surgical modifications of the upper airway for obstructive
50. Nimkarn Y, Miles PG, Waite PD. Maxillomandibular advancement surgery in obstructive
sleep apnea syndrome patients: long-term surgical stability. J Oral Maxillofac Surg. 1995
Dec;53(12):1414-86.
51. Lee SH, Kaban LB, Lahey ET. Skeletal stability of patients undergoing
52. Cillo JE Jr, Dattilo DJ. Maxillomandibular Advancement for Severe Obstructive Sleep
Apnea Is a Highly Skeletally Stable Long-Term Procedure. J Oral Maxillofac Surg. 2019
53. Conley RS, Boyd SB. Facial soft tissue changes following maxillomandibular
2007 Jul;65(7):1332-40.
54. Li KK, Riley RW, Powell NB, Guilleminault C. Patient's perception of the
55. Farrell BB, Tucker MR. Safe, efficient, and cost-effective orthognathic surgery in the
10.1016/j.joms.2009.04.096.
56. Cillo JE Jr, Dattilo DJ. Early major medical complications after surgical management of
obstructive sleep apnea: a retrospective cohort analysis and case series. J Oral Maxillofac
Figure 1.
A. Pre-operative facial view of male with severe obstructive sleep apnea syndrome (AHI =
97, ESS = 21), pre-operative profile view, pre-operative lateral cephalometric radiograph
A. Pre-operative facial view of individual with severe OSA (AHI = 66, ESS = 18), pre-
surgery.
Figure6. Model representation of the maxillomandibular advancement and genioglossus
advancement procedures.
Figure 7. Cephalometric evaluation before and after maxillomandibular advancement for