Surgical Maxillomandibular Advancement

Technique
Kok Weng Lye and Joseph R. Deatherage

Some of the most severe forms of obstructive sleep apnea are attributed to
anatomic 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 of
obstructive sleep apnea (OSA). There are complications associated with this pro-
cedure but these are minor when compared with the risk of inadequately treated
OSA. (Semin Orthod 2009;15:99-104.) © 2009 Elsevier Inc. All rights reserved.

ard tissue surgery for obstructive sleep ap- skeletal attachment of the suprahyoid and velo-
H nea (OSA) treatment includes genioglos-
sus advancement (GGA) and maxillomandibular
pharyngeal muscles and tendons and an increase
in volume of the nasopharynx, oropharynx, and
advancement (MMA). Genioglossus advancement hypopharynx. Together, this advancement leads
surgery initially was described as a rectangular to the anterior movement of the soft palate,
osteotomy at the chin, which contains the genial tongue, and anterior pharyngeal tissues. Subse-
tubercles.1 GGA has been a frequently per- quently, an enlargement of the posterior airway
formed procedure, but not as an isolated one, to and a decrease in laxity of the pharyngeal tissues
treat OSA. GGA often is performed together ensues and results in a decrease in the obstruc-
with uvulopharyngopalatoplasty, with an accept- tion of the posterior airway space. Since 1979,
able success rate of ⬎80% for moderate OSA there have been several publications that
(respiratory distress index [RDI] 21 to 40), 64% showed overall success rates of 96%,4 97%,5
for moderately severe OSA (RDI 41– 60), and 98%,6 and 100%.7 There is also strong evidence
only 15% for severe OSA (RDI ⬎61).2 Other of the long-term efficacy of the MMA approach,
techniques following the same principle of ad- as Li et al8 showed a 90% success rate for a group
vancing the genial tubercles along with the ge- of 40 patients with a mean follow-up period
nial glossal muscles are the inferior horizontal exceeding 50 months. These results are further
geniotomy and the mortized geniotomy. supported by a study examining the surgical sta-
Kuo et al3 initiated the use of orthognathic bility of MMA, which found that the large hori-
surgery for the treatment of OSA in 1979. The zontal advancement of the maxilla and mandi-
treatment involved the advancement of the max- ble is stable and without significant relapse.9
illa and mandible via traditional orthognathic However, there are 2 philosophies regarding
surgery, which was then called MMA. The ratio- the use of MMA. Some groups believed in a
nale for this treatment is the advancement of the 2-stage protocol where MMA is the stage 2 pro-
cedure if stage 1, which consists of uvulopharyn-
gopalatoplasty, GGA, and hyoid suspension,
Department of Oral and Maxillofacial Surgery, National Dental
fails.6,10 This latter protocol was developed to
Centre, Singapore; Department of Oral and Maxillofacial Surgery,
University of Alabama School of Dentistry, Birmingham, AL. reduce the use and complications of the more
Address correspondence to Kok Weng Lye, Department of Oral invasive MMA procedure for patients who would
and Maxillofacial Surgery, National Dental Centre, 5 Second Hos- have responded to the first-stage procedures. In
pital Avenue, Singapore, 168938. Phone: 65-6324 8890; E-mail: the landmark study6 from which this protocol
[email protected]
© 2009 Elsevier Inc. All rights reserved.
was developed, the authors found that the suc-
1073-8746/09/1502-0$30.00/0 cess rate was 60% for stage 1 surgery and 97%
doi:10.1053/j.sodo.2009.01.004 for stage 2 surgery. However, only 25% of the

Seminars in Orthodontics, Vol 15, No 2 (June), 2009: pp 99-104 99

stage 1 nonresponders went on to stage 2 sur- relevant preoperative records and planning, such
gery. This failure to proceed with the stage 2 as facial examination, radiographs, cephalometric
surgery was probably a result of the trauma ex- analysis, nasopharyngoscopy and model surgery.
perienced from the first surgery and being dis- Ideally, preoperative orthodontic treatment should
couraged by the failure of improvement after be used to ensure a good postoperative occlusion
the stage 1 surgery. as well as correcting any pre-existing malalign-
For these reasons, other groups of clinicians ment of the teeth to enhance the cosmetic ap-
believe in using the most efficacious technique pearance of the patients. However, many OSA
from the start and proceeding directly with patients are older and are unwilling to undergo
MMA.4,5 Waite et al,4 in a key study, evaluated 23 the recommended orthodontic phase of the
patients who had had MMA surgery together treatment, or they may not wish to delay the
with septoplasty and inferior turbinectomies. treatment of their OSA condition. In addition,
They achieved a success rate of 96%. Based on some OSA patients may have multiple missing
the criteria of a 50% reduction in the RDI and a teeth, active advanced periodontal disease, or
final RDI of less than 20,4 Hochban et al5 and complex fixed prosthodontic restorations, which
Prinsell7 also used MMA as the primary proce- may complicate orthodontic treatment. Further-
dure for 38 and 50 OSA patients, achieving 97% more, the patients’ problem is often a functional
and 100% success rate, respectively. one, and they may be less concerned with the
esthetic improvement of any treatment. Those pa-
tients who, for whatever reason, elect or are
Indications and Contraindications
advised not to undergo presurgical orthodontic
for MMA
treatment should clearly understand their possi-
To be a suitable patient for MMA treatment, a ble and potential need for postsurgical orth-
few prerequisites are necessary.11 The patients’ odontic and/or restorative dental treatment.
apnea-hyponea index or RDI must be greater
than 15, with a lowest desaturation ⬍90% and
Orthodontics
subjective excessive daytime sleepiness. In addi-
tion, conservative treatments, such as weight The objectives of presurgical orthodontic treat-
loss, mandibular repositioning devices, and/or ment for MMA patients is different from those of
continuous positive airway pressure, must have routine orthognathic surgery for patients who
been unsuccessful or intolerable for the patient. have dentofacial deformities. For the MMA pa-
The patient must also be medically fit to un- tients, the purpose of the presurgical orthodon-
dergo the surgery. If, in addition, the following 2 tic treatment is to assist in maximizing the ante-
clinical conditions also are present, then MMA rior positioning of the maxilla and mandible
should be the procedure of choice. First, there while attempting to obtain a reasonable occlu-
should be obstruction at multiple sites or ob- sion. In Class II patients, it is advisable to retract
struction could not be distinguished, as it was the lower incisor teeth and procline the upper
diffuse. Second, the patient should present with incisor teeth to maximize the amount of man-
a dentofacial skeletal deformity and malocclu- dibular advancement. This step will provide the
sion, most often a Class II relationship, and the greatest amount of airway improvement.
MMA surgery should be able to provide an op-
portunity to obtain multiple benefits. Obviously,
Cephalometric Analysis
patients who do not meet the criteria for the
MMA procedure or who are unwilling and/or In general, a lateral cephalogram is a standard-
unable to undergo MMA surgery should be ex- ized and repeatable radiograph that presents the
cluded. profile view of the viscerocranium. It is a routine
tool for the diagnostic workup of all OSA pa-
tients and the technique has been previously
Surgical Planning and Technique
described.12 Cephalometric analysis helps to
MMA is primarily orthognathic surgery in which confirm the clinical and nasopharyngoscopy
the maxilla and mandible are advanced through findings. The values of different parameters in
osteotomies. Thus, MMA surgery requires all the the analysis can be compared to normal values
 Surgical Maxillomandibular Advancement Technique 101

to characterize the craniofacial relationship and according to the prefabricated occlusal splint
the posterior airway status. into a Class III relationship. The occlusal splint
Cephalometric analysis reveals the severity of is made during the presurgical model surgery.
any craniofacial dysmorphy or abnormalities. The inferior alveolar nerve is kept intact but
Studies have referred to the retro-positioning of sustains some tension during the surgical ad-
the jaws, a short mandibular length, a long an- vancement procedure. The distal segment is
terior face height, clockwise rotation of the fa- then fixated with bicortical screws or titanium
cial structure, short cranial base, and decreased miniplates and screws. Performing the mandib-
craniofacial flexure angle as common abnormal- ular advancement first creates a more stable oc-
ities found in OSA patients.4,13-17 The underlying clusal platform. The advancement of the mandible
principle is that when the craniofacial structure is pulls the geniohyoid, genioglossus, mylohyoid and
retropositioned through either underdevelopment the digastric muscles anteriorly. This in turn
in the horizontal plane or a clockwise rotational brings the base of tongue and hyoid bone for-
growth pattern, the structures that form the an- wards and upwards. In addition, the advance-
terior and lateral boundaries of the posterior ment of the mandible creates a larger volume
airway, such as the palate, tongue, and pharyn- for the tongue and floor of mouth. These two
geal tissues are displaced posteriorly. The tissues effects result in the enlargement of the posterior
are also lax and more liable to collapse in the airway space at the retroglossal and hypopharyn-
presence of negative pressure. This results in the geal region level.
constriction of the posterior airway, increased air- The maxilla is then cut and mobilized at the
way resistance and obstructions. Moreover, the re- Le Fort I level. The advancement is then
striction generates turbulence of the airflow and
achieved with the aid of a final occlusal splint or
vibration of the redundant tissues, causing snor-
a stable final occlusion. The maxilla is then fix-
ing. Interestingly, significant craniofacial abnor-
ated with 4 titanium plates and screws. There are
malities are found in about 40% of these pa-
prebent OSA advancement plates19 that are de-
tients.18 In terms of treatment planning, it is an
signed for this purpose and have been shown to
important tool to help identify the patients who
be more resistant to relapse.20 Because there is
have severe craniofacial deficiency (SNB angle
very often a large gap and minimal bony contact
⬍ 75°), as they should be directly offered MMA
between the upper and lower segments of the
surgery instead of soft tissue procedures.10
maxilla, bone grafting is necessary to ensure
Although there are more advanced imaging
techniques to study the posterior airway, cepha- good bony healing, better stability, and the min-
lometric analysis still offers considerable advan- imization of relapse.21 Nasal septal defects and
tages, including low cost, ease of use and mini- enlarged inferior turbinates can be treated via
mal radiation exposure. It is also able to analyze the Le Fort approach after down-fracturing of
the craniofacial morphology, airway status, head the maxilla. The generally accepted magnitude
position and hyoid position simultaneously. In of advancement was 10 mm. The 10-mm quan-
addition, its acceptable reproducibility enables tum is not evidenced based, and the authors of
easy comparisons longitudinally, before and af- the present paper have achieved good success
ter procedures and between populations. despite surgical advancement of a lesser degree.
This is because the change in airway resistance is
inversely proportional to the radius of the airway
Technique raised to the power of four. The movement of
The MMA is achieved by use of the standard the maxilla and mandible will be the same only
bilateral sagittal split osteotomy technique for in cases in which there is no change in occlu-
the mandible and the Le Fort I level maxillary sion. Equal maxillary and mandibular advance-
osteotomy. The mandible is cut and a sagittal ment also occurs in patients who do not un-
split is carried out bilaterally in the posterior dergo preoperative orthodontic treatment.
body, angle and lower ramus region. The prox- Patients who have dysgnathia usually are sched-
imal segments with the condyles are kept in the uled for orthodontic treatment and improve-
same position while the distal segment; the body ment of their malocclusion. In patients with dys-
of mandible, alveolus and teeth, are advanced gnathia who undergo orthodontic treatment the
102 Lee and Deatherage

maxilla and mandible will obviously not be ad- can be improved with the assistance of speech
vanced equal amounts. therapy. Sometimes, speech difficulties from the
An additional procedure to complement the change in lip position also may require speech
MMA is the GGA. This could be done via the therapy.
rectangular osteotomy technique popularized by Esthetic alterations, especially widening of
Riley et al22 or an inferior horizontal geniotomy; the alar base of the nose and superior movement
the standard chin osteotomy used in orthog- of the nasal tip and a more acute nasolabial
nathic surgery. This technique increases the angle, are problems that should be discussed
magnitude of repositioning of the genioglossus, with the patient preoperatively. However, many
geniohyoid and digastric muscles.23 studies have indicated that the facial changes were
Simultaneous adjunctive soft-tissue proce- generally viewed favorably by the patients.25 This
dures can be considered during the MMA pro- change in facial appearance is more of a concern
cedure. However, any pharyngeal soft-tissue pro- among the Asians population because of the
cedures performed simultaneously with MMA common presentation of bimaxillary protrusion
may result in airway compromise secondary to in this group of patients.26 Another complica-
bleeding and swelling. These procedures in- tion that may arise is temporo-mandibular disor-
clude surgery to the soft palate, tonsils, and the der (TMD). The TMD is caused by the alteration
tongue. These cases may need surgical tracheos- in the condylar position and increased joint
tomy,4 prolonged endotracheal intubation or pressure from the large mandibular advance-
continuous positive airway pressure use for the ment. Pre-existing TMD is a risk factor that may
period of postoperative edema. In addition, any drastically increase the likelihood of postopera-
tension on the soft-tissue closure from the skel- tive TMD.
etal advancement may lead to poor healing or Additional reported concerns that may arise
even fibrosis and scarring.7 Nonpharyngeal pro- are limited range of motion, sinus dysfunction
cedures, such as nasal procedures, cervicofacial and decreased bite force. These complications
liposuction, or lipectomy can be done simulta- have been observed more frequently in older
neously with MMA because there is no potential patients. Bettega et al10 encountered some other
airway compromise in these procedures.7 minor complications, such as local infection, an
oro-nasal perforation that healed spontaneously,
and maxillary pseudo-union resulting in instabil-
ity and that required bone grafting. Prinsell11
Complications
reported minimal postoperative difficulties with
There are no major complications reported for a mean hospital stay of 1.6 days, no significant
the MMA procedure. Various authors have men- impairment from the hypesthesia, and good pa-
tioned some minor complications. As the ad- tient acceptance of their facial changes. Waite
vancement of the mandible is often 10 mm or et al4 also showed 95% patient satisfaction de-
greater, the incidence of permanent hypesthesia spite the minor complaints.1
of the lower lip is one of the commonest prob-
lems. Studies have shown long term hypesthesia
to be in the range of 13%6 and 20%.10 If there is
Advances in MMA
no concurrent orthodontic treatment, postoper-
ative occlusal changes, such as malocclusion and In the presence of modern technology, research-
open bites, are relatively common. This could ers and clinicians have started using computed
result in the need for reoperation, postoperative tomography (CT) and magnetic resonance (MR)
orthodontic treatment, or postoperative prosth- scans to evaluate the posterior airway 3-dimen-
odontic rehabilitation. When there has been sionally. This is superior to the widely used 2
previous or concurrent soft palate surgery to dimensional cephalograms. However, cephalo-
stiffen or shorten the palate, velopharyngeal in- metric analysis of the airway has been well
sufficiency can occur.24 Velopharyngeal insuffi- established and permits measurements at key
ciency results in a lack of palatal closure and anatomical locations. Although CT and MR pro-
allows air escape during speech and swallowing vide extremely accurate distance and area mea-
difficulty. This problem is usually temporary and surements of the airway in all dimensions, there
 Surgical Maxillomandibular Advancement Technique 103

are no recognized normal ranges. Furthermore, 4. Waite PD, Wooten V, Lachner J, et al: Maxillomandibu-
there is no standardization in the thickness, di- lar advancement surgery in 23 patients with obstructive
sleep apnea syndrome. J Oral Maxillofac Surg 47:1256-
rection and precise location of the sections as
1261, 1989
yet.27 In a recent study, 20 patients who under-
5. Hochban W, Conradt R, Brandenburg U, et al: Surgical
went MMA had CT scans preoperatively and maxillofacial treatment of obstructive sleep apnea. Plast
following surgery to analyze the morphologic Reconstr Surg 99:619-626, 1997
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strated significant increase in both the antero- tive sleep apnea: A review of 306 consecutive treated
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