Soft tissue changes after maxillo-mandibular advancement in OSAS patients: A three-dimensional study

Non-sleep related outcomes of maxillomandibular advancement, a systematic review

Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.

An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea

Background

Obstructive Sleep Apnoea (OSA) is a common sleep disorder marked by partial or total obstruction of the upper airway while a person is asleep leading to breathing difficulty, reduced oxygenation and frequent awakenings. This condition affects the general health significantly compromising quality of life. The objective of this overview  is to thoroughly assess the systematic reviews on current surgical therapies for the management of OSA in terms of patient outcomes.

Methods

A thorough literature search was performed from inception till 31st December 2022 using PubMed, and Cochrane databases. Studies evaluating the effectiveness and safety of different surgical techniques for the management of OSA were considered. The quality of articles was assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and Glenny et al. checklist.

Results

Out of eighteen studies, only seven studies met the inclusion and exclusion criteria. Results showed that the majority of studies were in the pediatric age group except one systematic  review which assessed the adult age group.

Conclusion

None of the published articles had compared all surgical procedures based on the standard evaluating procedure nor followed all reporting guidelines in the primary studies. For better implementation, further multi center studies are warranted with unique reporting criteria and guidelines about pre- as well as post-operative phases. Future research should concentrate on contrasting strategies, combination therapies, and evaluating long-term effects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12663-023-02051-x.

Satisfaction With Facial Aesthetic Appearance Following Maxillomandibular Advancement (MMA) for Obstructive Sleep Apnea (OSA): A Meta-Analysis

PURPOSE

A large cohort of patients diagnosed with obstructive sleep apnea (OSA) require surgical intervention, sometimes in the form of maxillomandibular advancement (MMA), to correct their functional disturbance. Such a surgical procedure typically results in a slight modification of the patients' facial appearance. The purpose of the current systematic review and meta-analysis was to examine the rate of satisfaction with facial aesthetics post-MMA intervention and to assess its dependability on and relationship with other patient or treatment factors. Based on the literature currently available, and to the best of our knowledge, this is the first paper to draw on the topic analytically.

METHODS

A search was conducted on four electronic literature databases (Pubmed, Ovid, Science Direct, and Scholar). Using referred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), our inclusion criterion covered any case with adequate reported data pertaining to the research question up to June 2021. Three evaluator groups were utilized. Satisfaction was defined as either an obvious reported increase in fondness for facial appearance or a state of indifference to the cosmetic results of the conducted changes. Dissatisfaction was defined as a clear discontent with the post-operative esthetic results. A multivariate analysis of the data was conducted, and Chi-square tests for independence were used to detect any significant associations. A meta-analysis of proportion was employed to permit for Freeman-Tukey double arcsine transformation and stabilize the variance of each study's proportion. Cochran's Q was computed, and the significance level was gauged as a function of P value.

RESULTS

Meta-analyses of proportion conducted for assessment of aesthetic appraisal following surgical MMA for OSA elucidated a significantly higher predilection towards aesthetic satisfaction after surgical MMA for OSA for all evaluator groups in the encompassed studies. 94.2% of patients were satisfied with their facial esthetics postoperatively.

CONCLUSION

The vast majority of patients that undergo MMA for the correction of OSA report satisfaction with post-surgical facial aesthetics. The subjective assessment of this parameter by physicians and laypeople portrays an equivalently significant skew toward post-surgical appearance improvement. MMA is a generally safe procedure that substantially contributes to enhancement of both overall quality of life and perceived aesthetic appeal.

Maxillomandibular Advancement and Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: A Systematic Review

This systematic review aimed to comparatively evaluate the efficacy and safety of maxillomandibular advancement (MMA) and upper airway stimulation (UAS) in obstructive sleep apnea (OSA) treatment. A MEDLINE and Embase database search of articles on MMA and/or UAS for OSA was conducted. Twenty-one MMA studies and nine UAS studies were included. All the MMA studies demonstrated a reduction in apnea hypopnea index (AHI) postoperatively, and success rates ranged from 41.1% to 100%. Ten MMA studies reported pre- and postoperative Epworth sleepiness scale (ESS), and all but one study demonstrated a reduction in ESS. In the UAS studies, all but one demonstrated a reduction in AHI, and success rates ranged from 26.7% to 77.8%. In the eight UAS studies reporting pre- and postoperative ESS, an ESS reduction was demonstrated. No studies reported any deaths related to MMA or UAS. The most common postoperative complications after MMA and UAS were facial paresthesia in the mandibular area and discomfort due to electrical stimulation, respectively. This systematic review suggests that both MMA and UAS are effective and generally safe therapies for OSA. However, due to the limitations of the included studies, there is no evidence yet to directly compare these two procedures in OSA treatment.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Virtual planning and CAD/CAM-assisted distraction for maxillary hypoplasia in cleft lip and palate patients: Accuracy evaluation and clinical outcome

The aim of this prospective study was to report the experience with a specific guided distraction protocol for the treatment of CLP patients with severe midface hypoplasia. From January 2016 to April 2019, six consecutive, non-growing, CLP patients with maxillary hypoplasia underwent a specific distraction protocol based on the use of VSP, CAD/CAM-generated surgical splints, cutting guides, prebent internal maxillary distractors, early removal of distractors, and acute callus manipulation and fixation. STL files for VSP, using multislice CT scans taken preoperatively (T0) and 3 months after distractor removal (T1) were superimposed using the free software 3D Slicer and Geomagic Wrap to evaluate the accuracy of maxillary repositioning and assess 3D bone changes. Clinical outcome was evaluated at the 1-year follow-up (T2). The patients and surgeon were satisfied with the occlusal and aesthetic outcomes. A maximum difference of 2 mm between the VSP and the actual surgical outcome was chosen as the success criterion for accuracy. The average linear difference for selected points was <2 mm in four patients and >2 mm in two patients. The average distance of the postoperative maxilla from the VSP model was 2.28 mm (median 1.85), while the average forward movement of the maxilla was 10.18 mm The protocol used is effective and accurate in the correction of severe maxillary hypoplasia in CLP patients. Early removal of the distractor and stabilization with plates reduces patient discomfort and does not jeopardize stability. This protocol should be reserved for complex cases due to the costs of the procedure, which are not negligible.

Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis

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.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis

Objective

To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA).

Data Sources

The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE.

Review Methods

Three authors systematically reviewed the international literature through July 26, 2018.

Results

A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term.

Conclusion

The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Three-dimensional region-based study on the relationship between soft and hard tissue changes after orthognathic surgery in patients with prognathism

Both deep understanding and reliable prediction of postoperative soft tissue changes are crucial for planning orthognathic surgery. Instead of estimating soft tissue responses by measuring individual landmark changes, this study aimed to investigate the relationship (ratio) between soft and hard tissue movements in different facial regions through three-dimensional cone-beam computed tomography (CBCT). Preoperative and postoperative CBCT images were superimposed using the surface registration method on the basis of the cranial base, and 10 facial regions of interest were defined. Region-based volumetric subtractions between the preoperative and postoperative segments were performed. The volumetric differences and surface of each region were used to estimate the average movement. Correlation and regression analyses were performed to examine the relationships between the corresponding soft and hard tissue movements. An overall pattern of facial soft tissue movement was observed in patients with prognathism who underwent orthognathic surgery. The experiment results have shown that mean ratios for the average soft-to-hard tissue movements in the facial regions varied, which may not exactly be similar to the published reports because of the population biocharacteristics and study methods, but the trend is in agreement with the previous studies. Additionally, the prediction capability of the regression model was significantly high, ranging from 0.786 to 0.857, in upper lip, upper vermilion, and chin regions, thus demonstrating that the skin outline changes in these critical regions could be reliably predicted from the underlying bone movements. These results could likely be applied in future soft tissue simulation in orthognathic surgery.

Facial Mobility after Maxilla-Mandibular Advancement in Patients with Severe Obstructive Sleep Apnea Syndrome: A Three-Dimensional Study

Introduction. The functional results of surgery in terms of facial mobility are key elements in the treatment of patients. Little is actually known about changes in facial mobility following surgical treatment with maxillomandibular advancement (MMA). Objectives. The three-dimensional (3D) methods study of basic facial movements in typical OSAS patients treated with MMA was the topic of the present research. Materials and Methods. Ten patients affected by severe obstructive sleep apnea syndrome (OSAS) were engaged for the study. Their facial surface data was acquired using a 3D laser scanner one week before (T1) and 12 months after (T2) orthognathic surgery. The facial movements were frowning, grimace, smiling, and lip purse. They were described in terms of surface and landmark displacements (mm). The mean landmark displacement was calculated for right and left sides of the face, at T1 and at T2. Results. One year after surgery, facial movements were similar to presurgical registrations. No modifications of symmetry were present. Conclusions. Despite the skeletal maxilla-mandible expansion, orthognathic surgical treatment (MMA) of OSAS patients does not seem to modify facial mobility. Only an enhancement of amplitude in smiling and knitting brows was observed. These results could have reliable medical and surgical applications.

A systematic review of soft-to-hard tissue ratios in orthognathic surgery. Part IV: 3D analysis - Is there evidence?

OBJECTIVE

The objective of this study was to determine the soft-to-hard tissue ratio using 3D analysis in different types of orthognathic surgery.

MATERIAL AND METHODS

A systematic search for relevant studies published in different languages through December 2016 was performed in the Medline, Embase, Lilacs, Scopus, and Science Direct databases. Additional studies were identified by reference analysis. The methodological quality of the included studies was evaluated using the method proposed by the Effective Public Health Practice Project. The level of evidence was assessed using the Level of Evidence (LOE) scale from the Oxford Center for Evidence-Based Medicine.

RESULTS

A total of 11 articles with 461 patients were included in the review, comprising 5 retrospective study and 6 prospective studies. The latter included 5 studies that performed anatomical area analyses of postoperative soft tissue results in the context of software-based planned surgeries without regard to hard tissues and 6 articles that presented analyses related to soft tissue in the preoperative and postoperative stage with certain points to be considered in hard tissues. The analysis of bias in the articles revealed a weak methodology in all included studies, which made it impossible to perform any type of comparison.

CONCLUSION

Bias governs many of the published studies related to 3D analysis. There are no data that can be applied to determine the soft-to-hard tissue ratio using 3D analysis in orthognathic surgery.

Upper Airway Changes After Mandibular Setback and/or Advancement Genioplasty in Obese Patients

PURPOSE

Orthognathic surgeries, such as bilateral sagittal split ramus osteotomy (BSSO) and genioplasty, can influence the pharyngeal airway space (PAS) and this has been supported by previous studies. The purpose of this study was to assess changes of the PAS in patients with a high body mass index (BMI) likely to have narrow airways before and after setback BSSO with or without advancement genioplasty surgery by 3-dimensional computed tomography.

MATERIALS AND METHODS

Thirty-five adults with a BMI of at least 24.0 kg/m² were treated from 2010 to 2016. Samples were grouped mandibular setback (group A; n = 11), advancement genioplasty (group B; n = 12), and mandibular setback plus advancement genioplasty (group C; n = 12). Computed tomograms were obtained 1 week preoperatively (T0), 1 week postoperatively (T1), and at least 1 year postoperatively (T2). The area of the posterior nasal spine and posterior plane (PPA), the soft palate plane (SPA), the plane of the most posterior point of the tongue base (PTA), the plane of the root of the epiglottis (EA), and the volumes of the palatopharyngeal part (VP), oropharyngeal part (VO), glossopharyngeal part (VG), and laryngeal part (VL) were measured and compared within groups using analysis of variance. The P value was set at .05.

RESULTS

In group A, all results showed statistically significant differences (P < .05) from T0 to T2 except for VO, VG, VL, SPA, PTA, and EA. In group B, VO, VG, VL, SPA, PTA, and EA showed statistically significant increases (P < .05) from T0 to T2. The hyoid at T2 showed significant advancement compared with T0 (P < .05). In group C, there were statistically significant decreases (P < .05) from T0 to T1 for VG, VL, PTA, and EA.

CONCLUSION

In adults with a high BMI, mandibular setback BSSO could decrease the PAS, whereas advancement genioplasty could enlarge the PAS, after surgery. Therefore, undergoing advancement genioplasty concurrently with mandibular setback BSSO could help in lessening the negative effects of a PAS decrease.

Improved apnea-hypopnea index and lowest oxygen saturation after maxillomandibular advancement with or without counterclockwise rotation in patients with obstructive sleep apnea: a meta-analysis

PURPOSE

This study investigated whether patients with obstructive sleep apnea (OSA) who undergo maxillomandibular advancement (MMA) with counterclockwise (CCW) rotation compared with those who undergo MMA without CCW rotation have better outcomes.

MATERIALS AND METHODS

This was a systematic review with meta-analysis. The Medline and Cochrane databases were searched for randomized controlled trials using Medical Subject Headings. The predictor variable was operative technique, namely MMA with or without CCW rotation of the maxillofacial complex. The key outcome variables were changes in pre- and postsurgical values of pharyngeal volume measured on computed tomogram or cone-beam computed tomogram and changes in Apnea-Hypopnea Index (AHI) and lowest oxygen saturation (LSAT) values after surgery. Data were subjected to a meta-analysis based on odds ratios (OR) with 95% confidence intervals (CIs) and P values lower than .05 by χ(2) test were considered significant.

RESULTS

Twenty-one randomized controlled trials were identified and 4 were assessed for the variables of interest. Postoperative AHI and LSAT measurements showed vast improvement. The sample was not large enough to make a correlation between pharyngeal volume changes and surgical method used. Postoperative parameters included an AHI lower than 5 (OR = 14.9; 95% CI, 2.7-83.5; P = .002), an AHI lower than 20 (OR = 114.8; 95% CI, 23.5-561.1; P <.00001), pooled results of a 50% decrease in the AHI (OR = 6.1; 95% CI, 2.2-17.0; P = .0006), and an increase greater than 90% in LSAT measurements during sleep (OR = 6.0; 95% CI, 1.8-19.9; P = .003). The funnel plot showed no evidence of publication bias.

CONCLUSION

CCW-MMA or MMA in patients with OSA results in a statistically meaningful decrease in postoperative AHI and a statistically meaningful increase in postoperative LSAT.

Comparison of the effects of mandibular protruding devices on obstructive sleep apnoea patients and healthy volunteers

PURPOSE

To evaluate upper airway diameter differences before and after placement of custom made mandible protruding devices (MPD) in OSAS group and to compare with control group using computerized tomography.

METHODS

The OSAS group was composed of 15 patients aged from 25 to 45 years with mild-moderate OSAS and the control group included 15 healthy volunteers, aged from 25 years to 44 years. On coronal and sagittal reformated CT images, anteroposterior (AP) and lateral (LAT) diameters at three levels (passing through soft palate [level 1], 5 mm above uvula [level 2] and 1 cm above the tip of epiglottis [level 3]) were measured before and after MPD placement in both groups.

RESULTS

LAT diameters at level 1, level 2 and AP diameter at level 2 in OSAS group were significantly lower than in control group before MPD placement. Only LAT diameters at level 2 in OSAS group were significantly lower than in control group after MPD placement. When we compared upper airway diameters before and after placement of the MPD within each group, statistically significant increase in diameters at all levels were observed.

CONCLUSION

MPD is a cheap, easily usable device providing increase in upper airway diameters.