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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4586_Библиотеки_им_академика_М_И_Перельмана
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Maxillomandibular Advancement
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NingZhou, Jean-PierreT.F.Ho, andJande Lange
25.1 Introduction
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. It is characterized by recurrent upper airway collapse during sleep, leading to
intermittent hypoxemia, hypercapnia, and frequent cortical arousals [1]. Continuous
positive airway pressure (CPAP) is generally regarded as the gold standard therapy
for patients with moderate to severe OSA [1, 2]. However, its efcacy is often hampered by the low tolerance and poor compliance, promoting OSA patients to seek
alternatives to CPAP, such as a mandibular advancement device or surgical therapy [2, 3].
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-34992-8_25. The videos can be accessed individually by click-
ing the DOI link in the accompanying gure caption or by scanning this link with the SN More
Media App.
N. Zhou
Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for
Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands
Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam
(ACTA), University of Amsterdam and Vrije Universiteit Amsterdam,
Amsterdam, The Netherlands
J.-P. T.F. Ho (*)
Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for
Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands
Department of Oral and Maxillofacial Surgery, Northwest Clinics, Alkmaar, The Netherlands
e-mail: j.p.ho@amsterdamumc.nl
J. de Lange
Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Centre for
Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, The Netherlands
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_25
311
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Of the surgical options for OSA, MMA has been widely demonstrated to be
the most effective treatment (apart from tracheotomy) [4, 5]. MMA involves
simultaneous advancement and rotation of the maxilla and mandible through a
Le Fort I osteotomy of the maxilla and bilateral sagittal split osteotomy (BSSO)
of the mandible [6]. It has been suggested that by altering the skeletal framework, MMA can enlarge the entire retropalatal and retrolingual airway and stabilize the pharyngeal dilator muscles, thereby reducing upper airway
collapsibility [7, 8].
Upper airway collapse may occur at the level of one or multiple pharyngeal
structures, usually the soft palate, the oropharynx, the base of tongue, and the
epiglottis [9, 10]. Identifying the collapse site(s) is crucial to determine the
appropriate therapeutic strategy for patients with OSA, especially when nonCPAP therapy is considered [11, 12]. Nowadays, drug-induced sleep endoscopy
(DISE) plays a key role in facilitating the decision-making process, through
visualizing the upper airway obstruction during sedated sleep. With the use of
DISE, epiglottis collapse has been found to occur more frequently than previously described [13]. While the role of the epiglottis in contributing to OSA has
been underestimated in early research, the importance of this anatomical site
and the management of epiglottis collapse have begun to gain more and more
attention [13–15].
In this chapter, we rstly present some general information regarding MMA surgery for OSA treatment, and secondly, we provide a review of the current evidence
on the role of MMA for epiglottis collapse.
N. Zhou et al.
25.2 Indication andContraindication
Despite there being several different protocols for MMA surgery in the OSA
management, the precise indications and staging protocols (primary and secondary MMA) remain undened. The most current American Academy of Sleep
Medicine (AASM) practice guidelines recommend that “MMA is indicated for
surgical treatment of severe OSA in patients who cannot tolerate or who are
unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients,
have been considered and found ineffective or undesirable (Option)“ [16]. Of
note, this practice recommendation is given as an “Option” instead of a
“Guideline”, as it is drawn from the relatively low quality of evidence. Most
recently, Liu etal. [17] adopted a protocol at Stanford, in which MMA surgery
is considered as a rst-line treatment in OSA patients with preexisting dentofacial deformity, severe OSA, and specic airway collapse pattern (complete centric collapse at velum, and complete collapse at lateral pharyngeal wall) during
DISE.The relative contraindications for MMA mainly include medical comorbidities (e.g., severe or unstable cardiopulmonary disease, uncontrolled diabetes, immune compromise), morbid obesity, older age, active alcohol/illicit drug
abuse, and unstable psychological problems [18, 19].
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25.3 Surgical Technique
25.3.1 Preoperative Planning
During the last decade, virtual surgical planning (VSP) has been utilized to plan and
perform MMA accurately [20]. VSP for MMA begins with the clinical data gathering phase, mainly involving medical and sleep history, polysomnography (PSG),
head and neck physical examination, radiographs, and facial analysis. Next, with
the use of proprietary virtual planning software, three-dimensional (3D) computed
tomography (CT) or cone beam computed tomography (CBCT) data and dental
model are integrated as a 3D virtual model of the patient, which is used to precisely
plan the operation based on surgeons’ expertise (Fig. 25.1). Three-dimensional
printed surgical splints allow for accurate translation of the virtual surgical plan to
the surgical procedure in the operating room (Fig.25.2).
25.3.2 Surgical Procedure
25.3.2.1 Bilateral Sagittal Split Osteotomy
The patient is in a supine position with a neutral head position. General anesthesia is administered through nasotracheal intubation. Local anesthesia is
then injected to help with hemostasis. The surgery can be performed through
either a maxilla-first or mandible-first protocol [21] (Fig.25.3). When the
mandible-first protocol is used, a mucosal incision is made along the anterior
border of the ramus which continues inferiorly, along the sulcus of the
Fig. 25.1 Virtual surgical planning for maxillomandibular advancement (left panel, before MMA;
right panel, after MMA)
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Fig. 25.2 Three-dimensional printed surgical splints (left side, intermediate splint; right side,
nal splint)
N. Zhou et al.
Fig. 25.3 (Video 25.1) Surgical technique of maxillomandibular advancement
(► https://doi.org/10.1007/000-bfv)
Fig. 25.4 Mucosal
incision for bilateral
sagittal split osteotomy for
the left side of the
mandible
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Fig. 25.5 Separation of
bone segments of the
mandible with osteotome
and bone spreader
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mandible till the first molar (Fig.25.4). Subperiosteal dissection is performed
to expose the lateral aspect of the mandible, the anterior ramus, and the
medial ramus above the inferior alveolar nerve. The Hunsuck modification of
the Obwegeser and Dal Pont BSSO technique is applied [22]. Using a bur or
saw, a horizontal osteotomy is made just above the lingula, parallel to the
occlusal plane. The osteotomy continues inferiorly along the oblique line of
the ramus to the level of the first molar (remaining approximately 5mm lateral to the teeth). Then, a vertical osteotomy is made along the buccal surface
of the mandibular body, to the inferior border which is extended from the
lateral to medial of the inferior border. Thin osteotomes are placed through
the entire length of the cuts to begin separation of bone segments (Fig.25.5).
The completion of osteotomy is confirmed using a bone spreader. At this
point, the distal tooth bearing segment can be moved three dimensionally.
The inferior alveolar nerve is then identified, and if it is present in the buccal
cortex, it is then completely dissected from the buccal cortex and positioned
toward the lingual side. Once completing the osteotomies on both sides, the
mobile distal tooth bearing segment is repositioned in the virtual planned
desired position with guidance of the intermediate surgical splint. After intermaxillary fixation (IMF) is applied (Fig.25.6), rigid fixation is utilized with
screws alone or a combination of titanium plates and screws on both sides
[23, 24] (Fig. 25.7). IMF is then released and the mandible is mobilized to
verify the planned occlusion. In cases where there are large gaps between
osteotomy segments, one may choose to augment the mandible with autogenous and/or alloplastic bone.
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Fig. 25.6 Intermaxillary
xation with the use of the
intermediate splint and
powerchains
Fig. 25.7 Rigid xation
with titanium plates and
screws for the right side of
the mandible
N. Zhou et al.
25.3.2.2 Le Fort IOsteotomy
Access to the Le Fort I osteotomy begins with a maxillary gingivobuccal incision,
which is made from the rst molar on one site to the rst molar on the opposite site
to expose both the lateral and medial buttresses of the maxilla. Subperiosteal dissection is performed to expose the anterior and lateral surface of the maxilla (from the
piriform rims to the pterygoid processes) (Fig.25.8). The nasal mucosa is dissected
and released. A xed skeletal marker (K-wire or screw) is placed in the glabella
region. This will allow vertical measurements before and after the osteotomy, to
ensure the correct maxillary planned height is achieved (Fig.25.9). Then, a maxillary osteotomy is made with a ssure bur or saw from the ipsilateral piriform rim to
the pterygomaxillary ssures bilaterally. A U-shaped or V-shaped osteotome is used
to separate the nasal septum from the maxilla (Fig.25.10). The posterior maxillary
wall and lateral nasal wall is then fractured with an osteotome. A curved osteotome
is then used to separate the pterygomaxillary junction. Once the osteotomies are
completed, the down-fracture is performed with digital pressure or a bone- hook
(Fig.25.11). After completing down-fracture and mobilization with Rowes forceps,
a nal surgical splint is used to position the maxilla accurately by IMF.The surgical
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Fig. 25.8 Subperiosteal
dissection for Le Fort I
osteotomy of the maxilla
Fig. 25.9 K-wire in the
glabella region for vertical
measurement
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splint ensures that the virtual plan is translated in all dimensions except for the
cranial-caudal dimension. The planned movement in this dimension achieved by is
maxillary impaction, which is often due to a planned counterclockwise rotation.
The impaction requires appropriate reduction of anterior maxillary bone, septum,
and/or vomer. Rigid xation is then accomplished utilizing four titanium miniplates
and mono-cortical screws [17, 25] (Fig.25.12). Following xation, IMF is released
and the mandible is mobilized to verify the planned occlusion. After conrming
proper occlusion, the incisions are closed with absorbable sutures. Orthodontic elastics may be used for postoperative guidance of the occlusion on orthodontic appliances or arch bars if present [17].
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Fig. 25.10 Separation of
the nasal septum from the
maxilla with a U-shaped
osteotome
Fig. 25.11 Down-fracture
of the maxilla with a
bone-hook
N. Zhou et al.
Fig. 25.12 Rigid xation
with titanium plates and
screws for the maxilla
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25.4 Postoperative Care
Following MMA, patients are often carefully monitored overnight in an intensive
care unit (ICU) [26]. Usually, the patients are transferred out of the ICU to a regular
ward with continuous airway monitoring on the rst postoperative day. The average
length of hospitalization is 3.5days [4]. Postoperative medications include antibiotics, analgesics, and steroids. Applying a light pressure dressing and ice is recommended for the rst 48 hours to help minimize the swelling. Rinses of the oral
cavity and gentle toothbrushing should start on the rst postoperative day to maintain proper oral hygiene. Patients’ diet is adapted with a clear liquid diet for the rst
week, followed by a strict non-chew diet for approximately 1month. The patients
can return to normal activities with physical restriction 1 or 2 weeks after surgery [27].
The frequency of follow-up generally depends on surgeons’ preference and
patients’ recovery. Usually, postoperatively radiographs and/or CT or CBCT are
made. An overnight PSG is necessary, typically 3–6months after MMA, to evaluate
therapeutic efcacy.
25.5 Complications
No death has been reported for the MMA procedure. Reoperation is likely
required for hardware removal, malunion, nonunion, and severe malocclusion.
Previously reported rates of reoperation range from 0 to 40% [16, 28, 29]. The
most common complication of MMA is facial paresthesia caused by impairment
of the inferior alveolar nerve and/or maxillary nerve. Our recent systematic
review shows that facial paresthesia was transient in 76.9% cases and persistent
in 18.5% of cases following MMA [4]. Patients’ age, addition of genioplasty, and
large degree of mandibular advancement may increase the risk of paresthesia of
the lower lip and chin [30]. Malocclusion can happen in some patients following
MMA, which requires orthodontic treatment or surgical correction. The reported
risk of malocclusion ranges from 0 to 24% [6, 31, 32]. Other less frequently
reported complications mainly include temporomandibular joint disorder, local
infection, and velopharyngeal insufciency in patients with previous or concurrent soft palate surgery, dyspnea, palatal perforation, and transient deviation of
angle of mouth [4].
Additionally, there are some concerns about aesthetic alterations resulting from
MMA, such as excessive maxillomandibular protrusion, increase of the alar base,
and nasal tip elevation. However, it has been suggested that a majority of patients
perceived the facial changes as positive or neutral [4, 31]. Various surgical techniques, such as counterclockwise rotation of the maxillomandibular complex and
recontouring of the anterior nasal spine, have been applied into MMA to limit the
potential negative aesthetic effect.
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N. Zhou et al.
25.6 Outcome ofMMA
MMA has been suggested to be the most successful surgical therapy for OSA (apart
from tracheostomy), with a therapeutic efcacy comparable to CPAP.As reported
in our recent meta-analysis, 19 MMA studies, describing 393 subjects with mean
preoperative apnea hypopnea index (AHI) of 57.3± 26.6/h, showed a statistical
improvement in AHI of 46.2/h, lowest oxygen saturation (LSAT) of 13.5%, oxygen
desaturation index (ODI) of −30.3/h, and Epworth Sleepiness Scale (ESS) of −8.5.
The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%,
respectively [4]. The predictors of increased surgical success include younger age,
lower preoperative weight and AHI, and greater degree of maxillary advancement [5].
The efcacy of MMA can persist for most patients on a long-term basis. A metaanalysis by Camacho etal. demonstrated that the improvements in AHI, LSAT, and
daytime sleepiness for patients who underwent MMA for OSA maintained in the
long term (4 to <8years), while the mean AHI increased to moderate OSA in the
very long term (≥8years) [33]. Vigneron etal. demonstrated that the success rate of
MMA was 41.4% at 12.5years after MMA, and the success rate was 100% in young
patients (age <45years old) with BMI <25kg/m2, AHI <45/h, SNB <75°, narrow
retrolingual space (<8mm), and preoperative orthodontics (success was dened as
an AHI of <10/h and almost a 50% reduction in AHI following MMA) [28]. Marked
weight gain, signicant skeletal relapse, and aging may counteract the benet of
MMA in the long term [34, 35]. To maintain the therapeutic efcacy, long-term
follow-up is needed for OSA patients.
Several studies have also evaluated the impact of MMA on quality of life.
Pottel etal. reported the OSA quality of life (OSA QoL) questionnaire score at
19-year follow-up in nine MMA patients [34]. They reported immediately postoperative improvements in symptoms of headache, blood pressure, daytime sleepiness, concentration, insomnia, nocturia, snoring, and sexual performance. At
approximately 19years after MMA, the improvements in all previously reported
symptoms persisted, except for blood pressure, nocturia, and sexual activity. Boyd
etal. investigated the QoL for 14 patients who underwent MMA for OSA using
the Functional Outcomes of Sleep Questionnaire (FOSQ) [31]. The patients
reported a signicant improvement in mean FOSQ scores of 4.7 at 2years after
MMA.It is suggested that the short-term improvements in QoL after MMA may
be maintained in a long term.
25.7 Role ofMMA forEpiglottis Collapse
To date, there is limited evidence on the role of MMA for epiglottis collapse [7, 36].
In 2016, Liu etal. used DISE to study dynamic changes of the upper airway following MMA [7]. In their study, MMA was performed in 20 patients. Four out of 20
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