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Original Investigation
January 2016

Maxillomandibular Advancement for Treatment of Obstructive Sleep ApneaA Meta-analysis

Author Affiliations
  • 1Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA (University of California, Los Angeles)
  • 2Pulmonary, Critical Care and Sleep Medicine Section, Pulmonary Division, Department of Medicine, Veterans Affairs Palo Health Care System, Stanford University, Palo Alto, California
  • 3Department of Otorhinolaryngology, Sleep Medicine Centre, Hospital CUF Porto, Porto, Portugal
  • 4Centre for Research in Health Technologies and Information Systems, University of Porto, Porto, Portugal
  • 5Department of Otorhinolaryngology, Hospital Bernardino Rivadavia, Buenos Aires, Argentina
  • 6Sleep Medicine Division, Department of Psychiatry and Behavioral Sciences, Stanford Hospital and Clinics, Redwood City, California
  • 7Sleep Surgery Division, Department of Otolaryngology–Head and Neck Surgery, Stanford Hospital and Clinics, Redwood City, California
  • 8Division of Sleep Surgery and Medicine, Department of Otolaryngology–Head and Neck Surgery, Tripler Army Medical Center, Honolulu, Hawaii
JAMA Otolaryngol Head Neck Surg. 2016;142(1):58-66. doi:10.1001/jamaoto.2015.2678

Importance  Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework.

Objective  To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies.

Data Sources  The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea.

Study Selection  Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded.

Data Extraction  Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015.

Main Outcomes and Measures  The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h.

Results  Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were −47.8 (25.0) and −44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates.

Conclusions and Relevance  Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.