Mandibular advancement for adult obstructive sleep apnea: A systematic review and meta-analysis

doi:10.1016/j.jcms.2017.10.006

Journal of Cranio-Maxillofacial Surgery

Volume 45, Issue 12, December 2017, Pages 2035-2040

https://doi.org/10.1016/j.jcms.2017.10.006 Get rights and content

Abstract

Objectives

Patients with mandibular insufficiency can be predisposed to obstructive sleep apnea (OSA). The objective of this study was to systematically review the international literature for mandibular advancement surgeries (MAS) as treatment for adult OSA, and then to perform a meta-analysis.

Methods

Four authors searched five databases from the inception of each database through April 5, 2017. The PRISMA statement was followed.

Results

972 studies were screened, 84 were downloaded, and 11 (57 patients) met criteria. In patients with mandibular insufficiency, MAS reduced apnea–hypopnea index (AHI) (50 patients) from 45.9 ± 24.7 to 6.2 ± 10.4 events/h (87% decrease). The lowest oxygen saturation (LSAT) (55 patients) increased from 71.9 ± 14.6% to 89.0 ± 11.0%. The AHI mean difference was −34.8 events/h [95% CI −43.9, −25.8]. The AHI standardized mean difference was −1.8 [95% CI −2.5, −1.2] (indicating a large magnitude of effect). Surgical cure was seen in 75% of those with >16 mm of mandibular advancement vs. 35% of those with <16 mm of advancement [Odds Ratio 5.5; 95% CI 1.06–28.4; Chi Square p = 0.035].

Conclusions

The current literature supports isolated mandibular advancement as an efficacious treatment modality for adult OSA in select patients with mandibular insufficiency.

Introduction

Obstructive Sleep Apnea (OSA) remains an ongoing concern for the medical and surgical communities due to its effects on sleep quality, and its associations with increased cardiovascular mortality (Somers et al., 2008). Of the many causes of OSA, the small or retrognathic mandible is an anatomical predisposition that is well documented to contribute to OSA severity. One of the leading treatments that have emerged for retrognathia is mandibular distraction osteogenesis (MDO), a surgical procedure that induces histogenesis by progressively advancing divided segments of the mandibular body (Natu et al., 2014). Additionally, mandibular advancement (MA) with placement of plates and screws has been used as well. Collectively, we will refer to MDO and MA as mandibular advancement surgeries (MAS).

The use of MAS for the treatment of OSA in congenital retrognathia has become increasingly common, and previous systematic reviews have been performed that address its success in children (Breik et al., 2016, Tsui et al., 2016). However, published results are relatively sparse for the procedure's benefit in acquired retrognathia of adulthood, and a meta-analysis of those published results has yet to be done to quantify the procedure's benefit.

The objective of this study was to systematically review all international publications reporting polysomnography data for MAS as an isolated treatment for OSA in adult patients, and then perform a meta-analysis with the available data. The study inclusion criteria were as follows using the PICOS acronym: (1) Patients: any adult patient (≥18 years old) with obstructive sleep apnea; (2) Intervention: mandibular distraction osteogenesis or mandibular advancement surgeries; (3) Comparison: polysomnography data pre-surgical and post-surgical; (4) Outcomes: oxygen desaturation index (ODI), apnea–hypopnea index (AHI), respiratory disturbance index (RDI), Lowest oxygen saturation (LSAT), mean oxygen saturation (MSAT), sleepiness, quality of life; (5) Study design: any study design from case reports through randomized controlled-trials.

Section snippets

Protocol

The Tripler Army Medical Center approved this study via the protocol TAMC 16N14 (systematic review and meta-analysis).

Study eligibility criteria

Studies were included without any limitations based on language or the year of publication. Articles were excluded if, in addition to MAS, surgical procedures known to affect obstructive sleep apnea (e.g. maxillary advancement, genioplasty, palate surgery etc) were also performed. Concomitant TMJ arthroplasty was not considered a reason for exclusion.

Information sources

The databases that were

Results

The search strategy yielded 972 studies, of which 84 were potentially relevant and were downloaded in their full versions. Studies were excluded for absent pre- and post-surgical polysomnography, for inadequate separation of results from pediatric patients, or for the inclusion of additional surgeries besides MDO. In total, 11 articles met inclusion and exclusion criteria (Paoli et al., 2001, Li et al., 2002, Harada et al., 2003, Wang et al., 2003, Woodson et al., 2003, Zhou et al., 2005,

Discussion

The major finding from this study is that OSA has been shown to improve significantly after mandibular advancement or mandibular distraction osteogenesis in adult patients with mandibular insufficiency. This significant improvement is demonstrated by the dramatic reduction in the apnea–hypopnea index from 46 to 6 events per hour (87% decrease) and also the dramatic increase in the lowest oxygen saturation from 72% to 89%. To our knowledge, this meta-analysis is the first to systematically

Conclusions

The current international literature has demonstrated a significant improvement in adult obstructive sleep apnea after isolated mandibular advancement or mandibular distraction osteogenesis in patients with mandibular insufficiency.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

There are no conflicts of interest between this research and any of the authors herein listed.

Disclaimer

The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

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Cited by (22)

Obstructive sleep apnea in adolescents
2023, Snoring and Obstructive Sleep Apnea in Children
Sleep disordered breathing constitutes a variety of sleep-related abnormalities, including obstructive sleep apnea (OSA). Pediatric OSA is relatively common in the United States, affecting 1%–5% of all children. Most of the literature is focused on evaluating children or adults, with less data specific to adolescents. Practice patterns follow the guidelines outlined by the American Academy of Otolaryngology—Head and Neck Surgery. Adolescent patients, mainly male or obese, are at increased risk of persistent OSA after adenotonsillectomy. A multidisciplinary approach to OSA management helps improve symptoms. Additional surgical options exist, targeted as the site of the collapse. Adolescents with Down syndrome are a unique cohort who may be eligible for hypoglossal nerve stimulation. The goal of this chapter is to review OSA in adolescents and describe differences in risk factors and management.
Central and mixed sleep apnea related to patients treated with maxillomandibular advancement for obstructive sleep apnea: A retrospective cohort study
2022, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
However, because of the limited interest in, and the limited published data on, central sleep apnea−related issues surrounding MMA, the results of our study offer some valuable insight into this topic. Additionally, it would be advantageous to gain more insight into these issues in other skeletal surgeries for OSA, which have been described with good success rates (Noller et al., 2017; Awad et al., 2019; Gupta et al., 2019; Tsui et al., 2019; Wu et al., 2019; Vinha et al., 2020). As this is the first study that has focused specifically on issues related to central sleep apnea and mixed apnea surrounding MMA in adult OSA patients, it would also be interesting to see whether these issues are present in children with OSA, as well and to evaluate what effect surgery has on the obstructive, central and mixed apnea components in these children (Dowgierd et al., 2020; Khonsari et al., 2020).
The aim of this study was to evaluate the clinical efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) patients with a percentage of central and mixed apnea index in the total apnea−hypopnea index (CMAI%) ≧25%.
Patients treated with MMA for OSA were retrospectively evaluated for baseline and postoperative patient data and polysomnographic results. The pre- and postoperative obstructive, central and mixed apnea parameters were compared.
Of the included 78 patients, 21 patients (27%) presented with CMAI% ≧25% (median CMAI%, 49.1%; 35.9–63.8) prior to MMA. In 67% of these cases, MMA resulted in CMAI% <25 (median CMAI%, 6.1%; 2.1–8.9) and significantly improved the apnea−hypopnea index (AHI) (p < 0.001), the lowest oxyhemoglobin saturation (p < 0.001), central and mixed apnea index (p < 0.001), percentage of central and mixed apneas of total AHI (p = 0.004), central apnea index (p < 0.001), and mixed apnea index (p < 0.001). CMAI% ≧25% emerged in 25% of patients after MMA (median CMAI%, 49.1%; 35.9–63.8).
Within the undeniable limitations of the study, it seems that the presence of CMAI% ≧25% should not be regarded as a contraindication for MMA in OSA patients.
How effective is a thick plate on stabilisation in 10 mm mandibular advancement?
2022, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
For all these reasons, the fixation method seems to be an important factor in attempts to reduce recurrence. Considering the clinical studies in the literature, it is obvious that the number of cases of SSRO with large advancements have increased, as it is done to treat sleep apnoea as well as maxillofacial deformities.8 Different fixation methods have been applied to increase stability and reduce the relapse rate in SSRO,7,9,10 but there is no clear consensus in the literature regarding which fixation method is the most reliable.6,11
We compared the stability and stress analysis of four different fixation methods after sagittal split ramus osteotomy (SSRO) in mandibular models. In the first model (1P1B) we adapted a four-hole, 2.0 mm standard miniplate on the osteotomy line with one bicortical screw at the top. In the second (2P) we placed two four-hole 2.0 mm standard miniplates above and below the osteotomy line. In the third (3B), we applied three inverted L-shaped bicortical screws, and in the last (1RP1B) we used a four-hole miniplate with increased thickness on the osteotomy line with one bicortical screw at the top. A static vertical load of 200 Newtons (N) was then applied to each model from the occlusal of the first molar. The maximum and minimum principal stresses on the bone were observed more in the proximal segment close to the osteotomy line in all groups. Maximum von Mises stresses were 2705.21 Megapascals (MPa), 1633.56 MPa, 1121.4 MPa, and 1734.44 MPa for the 1P1B, 2P, 3B, and 1RP1B groups, respectively. Displacement values were 1.92 mm, 1.15 mm, 0.79 mm, and 1.42 mm for the 1P1B, 2P, 3B, and 1RP1B groups, respectively. The reinforced plate contributed to the stabilisation, but it was not as effective as three bicortical screws and a double plate.
Stability of fixation methods in large mandibular advancements after sagittal split ramus osteotomy: an in vitro biomechanical study
2021, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
For OSA, the procedure is generally combined with a Le Fort 1 osteotomy with advancement and rotation of the occlusal plane, referred to as maxillomandibular advancement surgery (MMA). The effect of large MMA has proved highly effective in increasing the size of the upper airway and reducing the apnoea/hypopnoea index (AHI) in OSA patients.1–4 Stabilisation of SSRO is carried out with (semi)-rigid internal fixation techniques, such as miniplates with monocortical screws, bicortical screws, or a combination of both (hybrid).5
Sagittal split ramus osteotomy (SSRO) with large mandibular advancements is a common surgical procedure and could be indicated for patients with sleep apnoea. As a large variety of fixation methods is used for the stabilisation of SSRO, a biomechanical test model was used to analyse which fixation technique was most stable. For this in vitro study, 80 polyurethane hemimandibles with a prefabricated SSRO were used as substrates. Loads in Newtons were recorded at displacements of the mandibular incisive edge at 1 mm, 3 mm and 5 mm. The samples were divided into two groups: mandibular advancements of 10 mm and 15 mm. In both groups, four fixation techniques were used: (A) one four-hole miniplate; (B) two four-hole miniplates; (C) one four-hole miniplate plus one bicortical screw; and (D) three bicortical screws in an inverted-L arrangement. In group 1, three bicortical screws resulted in the best stability, and in group 2, two miniplates resulted in the best stability. The use of two miniplates did not show significant differences between both groups. Other fixation methods showed more stability with 10 mm advancements. This study therefore suggests that in SSRO with advancements exceeding 10 mm, the use of two miniplates is the optimal means of providing rigid fixation.
Maxillomandibular Advancement: The Canadian Experience
2019, Atlas of the Oral and Maxillofacial Surgery Clinics of North America
Citation Excerpt :
A patient with solely retrognathic mandible with an orthognathic maxilla and moderate OSA may benefit merely of a bilateral sagittal split osteotomy (BSSO) advancement with genioplasty only. Research has shown that a sole BSSO brings tridimensional volumetric changes in the airway by enlarging the airway space when a retrusive mandible is present.9–11 Cephalometric radiograph is traced with the architectural and structural Delaire analysis.5,7,12,13
Mandibular advancement for pediatric obstructive sleep apnea: A systematic review and meta-analysis
2018, Journal of Cranio-Maxillofacial Surgery
Citation Excerpt :
Previous authors have demonstrated the positive effects of MAS in children (Breik et al., 2016; Tsui et al., 2016), but to our knowledge this is the first study to perform a meta-analysis to quantify such effects numerically. The positive effects are remarkably similar to the AHI and LSAT improvements seen in isolated MAS in adult patients with mandibular insufficiency – 87% decrease in AHI and 17% increase in LSAT (Noller et al., 2017). That such effects are similar logically follows from consideration of the condition and this treatment.
Mandibular distraction osteogenesis and mandibular advancement, collectively referred to as mandibular advancement surgeries (MAS), have been used to treat children with mandibular insufficiency and obstructive sleep apnea (OSA). The objective is to perform a systematic review and meta-analysis for MAS as treatment for obstructive sleep apnea.
Three authors searched multiple databases (including PubMed/Medline) from inception through April 25, 2018.
1198 studies were screened, 128 were downloaded and 37 met inclusion criteria (376 patients, mean age: 1.5 years). Meta-analysis demonstrated a reduction in the apnea-hypopnea index (AHI), from a mean ± SD of 41.1 ± 35.8 to 4.5 ± 6.0 events per hour (89.1% decrease). The lowest oxygen saturation (LSAT) in 211 patients increased from a mean ± SD of 76.8 ± 13.0 to 91.1 ± 8.6 (14.3 oxygen saturation point increase). Individual patient data (105 patients) demonstrated AHI surgical success in 73.4% of patients and respiratory disturbance index (RDI) surgical success in 100% of patients. AHI surgical cure was seen in 25.5% of patients and RDI surgical cure was seen in 37.5% of patients.
This study's major finding is that obstructive sleep apnea has dramatically improved in pediatric patients with mandibular insufficiency when they have been treated with mandibular advancement or mandibular distraction osteogenesis.

View all citing articles on Scopus

^☆: Institution where the work was primarily performed: Tripler Army Medical Center, Honolulu, HI, USA.

^☆☆: This manuscript has not been presented at a meeting.

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Published by Elsevier Ltd on behalf of European Association for Cranio-Maxillo-Facial Surgery.

ReviewMandibular advancement for adult obstructive sleep apnea: A systematic review and meta-analysis☆,☆☆

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Protocol

Study eligibility criteria

Information sources

Results

Discussion

Conclusions

Funding

Conflicts of interest

Disclaimer

J Craniomaxillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

Am J Orthod Dentofacial Orthop

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Otolaryngol Head Neck Surg

J Craniomaxillofac Surg

Tongue-lip adhesion and tongue repositioning for obstructive sleep apnoea in Pierre Robin sequence: a systematic review and meta-analysis

J Laryngol Otol

Statistical power analysis for the behavioral sciences

Mandibular lengthening by distraction osteogenesis for treatment of obstructive sleep apnea syndrome: a case report

Cranio

Measuring inconsistency in meta-analyses

Bmj

Review
Mandibular advancement for adult obstructive sleep apnea: A systematic review and meta-analysis☆,☆☆