Title Efficacy of Maxillomandibular Advancement in Treating Obstructive Sleep Apnea
Clinical Question When compared to patients undergoing airway pressure (CPAP) therapy, oral appliances, and other traditional methods of treatment for obstructive sleep apnea, how does the post-operative efficacy and outcomes for maxillomandibular advancement, a commonly used upper airway surgical intervention, fare in comparison?
Clinical Bottom Line In treatment of obstructive sleep apnea (OSA), maxillomandibular advancement has been shown to be a safe and highly effective treatment for OSA, and seems to be as efficient as continuous positive airway pressure – the gold standard in OSA therapy. (See Comments on the CAT below)
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
23253570Hsieh/2012Patients who underwent maxillomandibular advancement surgerySystematic Review
Key resultsContinuous positive airway pressure (CPAP) is considered the gold standard for treatment of patients with obstructive sleep apnea (OSA), but its clinical effectiveness is limited by patient compliance. Primary and secondary maxillomandibular advancement surgeries resulted in mean reductions in the apnea/hyponea index and respiratory disturbance index of 61-92% and 82-92% respectively.
21605790Pirklbauer/2011Patients who underwent maxillomandibular advancement surgerySystematic Review
Key resultsA systematic literature search in the PubMed database was performed, reviewing information about patient data, success rates, and outcome measures. A final review of 39 studies concluded with a recommendation grade of A to B was achieved utilizing evidence-based medicine, and show that maxillomandibular advancement (MMA) is the most successful surgical therapy. Postoperative polysomnography data on patients following MMA surgery were shown to be comparable to those under continuous positive airway pressure therapy.
20189852Holty/201053 reports describing 22 unique patient populations with 627 adults who have OSA, and 27 reports on individual data on 320 OSA patientsSystematic Review; Meta-analysis
Key resultsThe mean apnea/hyponea index (AHI) decreased from 63.9/h to 9.5/h (p<0.001), dropping from severe levels of sleep apnea to mild. Under the random-effects model, the surgical success and cure rate – classified as having an AHI of less than 5 – were 86% and 43.2% respectively. The major and minor complication rates were 1.0% and 3.1% respectively, and no postoperative deaths were reported.
Evidence Search obstructive sleep apnea and maxillomandibular advancement
Comments on
The Evidence
Hsieh 2012 utilized findings taken from 15 studies out of 104 publications to come to their conclusions. Pirklbauer 2011 performed a systematic review of published data concerning maxillomandibular advancement (MMA)as treatment for OSA, and of the 101 articles reviewed, 39 studies were classified from evidence levels 1-5. Holty 2010 found that younger age, lower preoperative weight and AHI, and a greater degree of maxillary advancement were predictive of increased surgical success. All of the articles used are systematic reviews. It should be noted that in the the research performed for this critically appraised topic, the patient population who underwent MMA chose to do so for a variety of reasons, and the motivating factor i.e., intolerance to continuous positive airway pressure therapy, non-compliance to oral appliances, etc., is not always apparent to the author.
Applicability For patients who refuse or are unable to maintain compliance with continuous positive airway pressure therapy (CPAP) or oral appliances as their mechanism in treating obstructive sleep apnea (OSA), maxillomandibular advancement (MMA) surgery has been shown to yield safe and effective outcomes comparable to those under CPAP therapy and may be a viable alternative.
Specialty (General Dentistry) (Oral Surgery) (Dental Hygiene)
Keywords Obstructive sleep apnea, osa therapy, maxillomandibular advancement
ID# 2360
Date of submission 03/04/2013
E-mail LingA@livemail.uthscsa.edu
Author Alexander Ling
Co-author(s) e-mail
Faculty mentor Carol A. Nguyen, RDH, MS
Faculty mentor e-mail nguyenc@uthscsa.edu
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
by Marian Nagle (San Antonio, TX) on 05/17/2013
An article published by Dekeister in 2006 (PMID 17314742 ) states that maxillo-mandibular advancement is an effective therapy for the treatment of OSAS where CPAP is ineffective or the patient will not tolerate wearing an appliance. The study evaluated the outcomes of maxillo-mandibular advancement in OSAS patients who had first been treated with CPAP for at least 6 months. 25 patients with a mean AHI at 45/h (+/-15) were treated with maxillo-mandibular advancement surgery. 3 months following surgery the AHI had decreased to 7+/- 7. Success rate was defined as an AHI < 15/h was 89% and 73% for AHI < 10/h. Although this study represents a lower level of evidence than studies included in this CAT it reinforces the concept that mandibular advancement surgery is an effective means for treating OSAS where CPAP is ineffective.
by Katie Bemis, David Faltys (San Antonio, TX) on 05/13/2013
A study published by Giarda in 2013 (PMID: 23620639 ) also supports the efficacy of mandibular advancement for the treatment of adults with OSA. Although the study represents a lower level of evidence than the studies included in this CAT, it supports the current notion that mandibular advancement is an effective means for alleviating obstructive sleep apnea symptoms. All 16 patients were reported to have a post-surgical AHI<20 events/hr while 6 attained an AHI<5 events/hr.