OBJECTIVE: To evaluate the efficacy of eight different surgical treatments based on maxillomandibular advancement (MMA), which has emerged in recent years, for adult obstructive sleep apnoea (OSA) patients.
METHODS: The literature was searched from January 2010 to May 2020 for studies of adult OSA patients with different types of MMA procedures to perform a network meta-analysis. The outcomes were changes in the apnoea-hypopnoea index (AHI), the lowest pulse oxygen saturation (SpO2 min) and the Epworth Sleepiness Scale (ESS). Treatment hierarchy was summarized according to the rank charts.
RESULTS: Eight studies were included and encompassed a total of 227 adult patients diagnosed with OSA. Among them, 225 patients underwent combined surgery or simple MMA surgery, including modified maxillomandibular advancement (MMMA),counterclockwise maxillomandibular advancement (CMMA), drug-induced sleep endoscopy and maxillomandibular advancement (MMA + DISE), transoral robotic surgery and maxillomandibular advancement (MMA + TORS), uvulopalatopharyngoplasty (UPPP), maxillomandibular advancement and uvulopalatopharyngoplasty (MMA + UPPP), uvulopalatopharyngoplasty with uvula preservation and maxillomandibular advancement (MMA + HUPPP); MMA consisting of Le Fort I osteotomy and bilateral inverted-L osteotomy (ILOs), genioplasty and iliac bone grafting; and MMA consisting of Le Fort I osteotomy, bilateral sagittal split ramus osteotomies and genioplasty. The results showed that the most effective surgical treatment is MMA + HUPPP [- 56.79 (WMD); 95% confidence interval (CI): - 113.02 to - 3.33] (P < 0.00001), which was far superior to other approaches.
CONCLUSIONS: MMA combined with HUPPP had the highest efficacy. The MMA consisted of Le Fort I osteotomy, bilateral sagittal split ramus osteotomies and genioplasty; CMMA and MMA + TORS are likely also great choices.

This study aimed to compare the effectiveness and feasibility of inverted-L osteotomy (ILO) and sagittal split ramus osteotomy (SSRO) on obstructive sleep apnea (OSA) treatment. According to different surgery procedures, 28 OSA patients who underwent maxillomandibular advancement (MMA) were divided into 2 groups (group A: ILO, n = 9; group B: SSRO, n = 19). Polysomnography (PSG) and Epworth sleepiness scale (ESS) on T0, T1and T2 were used to evaluate the effectiveness of OSA treatments. Patients\' airway structures and facial appearances were also evaluated. From T0 to T1, the mean apnea-hypopnea index (AHI,/per hour) dropped from 69.2 ± 8.4 to11.2 ± 2.4 (P < 0.01) in group A and from 54.6 ± 14.6 to 9.4 ± 5.4 (P < 0.01) in group B; LSpO2 (lowest pulse oxygen saturation, %) increased from 66.5 ± 7.7% to 88.2 ± 4.6 (P < 0.01) and from 76.6 ± 10.7%to 89.4 ± 2.4% (P < 0.01) while the mean ESS score decreased by 51% in group A and 44% in group B. Most patients (group A: 88.9%; group B: 84.3%) were satisfied with their postoperative appearance. Mild relapse was observed in both groups on T2. This study concluded that MMA containing ILO and MMA containing SSRO are both feasible and effective for selected OSA patients.

While effects of maxillomandibular advancement (MMA) on respiratory parameters for patients with obstructive sleep apnea (OSA) are well described, effects on sleep architecture before and after MMA are not. A retrospective cohort analysis on sleep architecture was examined in 10 OSA patients who underwent MMA surgery between July 2013 and November 2014, and had prespecified complete polysomnography (PSG) datasets. Sleep stages were examined relative to a Western European population-based control group. All of the respiratory parameters improved significantly post MMA. Rapid eye movement (REM) latency decreased from 178.0±142.8 to 96.6±64.5min (P=0.035). %NREM (non-rapid eye movement)1 (P=0.045) and %WASO (wakefulness after sleep onset) (P=0.006) decreased, while %REM increased (P=0.002) after MMA. WASO decreased from 64.2±57min to 22.4±15.4min (P=0.017). Preoperatively, OSA subjects showed significantly lower sleep efficiency (P=0.016), sleep onset latency (P=0.015), and % REM (P<0.001) than the normative population dataset, while post MMA there was a significant decrease in %NREM1 sleep (P<0.001) and in %WASO (P<0.001). MMA results in a marked decrease in WASO and increase in REM, and to a lesser extent NREM sleep. Patients after MMA show values similar to population controls except for a lower WASO.

OBJECTIVE: Maxillomandibular advancement (MMA) is an effective alternative for treating severe obstructive sleep apnea (OSA). However, the promotion of MMA in China is limited by many Chinese patients having a convex facial profile. To achieve maximal upper airway enlargement without an esthetic disaster, we added counterclockwise rotation of the maxillomandibular complex (MMC) in the routine MMA. In this paper, we have evaluated the objective and subjective outcomes of this technology.
METHODS: In total, 33 severe OSA patients who accepted counterclockwise maxillomandibular advancement (CMMA) were investigated in this study. Genioplasty, uvulopalatopharyngoplasty (UPPP), and turbinate reduction were also performed on selected patients. Polysomnography (PSG) and Epworth sleepiness scale (ESS) were chosen to evaluate the effectiveness of this technology in treating OSA. Patients\' facial appearances were evaluated by cephalometric analysis and 5-point Likert scales.
RESULTS: After CMMA, the apnea-hypopnea index (AHI) decreased from 59.3 ± 14.6 to 10.2 ± 6.7 (P < 0.001), minimum SpO2 (pulse oxygen saturation, %) increased from 74.0 ± 11.7 to 88.8 ± 4.4 (P < 0.001), and ESS decreased from 12.5 ± 2.3 to 7.3 ± 2.1. It is encouraging that soft-tissue cephalometric measurements such as facial convexity angle, nasolabial angle, and labiomental fold were not worsening after surgery. The Likert scales revealed that 28 patients (85%) were satisfied or very satisfied with their facial changes. In addition, no patient complained about dental function after surgery.
CONCLUSIONS: These findings indicate that CMMA is an effective way to achieve a balance between airway enlargement and facial appearance for Chinese patients with severe OSA.