BACKGROUND: The American Association of Orthodontists white paper on obstructive sleep apnea and orthodontics remains the most authoritative statement on the topic. This was produced in 2019 due to increasing orthodontic interest in obstructive sleep apnea (OSA) and the lack of formal guidelines for orthodontists. Since the white paper\'s release, advocacy for contrarian ideas and practices remain. Orthodontists are sometimes acting as primary care providers for OSA. Procedures appropriate only for screening are sometimes being used for diagnosis. The side effects of effective treatments such as mandibular advancement devices need further consideration. Also, research has clarified the effectiveness and ineffectiveness of treatments such as palatal expansion.
RESULTS: Part of an orthodontist\'s role is screening for OSA. The correct action when this is suspected remains referral to the appropriate physician specialist for diagnosis and treatment or coordination of treatment. Orthodontists may participate in the treatment of patients with OSA as a member of a multi-disciplinary team. Effective orthodontic treatments may include orthognathic surgery with maxillomandibular advancement and mandibular advancement devices. The negative effects of the latter make this a choice of last resort. Current research indicates that OSA alone is not sufficient indication for palatal expansion.
CONCLUSIONS: Orthodontists should appropriately screen for obstructive sleep apnea. This may be done as part of our health histories, our clinical examination, and review of radiographs taken for purposes other than the diagnosis and screening for OSA. Orthodontic treatment for OSA can be helpful and effective. However, this may be done only after referral to the appropriate physician specialist, as part of a multi-disciplinary team, with consideration of the likely effectiveness of treatment, and after all likely and potential negative consequences have been considered and thoroughly discussed with the patient.

Obstructive sleep apnea (OSA) syndrome is not only a widespread pathology, but also has far-reaching social consequences due to patients\' poor quality of nighttime sleep and high daytime sleepiness. To date, a large number of methods, both conservative and surgical, have been developed for the treatment of OSA. Surgeries performed for OSA are aimed at correcting the structures of the nose, pharynx, larynx, as well as the hyoid and jaw bones and the muscles attached to them. Despite the seventy-five-year history of the use of surgical treatment methods, there is still no complete clarity regarding the advisability of certain types of operations. The article presents data from meta-analyses published over the last ten years and devoted to various types of surgical procedures aimed at combating OSA in adult and pediatric populations. Rhinosurgical approaches, uvulopalatopharyngoplasty, surgical advancement of the lower jaw in adults and expansion of the upper jaw in children, interventions on the hyoid bone and mental tubercle, removal of the palatine and pharyngeal tonsils, operations for laryngomalacia and bariatric surgery are considered. Data on the effectiveness of the most common operations: tonsillectomy in adults (85%), multilevel pharyngoplasty (60%); and about a wide range of data on the effectiveness of uvulopalatoplasty (25 to 94%) are presented. Effective surgical options and criteria for a positive prognosis of such treatment, the possibility of complete cure of OSA, that is, reducing the apnea/hypopnea index (AHI) below 5 events per hour in adults, are discussed. In conclusion, the need to continue research using Sher\'s criteria for the effectiveness of surgical operations is emphasized: a reduction in AHI by 50% or more or below 20 events per hour. Research that includes long-term postoperative follow-up is especially important.
Синдром обструктивного апноэ сна (СОАС) не просто является широко распространенной патологией, но и имеет далеко идущие социальные последствия в связи с низким качеством ночного сна пациентов и высокой дневной сонливостью. На сегодняшний день разработано большое количество способов лечения СОАС — как консервативных, так и хирургических. Операции, осуществляемые при СОАС, направлены на коррекцию структур носа, глотки, гортани, а также подъязычной и челюстных костей и мышц, прикрепленных к ним. Несмотря на 75-летнюю историю применения хирургических методов лечения, до сих пор нет полной ясности в отношении целесообразности отдельных видов операций. В статье приводятся данные метаанализов, опубликованных за последние 10 лет и посвященных различным видам хирургических пособий, нацеленных на борьбу с СОАС во взрослой и детской популяции. Рассмотрены ринохирургические подходы, увулопалатофарингопластика, хирургическое выдвижение нижней челюсти у взрослых и расширение верхней челюсти у детей, вмешательства на подъязычной кости и подбородочном бугорке, удаление небных и глоточной миндалин, операции при ларингомаляции, бариатрическая хирургия. Представлены данные об эффективности наиболее распространенных операций: тонзиллэктомия у взрослых — 85%, многоуровневая фарингопластика — 60%; и о широком разбросе данных об эффективности увулопалатопластики — от 25 до 94%. Обсуждаются эффективные варианты операций и критерии позитивного прогноза такого лечения, возможности полного излечения СОАС, т.е. снижения индекса апноэ/гипопноэ (ИАГ) ниже 5 событий/ч у взрослых. В заключение подчеркнута необходимость продолжения исследований с применением критериев эффективности хирургических операций Шер: снижение ИАГ на 50% и более или ниже 20 событий/ч. Особенно важны работы, включающие длительный послеоперационный катамнез.

Maxillomandibular advancement has been shown to be an effective treatment for obstructive sleep apnea; however, the literature focuses mainly on sleep-related parameters such as apnea-hypopnea index, respiratory disturbance index and Epworth sleepiness scale. Other factors that may be important to patients, such as esthetics, patient satisfaction, nasality, swallowing problems and so forth have been reported in the literature but have not been systematically studied. Together with an information specialist, an extensive search in Medline, Embase and Scopus yielded 1592 unique articles. Titles and abstracts were screened by two blinded reviewers. In total, 75 articles were deemed eligible for full-text screening and 38 articles were included for qualitative synthesis. The most common categories of non-sleep related outcomes found were surgical accuracy, facial esthetics, functional outcomes, quality of life, patient satisfaction, and emotional health. All categories were reported using heterogenous methods, such that meta-analysis could not be performed. There was lack of consistent methods to assess these outcomes. This work is the first to systematically review non-sleep related outcomes of maxillomandibular advancement. Despite growing interest in evaluating surgical outcomes through patient subjective experiences, this review points to the need of standardized, validated methods to report these outcomes.

OBJECTIVE: Maxillomandibular advancement (MMA) is an effective surgical option for patients suffering from obstructive sleep apnea (OSA). As a relatively new treatment option, patients may turn to the Internet to learn more. However, online patient education materials (OPEMs) on MMA may be written at a higher literacy level than recommended for patients. The aim of this study was to analyze the readability of OPEMs on MMA.
METHODS: A Google search of \"maxillomandibular advancement\" was performed, and the first 100 results were screened. Websites that met eligibility criteria were analyzed for their readability using the Automated Readability Index (ARI), Coleman-Liau Index (CLI), Flesch-Kincaid Grade Level (FKGL), Gunning Fog (GF), and Simple Measure of Gobbledygook (SMOG) and compared to the recommended sixth-grade reading level using one-tailed t tests. Readability scores were compared based on the type of website, including hospitals/universities or physician clinics, using ANOVA tests.
RESULTS: The mean (SD) for ARI, CLI, FKGL, GF, and SMOG was 11.91 (2.43), 13.42 (1.81), 11.91 (2.06), 14.32 (2.34), and 13.99 (1.56), respectively. All readability scores were significantly higher than a sixth-grade reading level (p < 0.001). After comparing readability scores between different website types (university/hospital, clinic, and other), there was no statistical difference found.
CONCLUSIONS: The available OPEMs on MMA surgery for OSA are above the recommended sixth-grade reading level. Identifying and reducing the gap between the reading levels of OPEMs and the reading level of the patient are needed to encourage a more active role, informed decisions, and better patient satisfaction.

OBJECTIVE: Maxillomandibular advancement (MMA) is an effective surgical treatment for obstructive sleep apnea (OSA); however, it is unclear how many patients who are referred for MMA actually undergo surgery. This study aims to determine follow-up rates for patients referred for MMA and the reasons behind their choices.
METHODS: Via retrospective review, we assessed consecutive patients with OSA intolerant to continuous positive airway pressure (CPAP) who underwent drug induced sleep endoscopy (DISE) between 2018 and 2020 at our institution. Patients recommended for MMA based on DISE and other findings were included. Patients were then contacted and administered an IRB-approved survey in present time.
RESULTS: One hundred and fifty nine patients were referred to oral maxillofacial surgery (OMFS) for MMA consult. Seventy seven patients (48%) followed up with OMFS and 29 (18%) underwent MMA. Sixty two (40%) patients resumed CPAP. Fifty eight patients (36.5%) were lost to follow up. Seventy three patients (46%) completed our survey. Of those patients, 37 (51%) followed up with OMFS and 17 (23%) underwent MMA. Patients who did not follow up with OMFS cited the invasiveness of the surgery (39%), recovery time (17%), or both (31%) as reasons. Those who pursued consultation cited inability to tolerate CPAP (73%), not being a candidate for inspire (14%), and desire to learn about alternative treatments (14%) as reasons. Of those who did not undergo MMA, 28.6% are not using OSA treatment.
CONCLUSIONS: Less than half of patients referred for MMA followed up, and less than half of those patients underwent MMA. Most patients cited concerns about the invasiveness of the surgery and recovery process.
METHODS: 4 Laryngoscope, 134:2964-2969, 2024.

Obstructive sleep apnoea (OSA) is a syndrome with a high burden on public health. Maxillomandibular advancement (MMA) has proven to be a highly effective treatment option. This retrospective analysis evaluated the safety of maxillomandibular advancement with rotation in patients with OSA. A total of 63 patients with OSA were included in this study. Surgical treatment by maxillomandibular advancement was virtually planned based on preoperative cone beam computed tomography (CBCT). A 3D printed guide and a customised implant were used for surgical transfer. The safety of MMA was evaluated based on the necessity of postoperative intermediate care unit (IMCU) stay, duration of stay in hospital, and recording of medical complications. A total of 63.5% of the OSA patients treated by MMA (n = 40/63) were postoperatively transferred from the recovery room directly to the regular ward, while 36.5% of the patients (n = 23/63) stayed on IMCU for at least one night. On average, the length of hospitalisation was four days after surgery. One patient from the ward group and one patient from the IMCU group developed a major complication according to Clavian-Dindo classification grade IV. MMA is a safe surgical procedure. The necessity for postoperative monitoring in an IMCU setting should be based on an individual risk evaluation. However, since major complications can occur, MMA should be performed as an inpatient procedure in a hospital with available intensive medicine care. This study underlines the safety of MMA in OSA patients.

To compare the efficacy of maxillomandibular advancement (MMA) for patients with obstructive sleep apnea (OSA) with class 2 versus 3 dentofacial deformities (DFDs).
Retrospective chart review.
Tertiary sleep surgery center.
Patients with OSA and DFD class 2 versus 3 undergoing MMA at Stanford Sleep Surgery between 2014 and 2021 were matched by preoperative body mass index (BMI), age, and sex. Postoperative outcome was compared with polysomnography measures and patient-reported outcome measures (PROMs).
Twenty-eight matched subjects, 14 in each deformity group were identified and assessed. The mean age (standard deviation) was 34.29 (10.21) and 33.86 (10.23) for classes 2 and 3, respectively. The apnea-hypopnea index (AHI) decreased from 43.42 (28.30) to 9.6 (5.29) (p < .001) and 37.17 (35.77) to 11.81 (15.74) (p = .042) in class 2 and 3 subjects, respectively. The oxygen desaturation index (ODI) changed from 30.48 (24.02) to 6.88 (3.39) (p = .024) and 11.43 (11.40) to 5.44 (7.96) (p = .85) in class 2 and 3 subjects, respectively. The Epworth sleepiness scale changed from 8.93 (5.28) to 3.91 (2.70) (p = .018) and 10.23 (4.38) to 4.22 (3.07) (p = .006) in class 2 and 3 subjects, respectively.
Among age, sex, and BMI-matched subjects, MMA is equally effective in both dentofacial class 2 and 3 groups, both objectively and subjectively. Preoperatively, dentofacial class 2 patients with OSA presented with the more severe disease with higher AHI and ODI. Dentofacial class 3 patients with OSA may require additional attention to improve nasal function outcomes.

The efficacy of mandibular advancement devices (MAD) and maxillomandibular advancement (MMA) in improving upper airway (UA) patency has been described as being comparable to continuous positive airway pressure (CPAP) outcomes. However, no previous study has compared MAD and MMA treatment outcomes for the upper airway enlargement. This study aimed to evaluate three-dimensionally the UA changes and mandibular rotation in patients after MAD compared to MMA.
The sample consisted of 17 patients with treated with MAD and 17 patients treated with MMA matched by weight, height, body mass index. Cone-beam computed tomography from before and after both treatments were used to measure total UA, superior/inferior oropharynx volume and surface area; and mandibular rotation.
Both groups showed a significant increase in the superior oropharynx volume after the treatments (p = 0.003) and the MMA group showed greater increase (p = 0.010). No statistical difference was identified in the MAD group considering the inferior volume, while the MMA group showed a significantly gain (p = 0.010) and greater volume (p = 0.024). Both groups showed anterior mandibular displacement. However, the mandibular rotation were statistically different between the groups (p < 0.001). While the MAD group showed a clockwise rotation pattern (-3.97 ± 1.07 and - 4.08 ± 1.30), the MMA group demonstrated a counterclockwise (2.40 ± 3.43 and 3.41 ± 2.79). In the MAD group, the mandibular linear anterior displacement was correlated with superior [p = 0.002 (r=-0.697)] and inferior [p = 0.004 (r = 0.658)] oropharynx volume, suggesting that greater amounts of mandibular advancement are correlated to a decrease in the superior oropharynx and an increase in the inferior oropharynx. In the MMA group, the superior oropharynx volume was correlated to mandibular anteroposterior [p = 0.029 (r=-0.530)] and vertical displacement [p = 0.047 (r = 0.488)], indicating greater amounts of mandibular advancement may lead to a lowest gain in the superior oropharynx volume, while a great mandibular superior displacement is correlated with improvements in this region.
The MAD therapy led to a clockwise mandibular rotation, increasing the dimensions of the superior oropharynx; while a counterclockwise rotation with greater increases in all UA regions were showed in the MMA treatment.

OBJECTIVE: To investigate subjective efficiency outcomes after maxillomandibular advancement (MMA) surgery in obstructive sleep apnea (OSA) patients.
METHODS: A prospective cohort study was carried out between December 2016 and May 2021, including 30 severe or treatment-refractory OSA patients treated by MMA surgery. All patients answered four validated questionnaires: the Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Mandibular Function Impairment Questionnaire (MFIQ), and EQ-5D-3L (i.e., EQ-5D and EQ-VAS). They also answered one custom-made questionnaire (AMCSQ). Questionnaires were requested to be filled out 1 week before surgery and at least 6 months after surgery.
RESULTS: The total preoperative and postoperative scores on the questionnaires were compared. The mean total ESS (p < 0.01), FOSQ (p < 0.01), EQ-5D (p < 0.05), and EQ-VAS (p < 0.01) scores showed significant improvement, which was in accordance with an improvement in the mean postoperative apnea/hypopnea index score (p < 0.01). In contrast, the mean total MFIQ score (p < 0.01) indicated a decline in mandibular function.
CONCLUSIONS: This study confirms the hypothesis that MMA surgery in OSA patients improves outcomes, both objectively and subjectively, with the exception of postoperative mandibular function.

The primary aim of this study was to assess the association between clinical efficacy outcomes (i.e., polysomnography (PSG) results) of maxillomandibular advancement (MMA) and surgeons\' experience. The second aim was to assess the association between the occurrence of postoperative complications of MMA and surgeons\' experiences. Patients treated with MMA for moderate to severe obstructive sleep apnea (OSA) were enrolled in this retrospective study. The patient population was divided into two groups based on two different surgeons performing MMA. The associations between surgeons\' experience on the one hand and PSG results and postoperative complications on the other hand were investigated. A total of 75 patients were included. There was no significant difference in baseline characteristics between the two groups. The reductions in apnea-hypopnea index and oxygen desaturation index were both significantly greater in group-B than group-A (p = 0.015 and 0.002, respectively). The overall success rate after MMA was 64.0%. There was a negative correlation between surgeon experience and surgical success (odds ratio: 0.963 [0.93, 1.00], p = 0.031). No significant association was found between surgeon experience and surgical cure. Additionally, there was no significant association between surgeon experience and the occurrence of postoperative complications. Within the limitations of this study, it is concluded that surgeon experience may have little to no influence on the clinical efficacy and safety of MMA surgery in OSA patients.