Although maxillomandibular advancement (MMA) is an orthognathic surgical procedure used to manage OSA in individuals who are noncompliant with continuous positive airway pressure therapy, simple MMA suffers from aesthetic outcome problems in Asian patients with preexisting dentoalveolar protrusions. Our current, prospective investigation describes the changes in the posterior pharyngeal space and the aesthetic outcomes after counterclockwise rotational orthognathic surgery, which has known difficulty in maintaining skeletal stability in patients with skeletal Class II deformities and OSA (Fig. 12.4, 12.5).

The orthognathic surgery steps were similar to those in the conventional procedure for patients with skeletal Class II deformities. Where mandibular advancement, using sagittal split ramus osteotomy (SSRO), was initially performed with clockwise MMC rotation followed by the LeFort I osteotomy, a counterclockwise rotation of the MMC with mandibular advancement, using SSRO, seems to be better suited for many Asian patients to prevent excessive dentoalveolar protrusion and retain facial aesthetics. Because we performed counterclockwise rotational orthognathic surgery, the mandible-first approach was chosen to maximize the accuracy of the orthognathic surgery. Fixation of the proximal and distal mandibular segments was achieved using the rigid fixation method and double miniplates. Preoperatively, three-dimensional (3D) computed tomography scans were obtained and cephalometric and polysomnographic analyses were conducted. The same examinations were repeated immediately after and 6 months after the orthognathic surgery. Subsequently, changes in cephalometric landmarks, including the angle of the lines connecting the sella, nasion, and point A (SNA); the angle of the lines connecting the sella, nasion, and point B (SNB); the angle of the lines connecting point A, the nasion, and point B (ANB); and the angle of the mandibular plane to the lower incisor (IMPA), were compared among the preoperative, immediate postoperative, and 6-month postoperative periods. To analyze the airway dimensions indirectly, lateral cephalometric changes in airway parameters were also evaluated. The PAS parameters included the distance from the most posterior soft palate point to a collinear point on the posterior pharyngeal wall (PSP-AP), the distance from the point crossing the inferior border of the mandible, in the posterior area of the tongue, to a collinear point on the posterior pharyngeal wall (PTO-AP), and the distance from most superior point of the epiglottis to a colinear point on the posterior pharyngeal wall (E-AP) (Fig. 12.1). The vertical upper airway length (UAL) was also measured as the distance from the most posterior point of the soft palate to the most superior point of the epiglottis. The positions of the cephalometric landmarks were compared at the following intervals: T0, preoperative period; T1, immediate postoperative period; and T2, 6-month postoperative period, and included the relapse ratio (T2–T1/T1–T0). Digitization of the cephalometric tracings (V-ceph, Osstem Implant, Seoul, Korea) was performed by two craniomaxillofacial surgeons. To evaluate patient facial appearance perception, each patient completed a questionnaire one year after the surgery. A visual analog scale (VAS: 0, absolute dissatisfaction; 10, full satisfaction) was used to assess the change in patient facial appearance perspectives. All statistical analyses were performed using SPSS software (SPSS, Chicago, IL, USA). Mann–Whitney U-tests were used to compare pre- and postoperative airway status. All reported p-values were two-sided, with p < 0.05 being considered significant (Table 12.1).