The primary goal of the surgical approach to severe cases of obstructive sleep apnea syndrome (OSAS) is to resolve or significantly improve the clinical situation, thus avoiding the use of nasal-continuous positive airway pressure (N-CPAP), which is frequently badly tolerated or refused. About 50% of patients in the USA and 25% in Europe have poor compliance with ventilatory therapy .

Surgical techniques involving the soft tissues, such as uvulopalatopharyngoplasty , hyoid suspension , partial glossectomy and lingual suspension have given partial results, mainly in cases of medium to light severity . The only technique that has given good results, including in obese patients, is resection of the base of the tongue with hyoidoepiglottoplasty but it has a high incidence of intra-operative and postoperative complications and sequelae.

Surgical methods involving skeletal components of the oro-maxillo-facial area have gained ground. Initially, mandibular advancement alone was employed , followed by anterior-inferior mandibular osteotomy and, more recently, maxillo-mandibular advancement (MMA) surgery has been employed . With MMA, all the soft-tissue structures making up the pharyngeal walls are tightened at once; this stops them from collapsing, or reduces this occurrence, by acting on the suprahyoid and palatal muscles and on the lateral musculature of the pharynx. The tongue is also pulled forward. The result is a significant increase of posterior airway space (PAS) and the resolution of the syndrome in a high (95%) percentage of cases.

At first, MMA was suggested for patients with clinical and cephalometric patterns of mandible and maxilla retrusion, and in a second stage of treatment, after nasal or palatal surgery without significant improvement . Later studies recommended the use of MMA as the first surgical choice in patients with severe OSAS and cranio-facial anomalies .

Although it is logical to advance both jaws in patients with clinical and/or cephalometric evidence of maxillo-mandibular hypoplasia or retrusion, the possibility of extending indications to include other types of patients remains unclear, and few studies have been published .

Regarding the maxilla, a wide advancement beyond the traditional cephalometric values could compromise the facial aesthetic. This retrospective study evaluates the results obtained in two groups of patients with abnormal or normal facial patterns, through MMA surgery. The results are discussed and compared with reports in the literature, in particular the indications and motivations for this treatment.

Materials and methods

Between January 2003 and November 2007, a retrospective study of two groups of patients affected by severe or moderate OSAS, with different skeletal patterns, and treated by MMA was carried out. Group I included 11 patients with known severe or moderate OSAS, who had been undergoing treatment with N-CPAP for some time but had not tolerated it well, and who had clinical and cephalometric evidence of dento-facial anomalies ( Table 1 ): SNA angle 78° or less or SNA > 78°, but with SNB angle < 65° and severe mandibular deformity with skeletal class II malocclusion. Group II included 11 patients with known severe or moderate OSAS, who had been undergoing treatment with N-CPAP for some time but had not tolerated it well, but who had cephalometric, occlusal and aesthetic characteristics within the normal range ( Table 2 ): SNA angle > 80° and class I occlusion. Other inclusion criteria were: apnea hypopnea index (AHI) > 20, and Epworth sleepiness scale (ESS) > 10 in both groups.

Table 1

Analytical results for group I.

	Patients		BMI	SNA		SNB		PAS		AHI		Epworth S.S.		Aesthetic satisfaction
	Age	Sex		Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post
1	56	M	24.6	74	79	64	70	4	13	46	6	16	0	C
2	63	M	31	85	88	64	68	3	10	48	9	17	2	C
3	45	M	29.6	71	74	65	66	5	10	71	18	14	1	B
4	29	M	22.2	74	83	68	72	8	11	31	3	13	0	C
5	26	M	24	73	89	79	85	8	14	70	1	16	0	C
6	49	F	17.5	80	83	65	75	0	7	62	4	15	2	C
7	42	F	28.7	77	87	71	80	3	9	75	11	14	2	B
8	51	M	25	80	88	65	80	5	9	72	10	20	2	B
9	48	M	26	75	88	74	80	5	19	75	7	18	1	B
10	42	M	24.1	78	84	71	80	4	9	51	5	12	0	B
11	37	M	26.9	73	75	69	74	4	11	36	3	13	0	C

 

Table 2

Analytical results for group II.

	Patients		BMI	SNA		SNB		PAS		AHI		Epworth S.S.		Aesthetic satisfaction
	Age	Sex		Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post
1	38	F	31.2	83	90	74	81	3	11	78	7	18	1	B
2	45	M	23.5	83	86	78	83	0	7	60	12	11	1	A
3	50	M	30.6	80	84	76	81	3	11	38	4	12	2	A
4	47	M	27.1	82	90	81	88	4	13	64	6	11	0	B
5	62	M	27.1	80	85	80	84	4	10	60	15	13	1	A
6	54	M	31	82	91	82	88	5	12	71	10	12	2	A
7	43	M	28	82	89	75	79	5	12	34	10	12	0	B
8	30	M	23.4	84	90	82	87	3	8	24	1	12	0	B
9	45	M	25.1	82	84	77	82	6	11	29	10	11	3	B
10	46	M	26	80	88	77	84	3	13	26	1	14	0	A
11	40	M	27.7	83	90	80	88	5	12	73	8	12	0	C

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