Since 1970s, when Dr. Christian Guilleminault gave definitions to obstructive sleep apnea (OSA), common ways of treatment included positive airway pressure (PAP) treatment, oral applinaces, weight reduction, and surgeries. Surgical treatments for OSA include soft tissue surgery and cranio-maxillofacial skeletal surgery to enlarge the upper airway. Maxiilomandibular advancement (MMA) has been the most effective surgery for airway expansion and Apnea-Hypopnea Index (AHI) reduction. Commonly, MMA move upper and lower jaw forwad together for more than 1 centimeter. However, the jaw movement may have certain impacts on facial apperance. Especially, for OSA patients with maxillary protrusion, the advancement of maxilla may combine with possible worsening of facial apperance after surgery and make MMA unacceptable to patients. Also, surgeons may have difficulties to find a balance between facial aesthetics and airway expansion while positioning the maxillomandibular complex.
From 2004, surgeons in Chang Gung Craniofacial Center took important roles in surgical treatments for OSA, and modified the surgical design of MMA. The surgical considerations are aiming to the facial characteristics of adult patients with OSA, which include mandibular retrognathism, Angle’s Class II maloccluison, high mandibular and occlusal plane, protrusion of upper and lower front teeth, and narrowed pharyngeal airway. An unique surgical design of Segmental Maxillomandibular Rotational Advancement (SMMRA)(Fig. 1) is composed by Maxillary LeFort I Osteotomy, Wassmund Maxillary Anterior Segmental Osteotomy, Bilateral Sagittal Splits Osteotomy of Mandible and Counterclockwise Rotational Advancement of Maxillomandibular Complex. By the surgical design, the craniofacial skeletal deformity, malocclusion, and narrowed airway are corrected within one surgery. With consideration of facial aesthetics, the surgical design is more acceptable to patients.
Of 75 (20 females, 31.0±9.5 years old) consecutive patients, polysomnographic results before and after surgery showed reduction of AHI from 39.6± 24.7/hr to 4.7± 7.0/hr, improvement of lowest O2 saturation from 84.4± 8.0% to 88.5± 11.9%, and Epworth Sleepiness Score from 12.6± 5.3 to 6.0± 3.4.
In summary, Segmental Maxillomandibular Rotational Advancement can effectively improve polysomnographic outcome in OSA patient with comprehensive considerations of airway, occlusion, and facial aesthetics.