Maxillomandibular Advancement Surgery in a Site-Specific ...

Maxillomandibular Advancement 

Surgery in a Site-Specific Treatment 

Approach for Obstructive Sleep Apnea 

in 50 Consecutive Patients* 

Jeffrey R. Prinsell, DMD, MD 

Objective: To report the efficacy of maxillomandibular advancement (MMA) surgery, with a 

description of several innovations, as a site-specific treatment of obstructive sleep apnea 

syndrome (OSAS) in selected cases with disproportionate velo-orohypopharyngeal anatomy. 

Design: Clinical series of 50 consecutive cases. 

Setting: Surgery was performed in a hospital operating room, and perioperative management was 

provided in an intensive care environment. Except for polysomnography (PSG), which was 

performed and interpreted by independent sleep facilities/physicians, all pre- and postoperative 

evaluations were accomplished in a solo office private practice setting. 

Patients: Patients were referred for MMA evaluation when applicable conservative therapies such 

as nasal continuous positive airway pressure (nCPAP) were not tolerated, refused, or unsuccessful. 

Case selection was based primarily on the sites of disproportionate upper airway anatomy. 

Interventions: MMA consisted of a Lefort I osteotomy, bilateral sagittal split ramus osteotomies, and 

a new modified procedure called an anterior inferior mandibular osteotomy with indirect hyoid 

suspension. Some patients also received concomitant adjunctive nonpharyngeal procedures. 

Measurements and results: Obtained at a mean of 5.2 months postoperatively, revealed significant 

improvement in all cases. Mean BPs (n 50) were lowered, subjective symptoms were ameliorated, 

and mean body mass index (n 50) was reduced. Cephalometric analysis (n 50), with several new 

modifications including standardization for phases of respiration, quantified structural changes in 

soft-tissue and bony landmarks. Postoperative PSG results (n 50) showed dramatic improvement 

over preoperative data (n 50), with therapeutic values similar to nCPAP (n 42). Mean values 

improved from preoperative to postoperative vs nCPAP for apnea index (34.5 to 1.0 vs 2.0, 

respectively), apnea-hypopnea index (59.2 to 4.7 vs 5.4, respectively), lowest arterial oxyhemoglobin 

desaturations (72.7% to 88.6% vs 88.6%, respectively), and number of desaturations < 90% (118.8 to 

6.6 vs 2.4, respectively). The success rate was 100%. 

Conclusion: MMA is highly successful and safe and may be a definitive primary single-staged surgical 

treatment of selected OSAS cases with diffusely complex or multiple sites of disproportionate 

velo-orohypopharyngeal anatomy. (CHEST 1999; 116:1519–1529) 

Key words: cephalometric; maxillomandibular advancement; obstructive sleep apnea; polysomnography; site-specific surgery 

Abbreviations: AHI apnea-hypopnea index; AI apnea index; AIMO anterior inferior mandibular osteotomy; 

BMI body mass index; BSSRO bilateral sagittal split ramus osteotomies; EDS excessive daytime sleepiness; 

ETT endotracheal tube; ETV end-tidal volume; GO-POG gonion to pogonion; LF Lefort I osteotomy; 

LSAT lowest arterial oxyhemoglobin desaturation; MM modified Müller maneuver; MMA maxillomandibular advancement; 

MMO maxillomandibular osteotomies; MP-H mandibular plane to hyoid; nCPAP nasal continuous 

positive airway pressure; OSA obstructive sleep apnea; OSAS obstructive sleep apnea syndrome; PAS posterior airway 

space; PNS-P length of soft palate from posterior nasal spine to uvula tip; PSG polysomnography; SNA sella nasion 

point A angle; SNB sella nasion point B angle; T/A tonsillectomy and/or adenoidectomy; UA upper airway; 

UPPP uvulopalatopharyngoplasty 

Obstructive sleep apnea syndrome (OSAS) 1 is a 

potentially life-threatening medical disorder2–4 with a projected prevalence of up to 18 million 

*From Jeffrey R. Prinsell, DMD, MD, 1950 Spectrum Circle, 

Suite B-300, Marietta, GA. 

Manuscript received December 14, 1998; revision accepted June 

23, 1999. 

Correspondence to: Jeffrey R. Prinsell, DMD, MD, 1950 Spectrum 

Circle, Suite B-300 Marietta, GA 30067; e-mail: drprinsell@ 

mindspring.com 

Downloaded From: http://chestioumal.chestpubs.org/ on 03/21/2013 

people in the U.S. population alone. 5 OSAS results 

from repetitive collapse of the soft tissues that form 

or lie into or adjacent to the lumen of the supraglot- 

For editorial comment see page 1503 

tic or upper airway (UA), while asleep. These pharyngeal 

soft tissues are suspended and supported by 

the cartilaginous and bony skeletal structures of the 

CHEST / 116 /6/DECEMBER, 1999 1519

lower face and upper neck. UA patency during sleep 

is dependent on a complex interplay of anatomic and 

physiologic factors. The balance of constricting 

forces, eg, negative inspiratory intraluminal suction 

generated by the diaphragm, and dilating forces of 

the pharyngeal musculature 6,7 is dysfunctional in 

obstructive sleep apnea (OSA). 8 Reduction in activity 

of the tensor palatini 9 and genioglossus 8,10 muscles 

may contribute to floppiness and collapsibility of an 

elongated soft palate in the velopharynx and a bulky 

retropositioned tongue base in the orohypopharynx, 

respectively. Efforts to enhance neuromuscular control 

of the abnormal pharyngeal dilator muscles with 

medications 11,12 and nerve stimulators 13,14 have been 

largely unsuccessful. More conventional OSA therapies 

seek to improve or correct abnormalities of the 

pharyngeal anatomic structure or physiologic function. 

15 

Comprehensive evaluation and treatment planning 

of OSAS cases requires a multidisciplinary team 

approach. The universal convenience of nasal continuous 

positive airway pressure (nCPAP) is that it 

pneumatically splints open the entire UA with a high 

degree of therapeutic efficacy, 16,17 eliminating the 

need to identify specific site(s) of obstruction. However, 

not all OSAS patients are compliant with its 

required lifetime of nightly use, caused primarily by 

intolerance. 18–23 Other devices, eg, oral appliances, 24,25 

are therapeutic only if selected appropriately for the 

specific site(s) of UA obstruction, which may vary 

among different individuals 26,27 ; and also may have 

compliance problems with habitual use while asleep. 

Although it is known that weight reduction may 

lessen OSA, 28 it is unknown what degree of weight 

loss is required. OSAS also occurs in nonobese 

patients. 29 Noncompliance is a common problem in 

that many patients have difficulty losing weight or 

maintaining weight loss. 30,31 

It is generally accepted that surgery is indicated 

when applicable conservative therapies are unsuccessful 

or not tolerated, and for patients with an underlying 

specific surgically correctable abnormality that is causing 

the OSAS. 32 Surgery can provide definitive treatment 

and, thus, eliminate issues of patient compliance, 

but only if performed competently, both in terms of 

technical skill, as well as on the “correct” area(s) of UA 

obstruction. Although many surgical procedures and 

protocols are reported, 33 maxillomandibular advancement 

(MMA), which “pulls forward” the anterior pharyngeal 

tissues attached to the maxilla, mandible, and 

hyoid to enlarge the entire velo-orohypopharynx 34 with 

minimal risks of edema-induced UA embarrassment or 

pharyngeal dysfunction, is the most effective, excluding 

tracheostomy, acceptable surgical treatment of OSAS, 

with success rates of 95%, 34 96%, 35 and 98%. 36 

Nevertheless, the indications for MMA remain 

unsettled, eg, it is often limited to severe cases of 

OSAS when other surgeries have failed, partly because 

of existing diagnostic dilemmas such as identifying 

and ranking, in terms of severity, the often 

multiple sites of obstruction, and knowing when and 

how to prioritize and combine surgical procedures in 

one or more stages, 33,36,37 which may be influenced 

and perhaps biased by the surgeon’s education, 

training, and experience. The primary purpose of 

this case series is to report the efficacy of MMA, 

often with concomitant adjunctive nonpharyngeal 

procedures, as a treatment of OSAS in a site-specific 

approach: the methodology for the selection of specific 

surgical procedures was not specialty- or stagespecific, 

but rather, based on each individual patient’s 

sites of disproportionate UA anatomy. 

Materials and Methods 

Presurgical Evaluation and Treatment Planning 

Patients were evaluated for MMA only if (1) they exhibited 

OSAS diagnosed by independent nocturnal polysomnography 

(PSG) (inclusion criteria of an apnea-hypopnea index [AHI] 15 

or an apnea index [AI] 5 and a lowest arterial oxyhemoglobin 

desaturation [LSAT] 90%) that was clinically significant (inclusion 

criteria of stated excessive daytime sleepiness [EDS]); (2) 

all applicable conservative therapies (eg, nCPAP, weight loss, 

positional therapy, reduction of late evening sedative-hypnotic 

medications or alcoholic beverages, oral appliances or other 

devices) or prior surgical procedures were unsuccessful, not 

tolerated, or refused, as determined by the referring sleep 

physician(s); and (3) they were medically stable and willing to 

proceed with surgery. 

Presurgical evaluations were performed by the author in a 

single office. Detailed head and neck examination was performed 

clinically and radiographically, using posterior-anterior panoramic 

and lateral cephalometric radiographs (described below). 

Cephalometric prediction tracings and photographic computer 

imaging (Everex; United Digital Systems, Inc.; Winston-Salem, 

NC) were used to illustrate proposed changes in UA size and 

facial appearance, respectively. Body weights were measured 

with a foot scale, and BP was recorded with the patients sitting 

using a digital BP monitor (Labron; Hauppauge, NY) with a 

full-sized arm cuff and with a paper printout. Patients’ OSASrelated 

symptoms were recorded on a standard screening questionnaire 

form. Hospital medical staff credentialing for surgical 

privileges for all procedures performed (Table 1) and written 

informed consent for all patients were obtained. 

Surgical treatment planning was “site-specific”: The selection 

of specific surgical procedures was individualized for each patient, 

based on their specific site(s) of disproportionate UA 

anatomy. The most severe sites were addressed first, with the 

hypopharynx as the area of most critical concern. MMA inclusion 

criterion was orohypopharyngeal narrowing caused by macroglossia 

with a retropositioned tongue base—determined by clinical 

examination and measured by cephalometric analysis (posterior 

airway space [PAS] 9 mm at end-tidal volume [ETV]), described 

below. Macroglossia was defined clinically as an enlarged 

tongue base that, at rest, extended above the horizontal plane of 

the mandibular dentition. Velopharyngeal narrowing, by cepha- 

1520 Clinical Investigations 

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Table 1—Surgical Procedures 

Procedure 

lometry, 34 was also treated with MMA, but only if coexistent with 

orohypopharyngeal narrowing. Nonpharyngeal sites coexistent 

with velo-orohypopharyngeal narrowing were treated with adjunctive 

procedures (described in “Surgical Techniques”) performed 

concomitantly with MMA. Patients with sites in the 

absence of orohypopharyngeal narrowing did not receive MMA, 

but rather received other procedures and, therefore, were excluded 

from this clinical series. Pharyngeal soft-tissue surgery 

(discussed in “Surgical Principles and Rationale”) was not performed 

concomitantly with MMA. 

All MMA patients included in this series had diffusely complex 

or multiple sites of disproportionate UA anatomy that included 

orohypopharyngeal narrowing, characterized by macroglossia 

with a retropositioned tongue base and constricted PAS. Although 

certain congenital craniofacial skeletal deformities, eg, 

retrognathia, may influence or predispose to OSA, 38,39 some 

MMA patients exhibited normal craniofacial skeletal morphology. 

Some had septal deviation, turbinate hypertrophy, anterior mandibular 

lingual tori, and/or thick necks with cervicofacial lipomatosis. 

Many also displayed encroachment of the lateral pharyngeal 

walls because of medially displaced tonsillar pillars associated 

with dysmorphic soft palates and, less commonly, tonsillar hypertrophy. 

Tonsillectomy and/or adenoidectomy (T/A) had been 

performed earlier, usually as a child, in 26 patients, and uvulopalatopharyngoplasty 

(UPPP) had been performed before MMA 

in 10 patients. For those patients who had failed prior surgery 

(Table 1), the baseline data described above, including diagnostic 

PSG, were obtained after prior surgery before proceeding with 

MMA. 

Lateral Cephalometric Analysis 

Prior to 

MMA* 

Concomitant 

With MMA 

MMA 

LF 0 50 

BSSRO 0 50 

AIMO 0 50 

Septoplasty 9 28 

Turbinate reduction 5 26 

Cervicofacial lipectomy 1 26 

Maxillary sinus surgery 0 13 

Mandibular lingual tori removal 0 1 

T/A 26 0 

UPPP 10 0 

Tracheostomy 2 0 

*Baseline (pre-MMA) diagnostic data (PSG, BP, weight, symptoms, and 

cephalometry) were obtained after these prior surgical procedures. 

Lateral cephalometric radiographs were obtained using an 

Oralix Pan DC III (model PT-11 P/C; Orion Corporation, 

Soredex, Helsinki, Finland for Philips Medical Systems, Inc. 

Shelton, CT) with wedge filter screens for tissue enhancement 

and clarity. To minimize variances in magnification, head position, 

and neck flexion, all films were obtained at a 5-ft x-ray 

source distance with the awake patients standing with head 

secured in a cephalostat and looking straight ahead with a 

radiopaque level taped to the temporal region. Volumetric 

luminal pharyngeal changes associated with different phases of 

respiration were standardized by obtaining two films: the first at 

ETV and the second during a modified Müller maneuver (MM). 

Acetate tracings with measurements of soft and bony tissue 


landmarks of all preoperative and postoperative cephalographs were 

made. Figure 1 illustrates a cephalometric tracing with several new 

modifications of measurements described previously by others. 

33,36,40–44 PAS was measured as the shortest horizontal line 

drawn perpendicular to the anterior and posterior pharyngeal walls 

at the most narrow level, rather than simply an extension of a straight 

line connecting point B to gonion. Length of the soft palate from 

posterior nasal spine to the uvula tip (PNS-P) and hyoid position 

below the mandibular plane (MP-H), as well as PAS, were recorded 

at both ETV and MM. Gonion to pogonion (GO-POG) was used as 

a direct linear measurement of absolute mandibular length, in 

addition to sella nasion point B angle (SNB), which is an angular 

measurement of anterior mandibular position in relation to the 

cranial base. Maxillary advancement was measured by sella nasion 

point A angle (SNA). Although only PAS at ETV was used as an 

MMA inclusion criterion, all of these cephalometric measurements 

were used to quantify the amount of: maxillary (SNA), mandibular 

(SNB), and genial (GO-POG) advancement; soft palatal (PNS-P) 

and hyoid (MP-H) suspension; as well as orohypopharyngeal enlargement 

(PAS). 

PSG 

Although there were several referring physicians associated 

with different facilities, each patient had both their pre- and 

postoperative PSG performed and interpreted independently by 

the same respective facility. Although different types of instrumentation 

were used, all stated their PSG methods were in 

accordance with conventional criteria, as described elsewhere. 45 

Obstructive apnea and hypopnea were defined as a cessation and 

diminishment, respectively, of airflow, despite respiratory effort, 

for 10 s. 

Surgical Principles and Rationale 

MMA (Figs 2 and 3) opens the velo-, oro-, and hypopharynx 34 

by “pulling forward” the anterior pharyngeal soft-tissue compo- 

Figure 1. Lateral cephalometric analysis. Measurements obtained 

were SNA, 82 2°; SNB, 80 2°; PNS-P, 35 3 mm; 

PAS, 11 1 mm; MP-H, 15 2 mm; and GO-POG, 84 5 mm. 

CHEST / 116 /6/DECEMBER, 1999 1521

Figure 2. Lateral cephalometric prediction of MMA. 

nents, which are attached to the maxilla, mandible, and hyoid. 

Mandibular advancement pulls forward the tongue base and 

suprahyoid muscles attached to the genial tubercles and the 

anterior inferior mandible to open the orohypopharynx. Maxillary 

advancement anterosuperiorly tightens the soft palate, which is 

suspended from the palatine bone of the maxilla, to open the 

velopharynx and, thus, may obviate surgery of the soft palatal 

tissues. 

The soft palate is a tissue organ whose known primary function 

is to prevent reflux of air and liquids into the nasopharynx during 

speech and swallowing, respectively. Also, its role in snoring may 

Figure 3. MMA. 

be a warning sign or “bell” (to the bed partner) of partial or 

impending UA obstruction, which may progress to OSA. A 

dysmorphic or abnormal-looking soft palate may be an anatomic 

variant of normal, which ensures compensatory functioning; and 

may not always be a cause of OSAS. Retropalatal narrowing and 

collapse, often induced by swallowing, eg, during nasopharyngolaryngoscopy, 

should be understood as normal velopharyngeal 

closure, rather than perhaps misinterpreted as a site of obstruction 

dictating surgery. A long or bulky soft palate does not 

necessarily mandate a UPPP, 46 laser-assisted uvuloplasty, 47 palatopharyngoglossoplasty, 

48 uvulopalatopharyngoglossoplasty, 49 

somnoplasty (Somnus Medical Technologies Inc; Sunnyvale, 

CA), or radiofrequency volumetric tissue reduction. 50 Surgical 

ablation or distortion may produce dysfunction (eg., velopharyngeal 

insufficiency, 51–53 nasopharyngeal stenosis, 51 voice changes, 

51 or dysphagia 52,53 ) and, in cases of snoring amelioration, may 

produce silent apnea 47 —either of immediate or delayed onset 

with advancing age and/or weight gain. Soft palatal surgery may 

also produce severe pain, hemorrhage, 51–54 and UA obstruction 

in the immediate postoperative period because of velopharyngeal 

edema that, particularly if compounded with coexisting untreated 

hypopharyngeal narrowing, can result in death. 51,52,54 

MMA not only preserves the functional integrity of the pharyngeal 

tissues but also minimizes the risk of worsened OSA in 

the immediate postoperative period because minimal edema 

occurs within the unoperated pharyngeal soft tissues. The edema 

resulting from the intraoral labial vestibular MMA incisions is 

physiologically shielded from the UA by the underlying bony 

structures and, thus, is confined to the facial soft tissues. Although 

this extraosseous edema may produce pronounced facial 

swelling, it does not extend to or compromise the UA, which is 

more patent at the moment of skeletal advancement, ie, like the 

immediate UA opening produced by a cardiopulmonary resuscitation 

jaw-thrust maneuver. Furthermore, rigidly fixated MMA 

osteotomy segments, unlike pharyngeal soft tissues that are 

operated on, do not move and, therefore, are not painful during 

the normal functions of swallowing, coughing, and vocalization. 

Maxillary and mandibular branches of the trigeminal (sensory) 

nerve, encased within bony canals, that innervate the intraoral 

and lower facial tissues are typically surgically traumatized or 

stretched, resulting in numbness, rather than severe pain. 

The primary functions of the maxilla and mandible, speech 

articulation and mastication, are determined by their interrela- 



tionship and enhanced by a harmonious dental occlusion. Except 

for isolated mandibular horizontal deficiency 55 with severe class 

II malocclusion characterized by pronounced incisal overjet 

(none seen in this series), mandibular advancement requires 

synchronous maxillary advancement to maintain a functional 

occlusion. Orthodontic therapy was performed in four patients to 

decompensate severely recumbent maxillary incisors to maximize 

mandibular advancement. However, in most patients with malocclusions 

who refused orthodontics, as well as in the patients 

with relatively normal occlusions, the maxilla and mandible were 

advanced the same amounts, maintaining the same presurgical 

occlusal relationship. 

Adjunctive nonpharyngeal surgical procedures (described under 

“Surgical Techniques”) were performed concomitantly with 

MMA because these additional sites could be operated on safely 

with minimal risk of postoperative edema-induced airway embarrassment. 

T/A, UPPP, laser-assisted uvuloplasty, palatopharyngoglossoplasty, 

uvulopalatopharyngoglossoplasty, radiofrequency 

volumetric tissue reduction, laser midline glossectomy, 56 or lingualplasty 

57 could conceivably be performed with MMA, but only 

if immediate tracheostomy, endotracheal tube (ETT) intubation, 

or nCPAP or bilevel pressure ventilation were to be used for 

several days during the resolution of postoperative pharyngeal 

edema. In this latter situation it would be difficult to know what 

pressures would be therapeutic—possibly requiring a continuous 

titration, eg, auto-adjusting continuous positive airway pressure— 

with increased risk of hemorrhage 51–54,56,57 caused by barotrauma 

of the recently operated on pharyngeal tissues. Thus, pharyngeal 

soft-tissue surgery was not attempted simultaneously with MMA. 

Surgical Techniques 

The author, always assisted by another surgeon, operated on all 

patients with hypotensive general anesthesia in a hospital operating 

room. A Lefort I osteotomy (LF) with allogeneic bone graft 

and rigid internal fixation using custom-bent bone plates was 

performed for maxillary advancement with anterosuperior tightening 

of the soft palate and to enlarge the velopharynx. Bilateral 

sagittal split ramus osteotomies (BSSRO) with rigid internal 

and/or maxillomandibular fixation was performed for mandibular 

advancement. An anterior inferior mandibular osteotomy 

(AIMO) was performed for additional advancement of the genial 

tubercles with attached tongue-related (eg, genioglossus) and 

suprahyoid muscles for additional advancement of the tongue 

base and an indirect hyoid suspension. The AIMO is a separate 

and distinct osteotomy, performed via incisions not connected 

with the BSSRO. Nevertheless, BSSRO and AIMO together are 

additive in terms of “doubling” the anterior inferior mandibular 

with genial tubercle advancement for orohypopharyngeal enlargement. 

The AIMO used as an integral component of MMA is a 

modification of previously reported similar osteotomies. 

33,35,36,42,43,58 This new trapezoid-shaped osteotomy, which 

preserves chin contour and muscle attachments, is made with one 

continuous bony cut and no sharp angles so as to minimize risk of 

anterior mandibular fracture. 43 The cut is directed superiorly 

toward the lingual cortex to ensure capture of the entire genial 

tubercles, but yet staying inferior labially to avoid cutting teeth 

apices. 43 Physiologic (indirect) hyoid suspension via anterosuperior 

tension on the intact suprahyoid musculature obviates additional 

hyoid surgery, (eg, hyoid myotomy for suspension with 

fascia lata 36,43 or hyoid fixation to the thyroid cartilage.) 59 The 

distal segment is advanced maximally the full thickness of the 

bicortical region and secured with interosseous wire fixation with 

a resultant protrusive chin and minimal bony contact that 

warrants concomitant (1) allogeneic cancellous bone grafting to 

prevent soft-tissue ingrowth between the osteotomy segments 


and to promote a complete bony union; and (2) reduction 

osteoplasty of the distal segment’s labial cortex for a tension-free 

soft-tissue closure to prevent wound dehiscence and infection. 

In addition to LF, BSSRO, and AIMO, which were performed 

in all 50 cases, several adjunctive nonpharyngeal procedures were 

performed concomitantly, when indicated (Table 1). Septoplasty 

and turbinate reduction were performed in 28 and 26 patients 

with septal deviation and turbinate hypertrophy, respectively. 

Enlargement of the piriform rims for additional relief of nasal 

obstruction, as well as removal of polypoid antral tissues (for 

biopsy) in 13 patients with chronic sinus problems were also 

performed with the maxilla down-fractured. Cervicofacial subcutaneous 

lipectomy was performed in 26 cases via a syringeaspiration 

technique. Because weight loss may reduce OSA by a 

proportionate reduction of adipose tissue affecting the airway, 

selective removal of bulky adipose tissue from the cervicofacial 

area might reduce the weight of these tissues against the 

underlying tongue-related muscles, which are in a state of flaccid 

paralysis during sleep and, thus, might reduce the extraluminal 

soft-tissue forces of collapse against the posterior pharyngeal 

walls, particularly when supine. In one patient, bilateral anterior 

mandibular lingual tori were removed to increase tongue space in 

the mouth floor. 

Postsurgical Management and Evaluation 

Because the UAs were immediately more patent after MMA 

and to minimize potential ETT-induced glottic edema, early ETT 

extubation was accomplished, even in the setting of maxillomandibular 

fixation, usually in the operating room before patient 

transport to the recovery area. A long-acting local anesthetic, 

0.5% bupivacaine with 1:200,000 epinephrine was injected intraorally 

postsurgically for wound hemostasis and to minimize the 

need for centrally-acting opiate or opioid narcotics, which can 

cause respiratory depression. Patients were carefully monitored, 

including continuous pulse oximetry with paper printout recordings, 

in an ICU environment while weaning off supplemental 

oxygen onto room air. Nurses and respiratory therapists were 

instructed to allow minor desaturations of 90% on room air 

and without nCPAP, provided the lower limit established for 

each individual patient was significantly higher than preoperative 

diagnostic PSG LSAT, to determine the early postoperative OSA 

status to be expected in the patient’s home the following nights. 

Patients were followed up with weekly visits at the author’s 

office for 3 months. Nutritional counseling was provided for 

liquids the first 2 weeks, followed by a strict nonchewing diet for 

2 months. Controlled weight reduction was encouraged and often 

expedited by maxillomandibular fixation in the morbidly obese 

patients. Overnight PSG was performed by the referring sleep 

facility at approximately 7 weeks postoperatively. Additional PSG 

at 6 months postoperatively and annually thereafter was encouraged. 

BP, weight, clinical examination, panoramic and cephalo- 

Table 2—Demographics, Orthodontics, and 

Hospital Stay* 

Characteristics Values 

Age, yr 

Gender 

42.7 (9.3) (19–66) 

Male 44 

Female 6 

Orthodontic therapy cases 4 

Hospital stay, No. of nights 

*Values given as No. or mean (SD) (range). 

1.65 (0.5) (1–2) 

CHEST / 116 /6/DECEMBER, 1999 1523

metric radiographs, and the patient’s symptoms were recorded by 

the same methods described above (in the presurgical evaluation) 

during the office visit closest to (usually the day after) each PSG 

obtained. Statistical analysis was performed using the paired 

Student’s t test. A p value 0.05 determined statistical significance. 

Mean values are presented with SD. 

Results 

Demographic data of the 50 MMA patients are 

summarized in Table 2. Forty-four patients were 

male and six were female. The mean age was 42.7 

years, with a range of 19 to 66 years. The postoperative 

data presented in Tables 3 –6 were obtained at 

the longest complete follow-up evaluation. The 

mean length of follow-up was 5.2 months, with the 

longest at 4 years 3 months postoperatively. PSG 

results are summarized in Table 3 and illustrated in 

Figures 4 and 5. Postoperative results (n 50) show 

significant improvement in all variables of AI, AHI, 

LSAT, number of desaturations, and percent (%) 

stage3&4sleep, percent rapid eye movement sleep, 

and percent sleep efficiency as compared with preoperative 

data (n 50), with success similar to that 

of nCPAP (n 42). All 50 patients were successful 

responders to MMA based on the criteria of an 

LSAT 80%, an AHI 15, and AI 5ora 60% 

reduction in AHI and AI, with all patients having an 

AI 10, for a success rate of 100%. 

OSAS-related symptoms, as subjectively reported 

by these patients, are shown in Table 4. Patients with 

preoperative EDS (n 50), memory loss (n 34), 

and impaired concentration (n 28) all reported 

amelioration of these symptoms. Snoring was eliminated 

in 44 of 50; depression, moodiness, and/or 

irritability was reduced in 36 of 39; and morning 

headaches were alleviated in 28 of 29 patients. BP 

and body mass index (BMI) data are stated in Table 

5. Both systolic and diastolic pressures improved 

significantly, lowering 15.0 and 9.6 mm Hg (difference 

of mean values), respectively (n 50). BMI 

(n 50) also improved significantly. 

Table 3—PSG Results* 

Variable Preoperative nCPAP Postoperative† p Value‡ p Value§ 

AI 34.5 (27.9) 2.0 (4.0) 1.0 (1.9) 0.001 0.078 

AHI 59.2 (28.4) 5.4 (6.8) 4.7 (5.9) 0.001 0.306 

LSAT, % 72.7 (13.6) 88.6 (6.3) 88.6 (3.9) 0.001 0.450 

No. of desaturation events 90% 118.8 (160.7) 2.4 (4.7) 6.6 (12.2) 0.001 0.022 

% Stage 3 4 6.2 (13.6) 10.1 (14.1) 9.0 (13.6) 0.037 0.210 

% REM 9.9 (7.7) 23.1 (19.5) 16.5 (7.4) 0.001 0.036 

Sleep efficiency, % 83.2 (11.9) 83.1 (16.7) 86.7 (9.9) 0.054 0.139 

*Values given as mean (SD), unless otherwise indicated. REM rapid eye movement sleep. 

†Obtained at 5.2 months (mean) postoperatively. 

‡Postoperative vs preoperative. 

§Postoperative vs nCPAP. 

Cephalometric results (n 50) are summarized in 

Table 6. The average amount (difference of mean 

values) of maxillary (via LF) and mandibular (via 

BSSRO solely, without AIMO) advancement, as 

measured by SNA and SNB, was 7.4° and 6.9°, 

respectively. GO-POG showed an average advancement 

of the genial region (via the additive affects of 

AIMO together with BSSRO) of 14.4 mm. PAS 

enlarged considerably postoperatively, both at ETV 

(6.5 mm) and during the MM (4.9 mm). PAS was 

more narrow during the MM, consistent with hypopharyngeal 

collapse induced by negative inspiratory 

forces generated against an occluded UA. PNS-P 

shortened slightly, both at ETV (1 mm) and during 

the MM (1.3 mm), because of anterosuperior tightening 

of the soft palate (via LF). MP-H results show 

the hyoid moved superiorly postoperatively, consistent 

with anterosuperior tension on the suprahyoid 

strap muscles attached to the anterior inferior mandible 

(via AIMO in combination with BSSRO). 

Discussion 

A comprehensive review of the OSA surgery literature 

33 showed that UPPP has been one of the most 

commonly performed, yet one of the least effective, 

surgeries for OSAS. Using the criteria of postoperative 

AHI 20 or AI 10 or 50% reduction in 

either value, 137 of 337 patients from 37 indepen- 

Table 4—Subjective Symptoms 

Symptom Preoperative Postoperative* 

Excessive daytime sleepiness 50 0 

Snoring 50 6 

Depression, moodiness, irritability 39 3 

Memory loss 34 0 

Morning headaches 29 1 

Impaired concentration 28 0 

*Obtained at 5.2 months (mean) postoperatively. 



Table 5—BP and BMI* 

Variable Preoperative Postoperative† p Value 

BP 

Systolic 138.9 (15.6) 123.9 (13.8) 0.001 

Diastolic 89.8 (12.3) 80.2 (11.1) 0.001 

BMI 30.7 (4.5) 28.6 (3.9) 0.001 

*Values given as mean (SD), unless otherwise indicated. 


dent case series were successful responders, for a 

combined success rate of only 41%. Furthermore, 

surgery directly on the pharyngeal tissues, eg, soft 

palate, may produce life-threatening postoperative 

UA edema and permanent disfigurement with functional 

impairment. 33,51,52,54 Tracheostomy bypasses 

the entire UA with all its potential sites of obstruction 

but has significant psychosocial and medical 

management problems and, thus, is no longer recognized 

as an ideal treatment of OSAS in relatively 

healthy ambulatory patients. Excluding tracheostomy, 

MMA, which opens the entire velo-orohypopharynx 

34 via an extrapharyngeal operation with minimal 

risks of UA embarrassment or pharyngeal 

dysfunction, is the most effective surgical treatment 

of OSAS. 

Riley et al 36 reported the largest series of maxillomandibular 

osteotomies (MMO), in which 89 of 91 

OSAS patients were successfully treated, based on 

postoperative AHI 20 or 50% reduction in AHI, 

for a success rate of 98%. However, it is perhaps 

misleading that MMO was labeled a phase II procedure 

in that 67 of the 91 patients did not participate 

in phase I of their two-phase protocol. Waite et al 35 

reported improvement in 22 of 23 patients, based on 

a mean postoperative AHI of 15, for a success rate of 

96%, in which MMA was performed as a primary 

procedure, often in combination with adjunctive 

Table 6—Lateral Cephalometric Analysis* 

Cephalometric Analysis Preoperative Postoperative† p Value 

SNA, degrees 79.0 (4.2) 86.4 (4.1) 0.001 

SNB, degrees 74.7 (4.1) 81.6 (4.1) 0.001 

GO-POG, mm 

PNS-P, mm 

72.1 (4.7) 86.5 (5.7) 0.001 

ETV 37.9 (6.7) 36.9 (6.0) 0.003 

MM 

MP-H, mm 

39.6 (6.8) 38.3 (6.4) 0.001 

ETV 24.3 (5.8) 22.4 (6.0) 0.002 

MM 

PAS, mm 

37.1 (10.6) 33.7 (9.0) 0.003 

ETV 5.1 (2.4) 11.6 (3.4) 0.001 

MM 0.8 (1.5) 5.7 (3.9) 0.001 

*Values given as mean (SD), unless otherwise indicated. 



Figure 4. PSG results, sleep-disordered breathing variables. 

Error bars indicate SD. CPAP continuous positive airway 

pressure; #Desats number of oxyhemoglobin desaturation 

events; Pre-op preoperative; Post-op postoperative. 

procedures. Hochban et al 34 reported a 95% success 

rate, based on relatively rigid criterion of postoperative 

AHI 10 in a series of 21 consecutive OSAS 

cases in which MMA was performed as a definitive 

primary surgery, without any adjunctive procedures. 

In Hochban’s series of carefully selected cases, 

which included only healthy nonobese patients with 

specific craniofacial skeletal deformities and pharyngeal 

narrowing, a “stepwise” algorithm of staged 

surgical procedures was “not justified.” 34 

A difficult diagnostic dilemma is deciding when 

and how to stage surgery in patients with diffusely 

Figure 5. PSG results, sleep-staging variables, shown as a 

percentage of total sleep time. Error bars indicate SD. 

REM rapid eye movement. 

CHEST / 116 /6/DECEMBER, 1999 1525

complex or multiple sites of disproportionate UA 

anatomy. One approach is to perform certain procedures 

in a stepwise 32 manner or particular order 

according to a methodical protocol, eg, UPPP first, 

then if unsuccessful, a hyoid suspension, then if that 

fails, a mandibular advancement, and so on. However, 

this may result in unnecessary additional surgery, 

which may be painful, dysfunctional, expensive, 

nontherapeutic, and, ultimately, a deterrent for patients 

to seek definitive surgical treatment. Riley et 

al 36 reported an overall success rate of only 61% (145 

of 239 patients) for phase I surgery, which consisted 

of UPPP and/or genioglossus advancement with 

hyoid myotomy suspension. Furthermore, only 24 of 

the 94 patients who had failed phase I surgery 

elected to proceed with phase II of their protocol, 

even though MMO was known to be highly 

successful. 

In this series, the approach and methodology of 

surgical treatment planning was site-specific: the 

selection of specific surgical procedures was based 

primarily on each individual patient’s sites of disproportionate 

UA anatomy. MMA was performed first 

for diffusely complex or multiple sites of disproportionate 

UA anatomy to enlarge and stabilize the 

velo-orohypopharyngeal airway to either (1) definitively 

treat the OSAS and, thus, eliminate additional 

unwarranted surgery or (2) reduce the risk of postoperative 

edema-induced UA embarrassment caused 

by secondary pharyngeal procedures, if still necessary 

in the setting of clinically significant residual 

OSAS. Unlike other less successful procedures, 33 

which focus on particular anatomic structures or 

segmental areas by operating within the UA, MMA 

addresses the entire velo-orohypopharynx by operating 

outside of the pharyngeal airway tissues. MMA 

was not confined by a staging algorithm and reserved 

only for the most severe OSAS cases as a last resort 

when all other surgery had failed; nor was it restricted 

to a set of craniofacial skeletal characteristics. 

Rather, it was also performed in some patients 

with mild OSAS, as well as in some who did not 

exhibit craniofacial skeletal deformities such as retrognathia. 

The results show that MMA, often performed 

concomitantly with adjunctive nonpharyngeal procedures, 

was a safe and successful primary singlestaged 

operation—even for those with morbid obesity 

and coexisting lateral pharyngeal tonsillar 

hypertrophy and/or dysmorphic soft palates with 

medially displaced tonsillar pillars. T/A and/or UPPP 

were not required subsequently in any of the 24 or 

40 patients in whom T/A or UPPP, respectively, had 

not been performed before MMA (Table 1). Nevertheless, 

those patients were informed that with advancing 

age and/or weight gain, the UA could pro- 

gressively narrow to such a degree as to necessitate 

T/A and/or UPPP as second-stage surgery if applicable 

conservative therapies, eg, nCPAP, were not 

tolerated, refused, or unsuccessful. In the setting of 

variable complex UA heterogeneity of the OSAS 

population referred for MMA, particularly in those 

with scar distortion from prior, often dissimilar surgery 

in which anatomically similar cohorts are not 

readily discernible, it is unknown how each individual 

procedure contributed to the results in this, as 

well as other, uncontrolled clinical case series. 

The surgical principles and techniques introduced 

in this series (eg, incorporation of the innovative 

AIMO with BSSRO and LF as an integral component 

of MMA, the understanding of which and when 

nonpharyngeal adjunctive procedures can be performed 

safely with MMA vs staged operations, early 

ETT extubation, and avoidance of narcotic analgesics) 

may have served to hasten postoperative recovery 

and convalescence, with minimal morbidity and 

no mortality. Waite et al 35 and Riley et al 36 reported 

mean hospital stays of 7.8 and 2.4 days, respectively. 

The results (Table 2) in this series show a mean 

hospital stay of 1.6 days: no patient required a 

hospital stay of 2 days; and 21 of the last 23 

patients were discharged home on the first postoperative 

day. There were no episodes of postoperative 

hemorrhage or edema-induced UA embarrassment, 

and postoperative nCPAP was not used in any 

patient. Postoperative discomfort was typically minimal. 

Those who experienced residual neurosensory 

deficits, the most common complication of MMA, 

reported significant resolution, which did not adversely 

affect their quality of life. MMA was not 

disfiguring, eg, no facial scars because all incisions 

were intraoral. On the contrary, all patients, especially 

those with preoperative craniofacial skeletal 

deformities such as retrognathia, accepted changes 

in facial appearances, predicted by preoperative 

computer imaging, as aesthetically pleasing. All resumed 

their normal lifestyles, usually returning to 

work full-time within 2 weeks postoperatively, with 

substantial improvement in their preoperative 

OSAS-related signs and symptoms. 

The results (Table 5) show that weight loss and a 

lowering of systolic and diastolic BP occurred after 

MMA. Riley et al 40 reported that 7 of 13 MMO 

patients no longer required antihypertensive medicines. 

Although OSAS can exacerbate and perhaps 

cause some cases of hypertension, these results 

suggest that resolution of OSAS after MMA may 

normalize hypertension in some cases. However, the 

hemodynamic significance of these data is unknown. 

Initial weight reduction, particularly in the morbidly 

obese, resulted primarily from controlled dietary 

restrictions, whereas weight loss maintenance after 



estoration of normal masticatory function may have 

resulted, in part, from increased metabolic rates 

associated with the resolution of OSAS-related EDS. 

It is unknown to what extent the weight loss contributed 

to the PSG results and whether those patients 

might eventually gain or regain weight and, therefore, 

experience progressive worsening of any residual 

OSAS. Furthermore, the relatively low mean 

BMI in this series may not represent the true general 

OSAS population. Other limitations of the results are 

that recording the patients’ stated symptoms (Table 

4) was subjective and qualitative; and that potential 

variability in the methodology of data collection and 

interpretation by different sleep facilities and physicians 

existed. 

The PSG results also support the use of cephalometry, 

although obtained in awake erect patients, as a 

reliable diagnostic adjunct to clinical examination. 

Although only ETV PAS 9 mm was used as an 

MMA inclusion criterion, the cephalometric data 

(Table 6) show that the maxilla and mandible advanced, 

the hyoid elevated, the soft palate tightened, 

and, most important, the orohypopharynx enlarged 

postoperatively. In comparison with other reputable 

diagnostic modalities (eg, invasive nasopharyngolaryngoscopy, 

intraluminal pressure transducers, 

somnoflouroscopy, CT scans, and MRI), cephalometry 

is comfortably noninvasive, safe with minimal 

radiation exposure, easy to perform in an outpatient 

setting, inexpensive, and with results that are objective, 

standardized, and reproducible. 

Two cephalometric modifications have been introduced. 

First, PAS was selected as the most critical 

measurement in that it quantitated (in a two-dimensional 

plane viewed laterally) the (velo)-orohypopharyngeal 

opening and, thus, was measured at the most 

narrow level of orohypopharyngeal anteroposterior 

collapse, rather than at a level determined by skeletal 

landmarks. Second, pharyngeal volumetric changes 

associated with different phases of respiration were 

standardized by obtaining two films—one at ETV 

and the other during MM, to simulate pharyngeal 

soft-tissue collapse associated with negative inspiratory 

forces generated during OSA events. The results 

show that PAS (1) enlarged significantly after MMA 

in all patients and (2) was always larger at ETV than 

during an MM, which suggests that the measurement 

of PAS should be standardized for breathing 

phases. 

The relatively short-term success of MMA in this 

series may equate with a definitive cure. Progressive 

worsening of OSAS in adults may be caused, in part, 

by aging of anatomically disproportionate pharyngeal 

soft tissues, which gradually lose neuromuscular 

tone, leading to increasing floppiness and collapsibility. 

In addition to structural enlargement of the 


pharyngeal lumen, MMA via tightening of the pharyngeal 

soft tissues attached to or suspended from 

the advanced skeletal structures may also enhance or 

rejuvenate neuromuscular tone of the anterior pharyngeal 

dilator musculature, such as the tensor palatini 

and genioglossus, to both open and stabilize the 

entire velo-orohypopharyngeal airway. Although 

these rejuvenated tissues will continue to lose neuromuscular 

tone with advancing age, advancement 

LF and BSSRO, which have been performed routinely 

and successfully for half a century (eg, as 

orthognathic surgery) do not relapse significantly, in 

that osteotomies, once healed to a bony union, are 

relatively stable. Hence, the surgically improved or 

corrected UA may be sufficiently patent and stable 

as to simulate an anatomically and physiologically 

normal UA, which can withstand normal soft-tissue 

aging without redeveloping OSAS. 

MMA as a potential definitively successful primary 

single-staged surgical treatment of OSAS, particularly 

when performed in a relatively young OSAS 

population, may result in a significant reduction in 

OSAS-related health risks (eg, hypertension, cardiovascular 

dysrhythmias, stroke, and myocardial infarction, 

as well as EDS-induced injuries such as motor 

vehicular accidents and neuropsychiatric disorders 

such as depression and cognitive dysfunction), 

which, when projected over a normal lifetime, 

should represent a considerable financial savings on 

the health-care system. 60,61 The one-time costs of 

early MMA is probably far less expensive than 

multiple less successful operations (with multiple 

hospitalizations), or even a lifetime of nCPAP with 

its associated costs of repeat sleep studies, eg, retitrations, 

equipment maintenance and replacement, 

technical support, and compliance counseling. 

Conclusion 

This clinical series of 50 consecutive OSAS patients 

reports a 100% success rate of MMA, often 

performed concomitantly with adjunctive nonpharyngeal 

procedures, as a safe primary single-staged 

type of site-specific surgical treatment for selected 

patients with diffusely complex or multiple sites of 

disproportionate velo-orohypopharyngeal anatomy. 

Although there is variation in the OSAS literature as 

to what specific criteria determine success, these 

results support previously reported data that MMA is 

the best surgical alternative to tracheostomy, with a 

therapeutic efficacy equal to nCPAP. The long-term 

validity and significance of these results, as well as 

the innovative techniques and postulates presented, 

are unknown. Additional studies with larger numbers 

of patients and longer follow-up are warranted. 

CHEST / 116 /6/DECEMBER, 1999 1527

ACKNOWLEDGMENTS: The author thanks Manuel Davila, 

DMD, Robert Lazerson, DDS, and Roger Meyer, DDS, MD, for 

assistance during surgery; the sleep facilities listed in the appendix 

and the following sleep physicians, listed alphabetically, for 

patient referrals and PSG data (Hal Alpert, MD, Maher Astwani, 

MD, Robert Bashuk, MD, Francis Buda, MD, Ralph Ciccone, 

MD, David DeRuyter, MD, William Dowdell, MD, Dale Green, 

MD, Aris Iatridis, MD, Walter James, MD, George Kanes, MD, 

Scott Karlin, MD, John Lee, MD, David Lesch, MD, Mark 

Pollock, MD, Russell Rosenberg, PhD, Robert Schnapper, MD, 

Trammell Starr, MD, Jonne Walter, MD, James Wellman, MD, 

Charles Wells, Jr, MD, David Westerman, MD, and Kevin Ziffra, 

MD); Simon Peimer, MD, PhD, for statistical analysis of this 

data; and Karen Cary, Misty Gendron, and Shay Hammonds for 

clerical assistance in manuscript preparation. 

Appendix 

PSGs were performed and interpreted at the following facilities, 

which are listed alphabetically: Astwani Neurology, P.C., 

Sleep Disorders Lab, Dublin, GA; Athens Regional Medical 

Center, Neurodiagnostics and Sleep Lab, Athens, GA; Cape Fear 

Memorial Hospital, Inc., Sleep Disorders Center, Wilmington, 

NC; Cobb Hospital, Sleep Center, Austell, GA; Dekalb Medical 

Center, Sleep Disorders Center, Decatur, GA; Dunwoody Medical 

Center, Sleep/Wake Center, Atlanta, GA; Floyd Medical 

Sleep Disorders Center, Rome, GA; Georgia Baptist Medical 

Center, Atlanta Center for Sleep Disorders, Atlanta, GA; Kennestone 

Hospital, Sleep Disorders Center, Marietta, GA; National 

Sleep Dynamics, Woodstock, GA; Neurology Associates, 

Neurodiagnostic and Sleep Disorders Center, Macon, GA; N. 

Broward Medical Center, Sleep Disorders Center, Pompano 

Beach, FL; Northlake Regional Medical Center, Sleep Disorders 

Laboratory, Tucker, GA; Northside Hospital, Sleep Disorders 

Center, Atlanta, GA; Piedmont Hospital, Sleep Laboratory, 

Atlanta, GA; Redmond Regional Medical Center, Sleep Disorders 

Center, Rome, GA; Sleep Disorders Center of Georgia, 

Atlanta, GA; and Staten Island University Hospital, Sleep Disorders 

Center, Staten Island, NY. 

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