maxillomandibular advancement for obstructive sleep...

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Maxillomandibular advancement for obstructive sleep apnea syndrome Marc B. Blumen, MD, a Jean Philippe Vezina, MD, FRCSC, a Jean Luc Pigot, MD, b Frédéric Chabolle, MD a From the a ENT and Head Neck Department, Foch Hospital, Suresnes, France; and the b Oral Surgery Department, Foch Hospital, Suresnes, France. Maxillomandibular advancement enlarges the entire pharynx by pulling anteriorly the bony squelettal structures. It is performed in sleep apnea patients who refuse or fail to use continuous positive airway pressure. It is constantly associated to esthetic modifications but not necessarily disgraceful. Periop- erative breathing complications can occur which implies a good cooperation between the surgeon and the anesthesiologists in the operating room and in the following hours in the ICU. Hypoesthesia of the lower lip and chin is the most frequent long term complication. Nevertheless, bimaxillary advancement is one of the most effective treatments for OSAS even on a long term basis. © 2012 Elsevier Inc. All rights reserved. KEYWORDS Sleep apnea; Surgery; Bony structures; Maxillomandibular advancement Obstructive sleep apnea syndrome (OSAS) affects 2-4% of the general population. Because it is associated with cardiovascular and metabolic complications, it requires a good management and an appropriate follow-up. Several pathophysiological factors are noted. One of them is often mentioned: the imbalance between the maxillofacial bony structures (“squelettal box”) and the pharyngeal soft tissue volume/compliance. Numerous surgical techniques have been developed by otolaryngologists to reduce the soft tissue volume or to put tension on these structures, whether directly or indirectly by reinserting them in a more forward position. Because they are performed by otolaryngologists who are first-line man- agers of patients with OSAS, these techniques are generally the first used. The bony structures can also be malformed. The maxilla and mandible are sometimes abnormally narrow trans- versely. They can also be positioned backward relative to the skull base. Bimaxillary advancement surgery increases the volume of the “squelettal box” of the face and thus corrects the mismatch between the soft tissues and their container. The surgical technique used for OSAS is the same as for orthognathic surgery. However, it is less com- monly performed than soft tissue surgery because it is more complex and more often performed by maxillofacial sur- geons who have generally less contact with OSAS. Surgical technique Preoperative workup A complete workup including the following items is required before bimaxillary advancement surgery: Facial photographs are taken for esthetic comparison pur- poses. A lateral skull radiograph is performed for cephalometric analysis to quantify the degree of maxillomandibular in- sufficiency and to plan the advancement needed. To allow the appropriate mandibular advancement, it is necessary to create an interim splint (see surgical technique). Dental casts are produced and mounted on a semiadjustable articulator to provide an exact assessment of the anatomic position of the maxilla and the mandible. A model plateform is used to simulate the planned movements of the 2 bones. Address reprint requests and correspondence: Marc B. Blumen, MD, ENT and Head Neck Department, Hospital Foch, 40 rue Worth, 92150 Suresnes, France. E-mail address: [email protected]. Operative Techniques in Otolaryngology (2012) 23, 60-66 1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2011.11.011

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Operative Techniques in Otolaryngology (2012) 23, 60-66

Maxillomandibular advancement for obstructive sleepapnea syndrome

Marc B. Blumen, MD,a Jean Philippe Vezina, MD, FRCSC,a Jean Luc Pigot, MD,b

Frédéric Chabolle, MDa

From the aENT and Head Neck Department, Foch Hospital, Suresnes, France; and the

bOral Surgery Department, Foch Hospital, Suresnes, France.

Maxillomandibular advancement enlarges the entire pharynx by pulling anteriorly the bony squelettalstructures. It is performed in sleep apnea patients who refuse or fail to use continuous positive airwaypressure. It is constantly associated to esthetic modifications but not necessarily disgraceful. Periop-erative breathing complications can occur which implies a good cooperation between the surgeon andthe anesthesiologists in the operating room and in the following hours in the ICU. Hypoesthesia of thelower lip and chin is the most frequent long term complication. Nevertheless, bimaxillary advancementis one of the most effective treatments for OSAS even on a long term basis.© 2012 Elsevier Inc. All rights reserved.

KEYWORDSSleep apnea;Surgery;Bony structures;Maxillomandibularadvancement

Obstructive sleep apnea syndrome (OSAS) affects 2-4%of the general population. Because it is associated withcardiovascular and metabolic complications, it requires agood management and an appropriate follow-up. Severalpathophysiological factors are noted. One of them is oftenmentioned: the imbalance between the maxillofacial bonystructures (“squelettal box”) and the pharyngeal soft tissuevolume/compliance.

Numerous surgical techniques have been developed byotolaryngologists to reduce the soft tissue volume or to puttension on these structures, whether directly or indirectly byreinserting them in a more forward position. Because theyare performed by otolaryngologists who are first-line man-agers of patients with OSAS, these techniques are generallythe first used.

The bony structures can also be malformed. The maxillaand mandible are sometimes abnormally narrow trans-versely. They can also be positioned backward relative tothe skull base. Bimaxillary advancement surgery increasesthe volume of the “squelettal box” of the face and thuscorrects the mismatch between the soft tissues and their

Address reprint requests and correspondence: Marc B. Blumen,MD, ENT and Head Neck Department, Hospital Foch, 40 rue Worth,92150 Suresnes, France.

E-mail address: [email protected].

1043-1810/$ -see front matter © 2012 Elsevier Inc. All rights reserved.doi:10.1016/j.otot.2011.11.011

container. The surgical technique used for OSAS is thesame as for orthognathic surgery. However, it is less com-monly performed than soft tissue surgery because it is morecomplex and more often performed by maxillofacial sur-geons who have generally less contact with OSAS.

Surgical technique

Preoperative workup

A complete workup including the following items isrequired before bimaxillary advancement surgery:

● Facial photographs are taken for esthetic comparison pur-poses.

● A lateral skull radiograph is performed for cephalometricanalysis to quantify the degree of maxillomandibular in-sufficiency and to plan the advancement needed.

● To allow the appropriate mandibular advancement, it isnecessary to create an interim splint (see surgical technique).Dental casts are produced and mounted on a semiadjustablearticulator to provide an exact assessment of the anatomicposition of the maxilla and the mandible. A model plateform

is used to simulate the planned movements of the 2 bones.

Iuap

S

61Blumen et al Maxillomandibular Advancement for OSAS

Then the interim splint is created using the advanced man-dibular cast referenced to the uncut mounted maxillary cast.It will be disinfected before the intervention and will beavailable to the surgeon when the time comes.

f the day before surgery dental arch bars are put in placender local anesthesia, the procedure can be shortened. Therches will allow intermaxillary fixation at the end of therocedure or several days after.

Operative technique

Bimaxillary advancement surgery combines 2 different pro-cedures: a bilateral sagittal split of the mandible followed bya Le Fort I maxillary osteotomy under general anesthesia.

Sagittal split of the mandible (technique ofObwegeser–Dalpont)

Preparation for the splitThe lateral aspect of the mandibular body, the retromolar

triangle, and the inner portion of the ramus are infiltratedwith xylocaine/epinephrine in the submucosal and subperi-osteal planes. A bite block and a tongue depressor are usedto expose the operative field.

The incision is carried out directly to the periosteum witha cold blade, starting at the level of the first premolaranteriorly and curving medially on the retromolar trigoneposteriorly. On the anterior portion, care is taken to keepabout 1 cm of unattached mucosa laterally to the gum to

Figure 1 (A) Mandibular osteotomy. Preparation of the split: Dagittal split. The integrity of the alveolar nerve is checked.

facilitate wound closure.

The subperiosteal plane is dissected with a periostealelevator, anteriorly to expose the mental nerve and inferi-orly to show the inferior border of the mandible. Superiorly,the anterior portion of the ascending ramus is exposed, andthe lower temporalis muscle fibers are cut up to the coronoidprocess. Medially, the periosteum is raised to show themandibular foramen and the lingula (spine of Spyx).Pledgets soaked with an epinephrine solution can be placedin that space to reduce bleeding.

A 2-mm cutting burr is used to cut the outer cortex of themandibular bone vertically at the level of a region betweenthe first and second premolar depending on the plannedadvancement (Figure 1A). The cut must extend to the lowestpart of the bone and should not be too deep to preventalveolar nerve damage. Starting at the top of this cut, adotted line is drilled through the upper cortex of the man-dible, laterally to the molars on the anterior part and in themiddle of the retromolar triangle posteriorly. A secondvertical cut is then made on the inner cortex of the ascend-ing ramus, posterior to the lingula. A Lindeman burr is usedto make a continuous cut through the dotted line, and thiscut is slightly enlarged with a large caliber burr to facilitatethe insertion of the osteotomes.

SplitVarious osteotomes are used to perform the split. At first

very thin, their size is gradually increased. Curved os-teotomes are used anteriorly. They are directed toward theouter cortex to keep the alveolar nerve in contact with themedial cortex. A separator is positioned on the inferiorborder cut to apply a constant split pressure. The split is

g of the cut with a burr at the level of the second premolar. (B)

rawin

performed carefully and gradually, using slight torsion

4/0 w

62 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

movements and driving the osteotomes deeper until thefragments are properly separated.

After the split is performed, the position of the alveolarnerve is verified. If needed, it is dissected from the proximalfragment to protect it during the advancement (Figure 1B).

The same procedure is performed on the opposite side.

Advancement and fixationA traction wire is passed around the 4 inferior incisors.

The mandible is advanced, and the teeth are positioned overthe intermediate interdental splint. The occlusion is fixed inthat position using four 4/10 metal wires secured on the archbars (Figure 2).

Rigid fixation of the fragments is performed using 1adjustable miniplate at the level of the anterior vertical cuton each side. The posterior fragment is pulled through theincision using forceps, and the nonadjustable side of theplate is fixed to its distal end (Figure 3). The plated proximalfragment is pushed back to its original position. The ad-vancement is performed using a distractor and measuredusing a caliper. For obstructive sleep apnea, 10 mm at leastis usually necessary (Figure 3). Two millimeters should beadded to the planned advancement to account for the widthof the cut itself. The lower border of both fragments shouldbe aligned, and no gap should be left. The plaque can bebent to ensure good contact. The first screw is placed in theadjustable hole, and the advancement is measured a second

Figure 2 (A, B) Placement of the intermediate splint. Once thintermediate splint is placed over the teeth and is maintained with

time before securing it. The other screws are placed there-

after. Care must be taken to protect the mental nerve duringthis step.

Once rigid fixation is done on both sides, bicorticalscrews are placed on both mandibular angles using a tran-sjugal approach (Figure 3). After the screws are tightened, itis important to make sure they involve both cortices bygently trying to pull them apart.

Le Fort I maxillary osteotomies and advancement

Preparation for osteotomiesThe subperiosteal plane of the upper gingivobuccal sul-

cus is infiltrated with xylocaine/epinephrine. The incision iscarried out directly to the periosteum using a cold blade,from 1 first molar to the other. A 1-cm cuff of unattachedgingival mucosa is kept to facilitate wound closure. At thelevel of the frenulum of the upper lip, a v-shaped incision ismade.

A periosteal elevator is used to dissect the subperiostealplane, posteriorly as far as the maxillary tuberosity, superi-orly to show the infraorbital pedicle, medially to uncoverthe border of the piriform aperture, and inferiorly to exposethe imprints of the dental roots. The anterior nasal spineshould also be completely released. Pledgets soaked withepinephrine can be placed posterior to the maxillary tuber-osity to reduce venous bleeding. The mucosa of the floor ofthe nasal fossae is raised using a curved elevator for the first

ittal split is performed, the mandible is pulled forward, and theires.

e sag

2-3 cm and a straight elevator for the posterior part. The

63Blumen et al Maxillomandibular Advancement for OSAS

lower septum and lateral nasal walls are also dissected usinga torsion movement of the elevator. Constant bony contactis important to avoid mucosal tears. Soaked pledgets canalso be left in this space.

Le fort I osteotomiesRetractors are placed to protect the nasal mucosa and

lateral soft tissues. A reciprocating saw is used to cut theanterior part of the maxillary bone, starting at the zygoma-ticomaxillary buttress up to the lateral nasal wall (Figure 4).The cuts should be symmetrical on both sides and awayfrom the dental roots.

The pterygoid plates are separated from the maxillarybone. This step is best performed with a manual osteotome.The lateral nasal walls and the posterior part of the maxil-lary bone are cut with a thin osteotome. The cartilaginousand bony nasal septum is freed from the nasal crest using aU-shaped osteotome.

If a need for impaction was determined in the preoper-ative planning, a uniform slice of bone could be removed onall osteotomies.

Advancement and fixationMaxillomandibular fixation is released. A distractor is

used to verify the mobility of the lower fragment of themaxillary bone. Any remaining attachment (especially atthe posterior aspect of the maxillary sinus) is cut. Forceps

Figure 3 Placement of the osteosynthesis plate. The posteriorfragment of the mandible is pulled through the incision with aforceps. The nonadjustable side of the plate is fixed first. Osteo-synthesis. The plate is fixed to ensure stability of the advancementof at least 10 mm. Some authors may put in the gap cortical boneharvested from the parietal bone. Osteosynthesis of the posteriorfragments. Through a transjugal approach, a bicortical screw isplaced in the mandibular angle to bring closer the 2 mandibular

valves.

are then used to mobilize the fragment (Figure 5). Themovements must be unrestricted in all directions. Gradualanterior traction allows muscle stretching in preparation forfixation. The superior dental arch should reach its finalposition without excessive tension.

The final interdental splint is positioned, and occlusion isobtained. Maxillomandibular fixation is performed using

Figure 4 Maxillary osteotomy. After having reclined the mus-cles and periosteum of the anterior aspect of the maxillar and themalar bone as well as the nasal cavity mucosa, anterior osteoto-mies are performed through the maxillar and zygomaticomaxillarybuttress.

Figure 5 Maxillary dysjunction using Rowe and Quiles for-

ceps.

64 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

four 4/10 metal wires. Anterior traction can be aided with ametal wire passed around the incisors, similar to the tech-nique described for the mandible.

Before rigid fixation is performed, burr holes are madethrough the zygomaticomaxillary buttresses on the upperand lower fragments, and 4/10 metal wires are passedthrough them. They are left untightened at this stage (Figure6). They will help prevent posterior open bite.

Rigid fixation is performed using 1 preformed miniplateon each side. The plates must clear the infraorbital foramenand dental roots. The plates are first secured to the lowerfragment with 5-mm screws and then to the upper fragmentafter fine-tuning (Figure 6).

The posterior metal wires are tightened, and maxilloman-dibular fixation is removed.

Surgical field is cleaned with saline. All wounds areclosed using absorbable sutures. A VY suture is performedon the maxillar mucosa on the midline. Blocks of the in-fraorbital and mental nerves are performed using bupiva-caine.

The intermaxillar fixation is secured either at the end ofthe surgical procedure or 1 or 2 days after and is left in placefor 3-4 weeks. A liquid diet is prescribed for �4 weeks.Dental and gum hygiene are mandatory for that period.

Differences with orthognathic surgery

The OSAS patient

The typical OSAS patient is middle aged, obese, and hassignificant comorbid medical conditions. He/she has a high

Figure 6 Zygomaticomaxillary buttress osteosynthesis usingwires to avoid posterior open bite. Maxillary fixation with mini-plates.

potential cardiovascular morbidity with a higher risk for

elevated blood pressure (which might remain undiagnosedbecause it occurs during the night), coronary artery disease,cardiac arrhythmia, neurovascular disease, and diabetes. Toavoid postoperative complications, all these factors need tobe assessed and properly managed before surgery.

Orthodontic considerations

One-third of OSAS patients show craniofacial abnormal-ities, with a predominance of dental malocclusion class II.In such a case, correcting the malformation itself in additionto improving sleep apnea appears logical. This might re-quire an orthodontic preparation that could last between 12and 18 months. However, this is seldom performed forseveral reasons. First, the patient who undergoes bimaxil-lary advancement usually has severe OSAS and has failedmost available treatments. If continuous positive airwaypressure (CPAP) therapy is not possible, the potential car-diovascular complications and the cognitive impairmentsrelated to the disease (sleepiness, irritability, memory loss,and concentration difficulties) usually preclude waiting sucha long time before surgery. Second, the teeth and gums inmiddle-aged patients are not always healthy enough to bearan orthodontic therapy. Third, the patient’s primary concernis not esthetics. Finally, the cost of such treatment is gen-erally high and is rarely reimbursed by our medical system.For all these reasons, the preoperative relationship betweenthe maxilla and the mandible is maintained for most pa-tients.

Perioperative anesthetic management

Perioperative anesthetic management is of high impor-tance. A preoperative consultation is mandatory to deter-mine the risk of cardiovascular morbidity during the proce-dure. The preoperative consultation helps screen forcardiovascular risk factors that should be controlled beforesurgery, especially hypertension and high blood glucoselevels for diabetic patients. The expected difficulty of intu-bation and risk of aspiration must be properly appreciated,as patients with a Mallampati grade 3 or 4 have a 20% riskof difficult intubation.

A fiberscope must be present in the operating room andwill be used if there is the slightest difficulty for intubation.An arterial catheter will be positioned to measure bloodpressure. A BIS may be used to monitor the depth ofanesthesia.

Preoxygenation using a facial mask will be performedbefore intubation. Nasotracheal intubation is used, whichmay be accomplished either under local anesthesia or undersedation (using a fast-action nondepolarizing curare andhypnotics). The endotracheal tube is secured to the colu-mella with a suture.

During the procedure, arterial blood pressure must becontrolled. The concentrations of anesthetic drugs will bedecreased in advance to allow awakening to coincide withthe end of the intervention. The extubation should be con-

ducted on the operating room table. Antibiotics, anti-inflam-

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65Blumen et al Maxillomandibular Advancement for OSAS

matory drugs, and analgesics will be prescribed for thepostoperative period.

The postoperative period needs to be carried out in anintensive care unit for 24 hours. The patient will be in asemiseated position. Oxygen supplementation is adminis-tered if necessary. Aspiration of the nasal cavity should beperformed. Control of blood pressure and pain is essential toavoid postoperative bleeding. Ice packs will be placed onthe patient’s cheeks. Some authors advocate CPAP useduring the postoperative period to prevent the occurrence ofapneas caused by swelling and hematomas secondary to thesurgical procedure. However, it is not always easy to usebecause the patient did not initially support CPAP andbecause the nasal cavities are full of blood and secretions.

Degree of advancement

The minimal effective advancement is impossible to de-termine beforehand. Some have proposed to use the sameadvancement as needed for an effective oral appliance.1

However, oral appliances do not advance the mandible inthe same plane as surgery does and do not displace themaxilla. Given the importance of the intervention, mostauthors suggest to achieve maximum advancement, ie, tonormalize the cephalometric measurements on a lateral x-ray and to produce a minimum advancement of 10 mm atthe level of the mandible. The length of mandibular ad-vancement usually varies from 10 to 12 mm. Maxillaryadvancement is the same or less (5-10 mm)2-5 taking intoaccount that the mandible does a counterclockwise rotationduring the advancement.

Combined surgical procedures

Three types of surgical procedures can be performedconcurrently to bimaxillary advancement.

Upper airway impairment from edema or a hematomacan result from bimaxillary advancement surgery.6 Fewauthors perform a preventive tracheostomy to help the pa-tient breath and facilitate aspiration of the secretions in theimmediate postoperative period.7 Tracheostomy is tempo-rary and removed after a few days.

Procedures that can improve the efficiency of maxillo-mandibular advancement can also be performed, especiallyif there is a specific complaint such as nasal obstruction. Inthis case, a septoplasty and/or lower turbinectomy may becarried out8 even if bimaxillary advancement often sponta-neously improves nasal breathing. Other authors have per-formed a genioglossus advancement using a genioplasty9 ora maxillary distraction osteogenesis and more rarely a man-dibular symphyseal distraction osteogenesis.10

Finally, some procedures allow for some modificationsof the patient’s esthetics. They can correct some adverseesthetic effects resulting from a large advancement in apatient with a normal preoperative cephalometric analysis.11

They can also further advance a patient’s chin position if it

was retruded before surgery.

Indications–contraindications

Bimaxillary advancement surgery is indicated in a pa-tient with severe sleep apnea syndrome or moderate OSASwith severe daytime sleepiness. The patient must have failedto use of CPAP or/and an oral appliance. Some authorsadvocate its use after treatment of the pharyngeal soft tis-sues (phase II of Stanford),12 and others perform it in thefirst place in the presence (or absence) of skeletal boneabnormalities.13,14

Contraindications can be related to either general or localfactors. Age of the patient (�65 years old), an unstablecardiovascular status, and for some,5 but not for all,15 obe-ity preclude the use of this therapy. The presence of centralleep apnea syndrome16 and alveolar hypoventilation are

elements that explain some cases of failure of this surgery.Poor teeth and gum status increase the risk of infectiousproblems. A massive edentulous state makes surgery moredifficult.

Results

Bimaxillary advancement is the most effective and defini-tive treatment among all therapeutic options (outside oftracheostomy) for sleep apnea syndrome. It is effective onclinical symptoms such as snoring, daytime sleepiness,16

and quality of life.17 It is also effective on objective poly-omnographic elements—ventilation and sleep. Short-termuccess rates range from 80 to 100% when success is de-ned as an apnea–hypopnea index �20 and a reduction ofore than 50% of the preoperative index.12-14

A meta-analysis comprising 22 studies evaluated 627patients. Cure (defined as an apnea–hypopnea index �5events/hr of sleep) was obtained in 43.2% of the cases.18

Mean apnea–hypopnea index decreased from 63.9 � 26.7to 9.7 � 1 0.7 hours. The effectiveness of the procedure hasbeen found to be comparable with that of mechanical ven-tilation.7,16,19 It remains effective in the long-term (morethan 24 months) in the absence of weight gain.20,21 Thepredictors of surgical success are a younger age, a lowerBMI, a lower AHI, and a larger maxillary advancement.18

Side effects and complications

Functional side effects

The most frequently reported complication is hypoesthe-sia of the lower lip and chin, which is constant in theimmediate postoperative period but may be permanent in11-86% of cases.22 Masticatory apparatus disorders can alsoe observed.23

Esthetic

Cosmetic changes are noticed by most of the patients and

their family.23,24 There is an enlargement of the nostrils, an

66 Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012

opening of the nasolabial angle, a widening of the lowerface,23 and a prognathism for patients with a normal preop-erative maxillomandibular complex position.24 The proce-dure, however, is regarded as unsatisfactory by only 5.2% ofthe patients.23

Complications

Complications are rare. Bleeding requiring surgery(1.3%), swelling, hematoma (20% of cases),6 superinfec-tion, and pseudarthrosis are rather rare.23 No deaths havebeen reported.18

Conclusions

Maxillomandibular advancement is one of the most effec-tive therapeutic options for treating patients with severesleep apnea syndrome who fail to respond to other treat-ments such as CPAP or oral appliance. Informed consentshould be obtained from these patients, especially if they areyoung. Frank and clear information about not only theeffectiveness of this procedure but also its potential func-tional and esthetic side effects should be given. Finally, itrequires trained surgical and anesthetic teams to operate ina safe environment, to limit the perioperative risks, and toperform a large and stable advancement.

References

1. Hoekema A, de Lange J, Stegenga B, et al: Oral appliances andmaxillomandibular advancement surgery: An alternative treatmentprotocol for the obstructive sleep apnea-hypopnea syndrome. J OralMaxillofac Surg 64:886-891, 2006

2. Waite PD, Wooten V, Lachner J, et al: Maxillomandibular advance-ment surgery in 23 patients with obstructive sleep apnea syndrome.J Oral Maxillofac Surg 47:1256-1261, 1989; discussion 62

3. Riley RW, Powell NB, Guilleminault C: Maxillofacial surgery andobstructive sleep apnea: A review of 80 patients. Otolaryngol HeadNeck Surg 101:353-361, 1989

4. Wagner I, Coiffier T, Sequert C, et al: Surgical treatment of severesleep apnea syndrome by maxillomandibular advancing or mentaltranposition [in French]. Ann Otolaryngol Chir Cervicofac 117:137-146, 2000

5. Smatt Y, Ferri J: Retrospective study of 18 patients treated by maxil-lomandibular advancement with adjunctive procedures for obstructivesleep apnea syndrome. J Craniofac Surg 16:770-777, 2005

6. Li KK, Riley RW, Powell NB, et al: Postoperative airway findingsafter maxillomandibular advancement for obstructive sleep apnea syn-

drome. Laryngoscope 110:325-327, 2000

7. Vicini C, Dallan I, Campanini A, et al: Surgery vs ventilation in adultsevere obstructive sleep apnea syndrome. Am J Otolaryngol 31:14-20,2010

8. Ronchi P, Novelli G, Colombo L, et al: Effectiveness of maxillo-mandibular advancement in obstructive sleep apnea patients with andwithout skeletal anomalies. Int J Oral Maxillofac Surg 39:541-547,2010

9. Prinsell JR: Maxillomandibular advancement surgery for obstructivesleep apnea syndrome. J Am Dent Assoc 133:1489-1497, 2002; quiz539-540

10. Boyd SB: Management of obstructive sleep apnea by maxillomandibu-lar advancement. Oral Maxillofac Surg Clin North Am 21:447-457,2009

11. Bruno Carlo B, Mauro P, Silvia B, et al: Modified genioplasty andbimaxillary advancement for treating obstructive sleep apnea syn-drome. J Oral Maxillofac Surg 66:1971-1974, 2008

12. Riley RW, Powell NB, Guilleminault C: Obstructive sleep apneasyndrome: A review of 306 consecutively treated surgical patients.Otolaryngol Head Neck Surg 108:117-125, 1993

13. Prinsell JR: Maxillomandibular advancement surgery in a site-specifictreatment approach for obstructive sleep apnea in 50 consecutivepatients. Chest 116:1519-1529, 1999

14. Hochban W, Brandenburg U, Peter JH: Surgical treatment of obstruc-tive sleep apnea by maxillomandibular advancement. Sleep 17:624-629, 1994

15. Li KK, Powell NB, Riley RW, et al: Morbidly obese patients withsevere obstructive sleep apnea: Is airway reconstructive surgery aviable treatment option? Laryngoscope 110:982-987, 2000

16. Conradt R, Hochban W, Heitmann J, et al: Sleep fragmentation anddaytime vigilance in patients with OSA treated by surgical maxillo-mandibular advancement compared to CPAP therapy. J Sleep Res7:217-223, 1998

17. Lye KW, Waite PD, Meara D, et al: Quality of life evaluation ofmaxillomandibular advancement surgery for treatment of obstructivesleep apnea. J Oral Maxillofac Surg 66:968-972, 2008

18. Holty JE, Guilleminault C: Maxillomandibular advancement for thetreatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev 14:287-297, 2010

19. Hochban W, Conradt R, Brandenburg U, et al: Surgical maxillofacialtreatment of obstructive sleep apnea. Plast Reconstr Surg 99:619-626,1997; discussion 27-28

20. Li KK, Powell NB, Riley RW, et al: Long-term results of maxillo-mandibular advancement surgery. Sleep Breath 4:137-140, 2000

21. Conradt R, Hochban W, Brandenburg U, et al: Long-term follow-upafter surgical treatment of obstructive sleep apnoea by maxilloman-dibular advancement. Eur Respir J 10:123-128, 1997

22. Al-Bishri A, Rosenquist J, Sunzel B: On neurosensory disturbanceafter sagittal split osteotomy. J Oral Maxillofac Surg 62:1472-1476,2004

23. Blumen MB, Buchet I, Meulien P, et al: Complications/adverse effectsof maxillomandibular advancement for the treatment of OSA in regardto outcome. Otolaryngol Head Neck Surg 141:591-597, 2009

24. Li KK, Riley RW, Powell NB, et al: Patient’s perception of the facialappearance after maxillomandibular advancement for obstructive sleepapnea syndrome. J Oral Maxillofac Surg 59:377-380, 2001; discussion

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