Orthognathic Surgery for OSA with Maxillary and Mandibular Deficiency

Patient Assessment and Indications

The patient has documented OSA with unrefreshing sleep and daytime fatigue for many years, as assessed by the American Academy of Sleep Medicine 1
The patient has failed multiple conservative therapies, including CPAP and oral appliance therapy, as recommended by the European Respiratory Society 2, 3, 1

Maxillomandibular advancement (MMA) is recommended for OSA patients who refuse or cannot tolerate conservative treatment, particularly in younger patients without excessive BMI, according to the European Respiratory Society 3, 4
MMA has been shown to be as effective as CPAP in appropriately selected patients, with success rates ranging from 67% to 100%, as reported by the European Respiratory Society 2, 3, 4
An advancement of 10-15mm of the maxilla and mandible is necessary to effectively treat OSA when maxillomandibular abnormality exists, as stated by the European Respiratory Society 2

The classical procedure consists of bilateral sagittal split ramus osteotomies with rigid internal fixation and Le Fort I osteotomy with rigid internal fixation, as described by the European Respiratory Society 2

Improvement in AHI and sleep architecture can be expected after MMA, as reported by the European Respiratory Society 2, 4
Potential reduction in blood pressure and cardiovascular risk is a benefit of MMA, as stated by the European Respiratory Society 2
One-time cost of MMA may be less expensive than lifetime use of CPAP, according to the European Respiratory Society 3
Long-term effectiveness has been demonstrated with success rates of approximately 60% on long-term follow-up, as reported by the European Respiratory Society 3, 4
Transient anesthesia of the cheek and chin area is a common risk of MMA, as reported by the European Respiratory Society 5
Residual neurosensitive deficit and potential for local infection are risks of MMA, as stated by the European Respiratory Society 5

Full in-laboratory polysomnography should be performed between 2-6 months after surgery to assess effectiveness, as recommended by the American Academy of Sleep Medicine and the European Respiratory Society 1, 5
Long-term follow-up with a sleep specialist is recommended after surgical treatment is completed, according to the American Academy of Sleep Medicine 1

A 38-year-old female patient with skeletal deformity, including maxillary hypoplasia, mandibular hyperplasia, and facial asymmetry, was assessed for midface and mandibular reconstruction 6
The patient's physical examination revealed a slight long face with maxillary hypoplasia and hypoplastic malar eminence, mandibular hyperplasia with slight prognathism, reverse overjet of -1mm, and overbite of 0mm 7
The patient also had a right posterior crossbite with some teeth edge to edge, and a large chin (macrogenia) 6

Orthognathic surgery is considered medically necessary only when skeletal deformities contribute to significant masticatory dysfunction, and when the severity precludes adequate treatment through dental therapeutics and orthodontics alone, as recommended by the European Respiratory Society 8, 7
Specific measurement criteria for medical necessity include antero-posterior discrepancies, maxillary/mandibular antero-posterior molar relationship discrepancy, vertical discrepancies, transverse discrepancies, and total bilateral maxillary palatal cusp to mandibular fossa discrepancy, as outlined by the European Respiratory Society 8

LeFort osteotomy and mandibular reconstruction are medically indicated in cases with significant masticatory dysfunction, severe skeletal discrepancies, obstructive sleep apnea caused by craniofacial abnormalities, and craniofacial syndromes with functional impairment, according to the European Respiratory Society 8, 7, 9, 10, 11
Orthognathic surgery for primarily aesthetic concerns without documented functional impairment is not considered medically necessary, as stated by the European Respiratory Society 8, 7

Surgical procedures for dentofacial deformities, including mandibular distraction osteogenesis, orthognathic surgery with TMJ preservation, and TMJ reconstruction, are indicated when there is significant functional impairment that cannot be addressed through non-surgical means, as recommended by the American College of Rheumatology 12, 13
The selection of surgical method should be influenced by the severity of deformity, functional impairment, and stability of the TMJ, according to the American College of Rheumatology 12, 13

Dental therapeutics and orthodontics should be considered first-line treatment for minor to moderate dentofacial deformities, as suggested by the American College of Rheumatology 12, 13
Fixed appliance orthodontic treatment may be used to correct minor malocclusions separately from surgical treatment, as recommended by the American College of Rheumatology 12, 13
Non-surgical management options, including medication, orthotic appliances, and physical therapy, may be considered for patients with dentofacial deformities, according to the British Medical Journal 14