Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis

To evaluate the effectiveness of maxillomandibular advancement surgery in the treatment of Obstructive Sleep Apnea by comparing the pre- and postoperative Apnea and Hypopnea Index, in addition to classifying the degree of evidence and risk of intervention bias.

Methods

A systematic review of the literature was carried out in the PUBMED, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE and COCHRANE platforms, including cohort studies with polysomnographic follow-up, without other associated pharyngeal or nasal surgical procedures. The risk of study bias was assessed using the Modified Delphi technique. Pre- and postoperative Apnea and Hypopnea Index data were plotted for meta-analysis, and the quality of evidence was assessed using the GRADE system.

Results

Of 1882 references, 32 articles were selected for full-text reading, of which four studies were included, totaling 83 adults with obstructive sleep apnea who underwent maxillomandibular advancement. The meta-analysis was in favor of the intervention (DM = −33.36, 95% CI −41.43 to −25.29, p< 0.00001), with a mean percentage reduction in the Apnea and Hypopnea Index of 79.5% after surgery, even though the level of evidence was classified as very low quality by the GRADE system.

Conclusion

The meta-analysis was in favor of the intervention, characterizing maxillomandibular advancement surgery as an effective treatment for obstructive sleep apnea in adults.

Keywords
OSA; Maxillomandibular advancement; Polysomnography

Summary of results:

Comparison of AHI pre- and post-MMA

Population: adult individuals diagnosed with OSA

Intervention: MMA (maxilomandibular advancement)

Comparison: non-treatment (pre‒op) & MMA (post‒op)

Outcomes	Potential absolute effects* (95%CI)		Relative effect (95%CI)	N. of participants (studies)	Certainty of the evidence (GRADE)
	Risk with placebo	Risk with MMA X no MMA
AHI	‒	DM 33.36 lower (41.43 lower to 25.29 lower)	‒	83 (4 observational studies)	⨁◯◯◯ very low^a a All included studies are series of cases. ,^b b Although the I2= 77%, the individual results of each study had the same effect direction, favoring the intervention.
*The risk in the intervention group (and its 95% Confidence Interval) is based on the assumed risk of the comparison group and the relative effect of the intervention (and its 95% CI). CI, Confidence Interval; DM, difference of means
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] ⁎ Corresponding author. E-Mail:paulotrin@usp.br (P.A. Trindade).

Population	Adult individuals diagnosed with OSA (PSG)
Intervention	Orthognathic surgery (maxillomandibular advancement)
Comparison	Non-treatment (pre-op) & orthognathic surgery (post-op). NOTE: patients are their own controls
Outcomes	Outcome 1: apnea resolution (AHI < 5 events/h)
	Outcome 2: AHI < 15 events/h. NOTE: values greater than 15 are indicators of increased cardiovascular risk secondary to OSA
	Outcome 3: 50% reduction of the initial preoperative AHI value
	Outcome 4: preoperative AHI X postoperative AHI. Variable submitted to meta-analysis

Sample	83 adult individuals submitted to MMA
Male sex	68.68%
Female sex	31.32%
Pre‒op AHI (overall average)	40.81 ± 15.66 (events/h)
Post‒op AHI (overall average)	8.33 ± 7.03 (events/h)
Mean reduction of AHI	79.5%
Pre‒op BMI (overall average)	28.13 kg/m²± 4.17 (overweight)
Post‒op BMI (overall average)	27.30 kg/m²± 3.91
Average amount of maxillary advancement	6.53 ± 2.74 mm
Average amount of mandibular advancement	10.02 ± 3.29 mm