Maxillomandibular Advancement Treatment of Obstructive Sleep Apnea Does Not Compromise Facial Esthetics

Maxillomandibular advancement (MMA) to treat obstructive sleep apnea (OSA) often leads to the facial skeleton being positioned beyond the upper limits of cephalometric norms.   Concomitant soft tissue changes raise concerns about unesthetic postoperative facial soft tissue changes from this surgical treatment. The purpose of this study is to determine if facial esthetics change significantly in patients undergoing MMA for treatment of OSA.

This is a retrospective cohort study of adult patients who underwent MMA for treatment of OSA in the Department of Oral and Maxillofacial Surgery at Massachusetts General Hospital, between October 2003 and February 2015. Cephalometric measurements of patients who met inclusion criteria were calculated and compared on lateral cephalograms obtained for each patient at preoperative (T1) and at the longest postoperative (T2) follow up (at least 6 months after MMA) time points. Records were reviewed for patient and/or surgeon reported postoperative esthetic concerns.  Bivariate statistics were computed to compare change in variables at T1 and T2 time points. Parametric methods were used to evaluate the changes of cephalometric parameters at T2 (paired t test).    

A total of 46 patients with a mean age of 40.29 (± 11.63) years were studied. Each cephalometric measurement was repeated once and intraclass correlation coefficient showed high agreement. The pre- and post-operative means and 95% confidence intervals were calculated and compared. Facial convexity (p=0.13), upper lip length (p=0.10), lower facial proportion (p=0.93), and interlabial distance (p=0.07) showed no statistical difference at the two times. Nasolabial angle (p<0.01), total facial proportion (p=0.02), and chin-neck distance (p=0.05) differences between the two time points were found to be statistically significant.  There were no recorded concerns about postoperative facial esthetics by patient or surgeon found.  The McNemar test demonstrated that the number of patients with normal and abnormal measurements at the two time points were not statistically different for any measure.

The comparison of preoperative and postoperative cephalometric measurements shows that while some changes in cephalometric measurements  were significantly different between the T1 and T2 time points, the cohort as a whole showed no significant difference in makeup of total cephalometric soft tissue abnormalities.  There were the same numbers of patients with cephalometrically normal and abnormal values after MMA as there were before the procedure.

		POST
		Facial Convexity		Nasolabial Angle		Facial Proportion		Upper Lip Length		Lower Facial Proportion		Interlabial Distance		Chin Neck Distance
		NORM	ABN	NORM	ABN	NORM	ABN	NORM	ABN	NORM	ABN	NORM	ABN	NORM	ABN
PRE	NORM	11	11	16	7	12	11	13	12	20	9	29	3	3	1
	ABN	10	13	14	8	5	18	6	15	11	6	10	4	4	16
p-value		1.00		0.19		0.21		0.24		0.82		0.09		0.37

PRE - preoperative; POST - postoperative; NORM - normal range (# of patients); ABN - abnormal range (# of patients)

p calculated by McNemar Exact Test

Li KK, Riley RW, Powell NB, Guilleminault C, Patient's perception of the facial appearance after maxillomandibular advacement for obstructive sleep apnea syndrome. J Oral Maxillofac Surg 59:377, 2001.

Cohen-Lew J, Petelle B, Vieille E, Dumitrache M, Fleury B, Changes in facial profile after maxillomandibular advancement surgery for obstructive sleep apnea syndrome.  Int Ortho 11:71, 2013.