Phẫu thuật tiến hai hàm trong điều trị ngưng thở khi ngủ tắc nghẽn Maxillomandibular advancement for obstruCTive sleep apnea

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by recurrent narrowing or collapse of the upper airway, resulting in repeated episodes of reduced or absent airflow despite ongoing respiratory effort.

Common manifestations include loud snoring, witnessed apneas, non-restorative sleep, excessive daytime sleepiness, fatigue, and impaired concentration.

In selected patients, craniofacial anatomy contributes substantially to upper-airway restriction. In this setting, orthognathic surgery can serve not only to modify occlusion and facial appearance, but also as a surgical treatment for OSA.

When craniofacial anatomy contributes to airway obstruction

The patient in this case presented with a history of severe snoring, daytime sleepiness, fatigue, and difficulty concentrating.

Clinical examination demonstrated mandibular deficiency and retrusion, limited chin projection, and an obtuse cervicomental relationship. The patient also tended to maintain a slightly forward head posture.

Craniofacial imaging demonstrated a relatively narrow posterior airway space.

Imaging alone, however, cannot establish the diagnosis or severity of OSA.

Polysomnography demonstrated an apnea–hypopnea index (AHI) of 47 events per hour, consistent with severe obstructive sleep apnea.

Combining objective sleep assessment with craniofacial analysis allowed the treatment strategy to address both the sleep disorder and the patient's underlying skeletal anatomy.

Why can maxillomandibular advancement improve the airway?

Maxillomandibular advancement (MMA) is an established surgical option for the treatment of obstructive sleep apnea.

Unlike procedures targeting a single anatomical level of obstruction, MMA modifies the skeletal framework supporting multiple levels of the upper airway by advancing both the maxilla and mandible.

Advancement of the jaws carries forward associated soft-tissue attachments involving the palate, tongue, and suprahyoid complex. This can increase upper-airway dimensions and reduce its tendency to collapse during sleep.

For this reason, MMA is particularly relevant in appropriately selected patients with OSA and retrusive craniofacial anatomy.

More than simply moving both jaws forward

In this patient, the surgical plan involved more than straightforward anteroposterior advancement.

The maxillomandibular complex was advanced and underwent counterclockwise rotation.

This movement pattern allowed substantial advancement of the mandible and chin while simultaneously controlling the occlusal relationship, vertical facial proportions, and overall facial profile.

Genioplasty was performed concurrently to further optimize chin projection, lower facial balance, and the cervicomental contour.

Importantly, there is no universal amount of advancement or rotation that can be applied to every patient.

Planning requires simultaneous assessment of the airway, occlusion, skeletal framework, and facial soft tissues before determining the final position of the jaws.

Three-dimensional surgical planning

The operation was planned preoperatively using a three-dimensional model of the patient's craniofacial anatomy.

The initial skeletal position, occlusal relationship, and facial morphology were analyzed before determining the direction and magnitude of movement for each skeletal segment.

Patient-specific surgical guidance was then used to transfer the virtual plan to the operating room.

In OSA surgery, three-dimensional planning is particularly valuable because obtaining an appropriate occlusion is only one component of the treatment objective.

The surgical plan must also create a favorable airway change while maintaining or improving facial harmony.

Six-month outcome

At six months after surgery, the patient reported a substantial improvement in sleep quality.

Snoring had markedly decreased, sleep was deeper and more restorative, and daytime alertness and concentration had improved.

Advancement of the mandibular and chin framework also produced a significant change in lower facial projection, lip–chin balance, and cervicomental contour.

These subjective improvements are clinically meaningful. However, in OSA treatment, symptomatic improvement does not replace objective postoperative sleep assessment. Long-term follow-up and repeat sleep testing remain important for determining the degree of disease control.

MMA is one of the most effective surgical treatments for appropriately selected patients with OSA

Maxillomandibular advancement can produce substantial reductions in AHI and is regarded as one of the most effective surgical options for appropriately selected patients with obstructive sleep apnea.

However, surgical “success” and “cure” should not be considered synonymous.

Studies of OSA surgery commonly define surgical success according to a specified reduction in AHI combined with a postoperative AHI threshold, whereas cure or remission requires more stringent criteria. A reported surgical success rate should therefore not be interpreted as a universal probability of complete elimination of OSA.

Outcomes also depend on multiple factors, including baseline disease severity, craniofacial anatomy, body weight, age, magnitude of skeletal advancement, sites of airway obstruction, and other anatomical and physiological factors.

Orthognathic surgery is not only about occlusion

This case illustrates a broader role of orthognathic surgery.

In appropriately selected patients, jaw position influences not only dental occlusion and facial appearance but also the skeletal support of the upper airway.

A comprehensive surgical plan should therefore consider four interconnected objectives:

occlusion – facial aesthetics – airway – sleep.

The ultimate goal is not simply to create a more balanced facial profile, but to improve function, sleep, and quality of life.