CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

Maxillomandibular Advancement for

Severe Obstructive Sleep Apnea Is a
Highly Skeletally Stable Long-Term
Procedure
Joseph E. Cillo, Jr, DMD, MPH, PhD,* and David J. Dattilo, DDSy
Purpose: To evaluate long-term clinically significant cephalometric skeletal stability with maxilloman-
dibular advancement (MMA) for obstructive sleep apnea (OSA).
Materials and Methods: We performed a retrospective cohort analysis of long-term clinically signifi-
cant skeletal stability in patients who underwent MMA for OSA. The primary predictor and outcome vari-
ables were the occurrence of and time to loss of clinically significant skeletal stability, respectively, at sella–
nasion–B point (SNB). The inclusion criteria included severe OSA (apnea-hypopnea index > 30), MMA,
diagnostic preoperative and postoperative lateral cephalometric radiographs, and a minimum of 5 years
of follow-up. Digitized cephalometric radiographs were analyzed at 3 time points: preoperatively, postop-
eratively, and at last follow-up. Statistical analyses included Kaplan-Meier time–to–loss of clinical stability
analysis, the log-rank test, and the Cox proportional hazards model for hazard ratio determination for the
influence of the following independent variables on loss of clinical stability: gender, age at the time of sur-
gery, time to follow-up, and amount of surgical movement. Post hoc stratification for bone grafting was
completed. Statistical significance was set at the P < .05 level.
Results: Thirty consecutive patients with an even gender distribution and average follow-up period of
10.7 years were included in this study. Preoperatively, the average age was 43.7 years; apnea-hypopnea in-
dex, 59.8; and body mass index, 39.3. Half of the cohort had clinically significant loss of skeletal stability at
sella–nasion–A point (SNA), SNB, and A point–nasion–B point (ANB) approximately 13 years after surgery,
with no statistically significant difference between SNA, SNB, and ANB curves (c2 = 0.12) independent of
the independent variables at SNB (c2 = 1.9), SNA (c2 = 1.3), or ANB (c2 = 1.3). The average hazard ratio
ranged from 0.89 to 1.02.
Conclusions: Within the limitations of this study, MMA in the treatment of severe OSA is a highly skel-
etally stable long-term procedure independent of gender, age at the time of surgery, time to follow-up, and
amount of surgical movement.
Ó 2019 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 77:1231-1236, 2019

Obstructive sleep apnea (OSA) is a serious medical
condition characterized by repeated collapse of the
upper airway during sleep that leads to airway resis-
tance and obstruction, snoring, fatigue, and daytime
sleepiness.1 This condition may have a significant
impact on cognitive behavior and occupational
disability and may worsen medical comorbidities,
such as cerebrovascular and cardiovascular disease.2
Conservative methods in some situations, such as
continuous positive airway pressure, have proved suc-
cessful but have significant compliance issues. Oral
appliance therapy has proved effective in some cases

Received from Division of Oral and Maxillofacial Surgery, Allegheny Allegheny Health Network, 320 E North Ave, Ste 6100 ST, Pittsburgh,
General Hospital, Allegheny Health Network, Pittsburgh, PA. PA 15212; e-mail: jecdna@aol.com
*Associate Professor and Program Director. Received July 1 2018
yAssociate Professor and Division Director. Accepted January 6 2019
Conflict of Interest Disclosures: Drs Cillo and Dattilo are paid con- Ó 2019 American Association of Oral and Maxillofacial Surgeons
sultants for Zimmer Biomet. 0278-2391/19/30012-6
Address correspondence and reprint requests to Dr Cillo: Divi- https://doi.org/10.1016/j.joms.2019.01.009
sion of Oral and Maxillofacial Surgery, Allegheny General Hospital,

1231
1232
of mild OSA but may result in occlusal changes and
temporomandibular joint disorders.
Surgical procedures such as maxillomandibular
advancement (MMA) have been proven effective in
improvement or elimination of OSA regardless of
age, craniofacial anomalies, weight, body habitus, or
medical history.3-8 MMA routinely requires
advancement of the maxillomandibular complex by
8 mm or more to increase the upper airway space to
afford its intended results. Although any surgical
manipulation of the maxillomandibular complex may
undergo relapse,9 this magnitude of advancement
may result in excessive relapse, particularly in the
long-term. Most studies have investigated the skeletal
stability of MMA for OSA over the short and medium
term, but there remains a lack of data on the long-
term stability.
The purpose of this study was to evaluate loss of
long-term clinically significant cephalometric skeletal
stability of MMA in the treatment of severe OSA. We hy-
pothesized that half of the patients who underwent
MMA for severe OSA would not have long-term loss
of clinically significant cephalometric skeletal stability,
defined as a change of 2 or more, at median follow-up
time. The specific aims of this study were 1) to deter-
mine the frequency of long-term loss of clinically signif-
icant cephalometric skeletal stability; 2) to determine
the influence of independent factors (gender, age at
the time of surgery, amount of surgical movement,
time to follow-up, and bone grafting) on loss of clini-
cally significant skeletal stability; and 3) to evaluate
the time to loss of clinically significant skeletal stability
with MMA for the treatment of severe OSA.
Materials and Methods
STUDY DESIGN
To meet the research goals of this study, a retrospec-
tive cohort analysis of adult patients treated with MMA
for polysomnogram-confirmed OSA between January
1992 and April 2013 was developed. Owing to the
retrospective nature of this study, exemption approval
by the institutional review boards of Allegheny Gen-
eral Hospital (RC5727) and the University of Pitts-
burgh Medical Center (PRO13050368) was obtained.
This study was designed according to the Declaration
of Helsinki, as well as good clinical practice guidelines.
The results are reported according to the STROBE
(Strengthening the Reporting of Observational Studies
in Epidemiology) criteria.10
INCLUSION AND EXCLUSION CRITERIA
The inclusion criteria for this study were adult pa-
tients (age > 18 years) with overnight polysomnogram-
SEVERE OBSTRUCTIVE SLEEP APNEA
confirmed severe OSA (apnea-hypopnea index
[AHI] > 30) treated with MMA that consisted of Le Fort
I osteotomy and bilateral sagittal split ramus advance-
ment osteotomies, as described by Prinsell,11 that used
rigid internal fixation with plates and screws; advance-
ment of at least 8 mm at the maxillary central incisor; a
period of at least 3 weeks of wired intermaxillary fixa-
tion, with or without concomitant genioglossus
advancement and/or maxillary bone grafting; diagnostic
preoperative and postoperative lateral cephalometric ra-
diographs; and at least 5 years of follow-up. The exclu-
sion criteria were a history of any congenital
craniofacial deformities, a genetic syndrome, acquired
craniofacial deformity related to tumor, and/or trauma;
insufficient radiographs or records; and/or inability or
unwillingness to participate in the study.
DATA COLLECTION
Lateral cephalometric radiographs were digitized
and calibrated with an Epson Perfection V700 scanner
(Long Beach, CA) for 3 time points: up to 2 months
preoperatively (T0), up to 1 month postoperatively
(T1), and last follow-up of at least 5 years (T2). All digi-
tized lateral cephalometric radiographs were analyzed
by masked, independent, third-party, cloud-based
cephalometric analysis and tracing software (CephX;
ORCA Dental AI, Las Vegas, NV; http://www.CephX.
com) for the following cephalometric angular mea-
surements: sella–nasion–A point (SNA), sella–nasion–
B point (SNB), and A point–nasion–B point (ANB).
CEPHALOMETRIC SKELETAL STABILITY ANALYSES
Skeletal stability analyses consisted of horizontal
skeletal angular measurements of the relationships of
the maxilla and mandible to the cranial base (SNA
and SNB, respectively), as well as the relationship of
the maxilla and mandible to each other (ANB). Clini-
cally significant loss of skeletal stability was defined
as a difference of 2 or more in a cephalometric mea-
surement between time points immediately after sur-
gery (T1) and at last follow-up (T2).
Primary and Secondary Predictor and Outcome
Variables
The primary predictor variable was change in SNB.
The primary outcome variable was time to loss of clin-
ically significant skeletal stability at SNB at last follow-
up. Secondary outcome variables were change in SNA
and ANB. Secondary predictor variables were time to
loss of clinically significant skeletal stability of the
maxilla and the relationship of the maxilla to the
mandible at last follow-up. Loss of clinically significant
skeletal stability was defined as a difference of 2 or
more12 between the immediate post-surgery time
CILLO AND DATTILO
point (T1) and last follow-up (T2) for each cephalo-
metric measurement.
STATISTICAL ANALYSIS
Descriptive percentage statistics of patients with clin-
ically significant loss of skeletal stability at last follow-up
were determined for SNA, SNB, and ANB. Kaplan-Meier
curves were used to evaluate the time to loss of clinically
significant skeletal stability for SNA, SNB, and ANB, with
the log-rank test used to test the null hypothesis that
there is no difference between the curves. The Cox pro-
portional hazards model was used to evaluate the influ-
ence of the independent variables gender, age at the
time of surgery, time to follow-up, and amount of surgical
movement—defined as the cephalometric difference be-
tween time points T0 and T1—on time to loss of clini-
cally significant skeletal stability. Stratification between
patients who underwent maxillary bone grafting and
those without grafting was completed with the Mann-
Whitney test for differences between group means.
To determine any statistically significant differences
between included and excluded patients, the Mann-
Whitney test was conducted on age at the time of sur-
gery, body mass index (BMI) at the time of surgery, pre-
operative AHI, and time (in weeks) since surgery
between patients included in this study and those un-
willing or unable to participate. Descriptive and infer-
ential statistical analyses were performed with the
Excel statistical package (Microsoft, Redmond, WA)
and a web-based statistical package (VassarStats,
http://vassarstats.net/). Statistical significance was
set at the P < .05 level.
SAMPLE SIZE CALCULATION
To detect an effect size of 0.5 with a power of 80%
and an alpha error of .05, the sample size calculation
showed that 30 patients were required to be entered
into this study.
Results
DEMOGRAPHIC CHARACTERISTICS AND
DESCRIPTIVE STATISTICS
From a cohort of 47 eligible patients, 30 consecutive
patients (64% response rate) who met the inclusion
criteria were entered into this study (Table 1). The
mean age was 43.7  10.7 years (range, 32 to 65 years;
median, 40.0 years) at the time of surgery and
53.9  10.6 years (range, 40 to 74 years; median,
51.0 years) at last follow-up, with an even gender distri-
bution. Preoperatively, the average AHI was 59.8  17.9
and the average BMI was 39.3  7.9. Average advance-
ment at the maxillary central incisor was
8.7  0.3 mm (range, 8 to 10 mm). All patients received
rigid fixation with plates and/or screws and underwent
1233
Table 1. DEMOGRAPHIC CHARACTERISTICS (N = 30)
Mean SD Range
Age at surgery, yr 43.7 10.8 32-65
Age at last follow-up, yr 57.9 9.0 40-74
AHI 59.8 17.9 35.6-102.7
BMI 39.3 7.9 33.4-44.7
Advancement, mm 8.7 0.3 8-10
Length of IMF, wk 3.5 0.4 3-5
Length of follow-up, yr 10.7 3.6 5.6-18.8
Abbreviations: AHI, apnea-hypopnea index; BMI, body mass
index; IMF, intermaxillary fixation; SD, standard deviation.
Cillo and Dattilo. Severe Obstructive Sleep Apnea. J Oral Maxillofac
Surg 2019.
intermaxillary fixation for an average period of
3.5 weeks (range, 3 to 5 weeks). The average length
of follow-up was 11.0  3.6 years (range, 5.6 to
18.8 years; median, 10.0 years).
No statistically significant differences were found be-
tween mean values of included and excluded patients in
the cohort for age at the time of surgery
(43.1  10.7 years vs 47.9  13.5 years, P = .4), time
since surgery (11.0  3.6 years vs 11.8  3.0 years,
P = .3), preoperative AHI (59.8  17.9 vs 69.1  17.5,
P = .95), and preoperative BMI (39.3  7.9 vs
41.2  8.3, P = .6). Loss of clinically significant skeletal
stability was observed in 40% of patients (12 of 30) for
both SNA and ANB and in 33% of patients (10 of 30)
for SNB at the time of last follow-up, an average of
11.0 years after surgery.
TIME–TO–LOSS OF STABILITY ANALYSIS
Loss of clinically significant skeletal stability at SNA,
SNB, and ANB began virtually simultaneously at
approximately 8 years after surgery (Fig 1). Half of
the cohort lost clinically significant skeletal stability af-
ter approximately 13 years for both SNA and SNB and
after approximately 15 years for ANB. The hypothesis
that half of the patients who underwent MMA for se-
vere OSA would not have long-term loss of clinically
significant cephalometric skeletal stability, defined as
a change of 2 or more, at median follow-up time could
not be rejected. The log-rank test for the time–to–loss
of stability analysis showed no statistically significant
difference between the SNA, SNB, and ANB curves
(c2 = 0.1219, df = 2, P = .94).
COX PROPORTIONAL HAZARD RATIO
The Cox proportional hazard ratio (HR) model for the
influence of independent variables on long-term loss of
clinically significant skeletal stability after MMA for OSA
showed no statistically significant findings in the overall
model fit for gender, age at the time of surgery, amount
of surgical manipulation, or time to follow-up at SNB
1234
FIGURE 1. Kaplan-Meier time–to–loss of skeletal stability curves for sella–nasion–A point (SNA), sella–nasion–B point (SNB), and A point–
nasion–B point (ANB) for long-term maxillomandibular advancement in the treatment of severe obstructive sleep apnea.
Cillo and Dattilo. Severe Obstructive Sleep Apnea. J Oral Maxillofac Surg 2019.
(c2 = 1.9095, df = 4, P = .75), SNA (c2 = 1.3525, df = 4,
P = .85), or ANB (c2 = 1.3364, df = 4, P = .86) (Table 2).
Average HRs for all measurements ranged between 0.89
and 1.02, giving an indication that these predictors did
not affect loss of stability. However, although statisti-
cally insignificant, the HR 95% confidence interval
range of 0.69 to 2.27 may indicate there is some influ-
ence in some individuals.
STRATIFICATION ANALYSIS
Two patients underwent either autogenous or allo-
geneic maxillary bone grafting in this cohort. Measure-
ments between grafted and nongrafted patients
showed no clinically or statistically significant differ-
ences in SNA (P = .5), SNB (P = .6), and ANB (P = .8).
Discussion
Skeletal stability of MMA in the treatment of OSA is an
important aspect of long-term success. In MMA, large
advancements of the mandible and maxilla are intended
to volumetrically expand the upper airway in the
attempt to decrease upper airway resistance, relieve
obstruction, and reduce the AHI.5,6 Advancement of
the maxillomandibular complex by 8 to 12 mm is
generally required to obtain this intended result.6 This
large amount of movement may result in craniofacial
skeletal instability with relapse and undesirable possible
SEVERE OBSTRUCTIVE SLEEP APNEA
recurrence or worsening of OSA. Factors that affect
skeletal stability are multifactorial and may include ad-
vancements over 7 mm; type and material of fixation;
and proper management of the proximal segment,
soft tissue, and muscles.13
The literature has concentrated mainly on cephalo-
metric skeletal stability of MMA over a relatively short
period, with few studies that have examined postoper-
ative times of greater than 4 years.14,15 Nimkarn et al14
reported that medium-term (1 to 4 years) and long-
term (>4 years) MMA showed minimal and clinically
insignificant skeletal relapse. Similarly, Lee et al15 retro-
spectively evaluated 25 patients with just over a 2-year
follow-up period and showed minor clinically insignif-
icant cephalometric skeletal changes with no develop-
ment of malocclusion. Schwartz et al,13 in a cohort of
33 patients who underwent correction of skeletal Class
II malocclusion with a mandibular advancement of
greater than 10 mm, found a limited amount of skeletal
relapse at an average follow-up of 19.4 months.
Our study evaluated long-term loss of clinically sig-
nificant cephalometric skeletal stability, defined as a
change of 2 or more for skeletal measurements, in
patients who underwent MMA for OSA. The use of
standard cephalometric skeletal measurements has
been shown to give some indication of the craniofa-
cial skeletal stability that results from MMA surgery.
Bailey et al16 defined highly stable orthognathic
CILLO AND DATTILO 1235

Table 2. COX PROPORTIONAL HAZARDS MODEL FOR LONG-TERM SKELETAL STABILITY FROM MAXILLOMANDIBU-
LAR ADVANCEMENT FOR OBSTRUCTIVE SLEEP APNEA (N = 30)

Measurement Coefficient SE 95% CI for SE HR 95% CI for HR

Gender (1:1 M:F)

SNB –0.3784* 0.4016 –1.1 to 0.4 0.99 0.69-1.50
SNA –1.1195* 0.3754 –0.86 to 0.62 1.02 0.98-1.15
ANB –0.0043* 0.4201 –0.83 to 0.82 1.00 0.44-2.27
Movement, 
SNB –0.1166* 0.1044 –0.32 to 0.09 0.89 0.73-1.09
SNA 0.0160* 0.0207 –0.02 to 0.14 1.02 0.98-1.07
ANB 0.0835* 0.0855 –0.08 to 0.25 1.09 0.92-1.29
Age at surgery (mean, 42.2 yr)
SNB 0.0039* 0.0197 –0.03 to 0.04 1.00 0.88-1.05
SNA 0.0240* 0.0207 –0.86 to 0.62 1.02 0.98-1.07
ANB 0.0012* 0.0208 –0.04 to 0.04 1.00 0.96-1.05
Time to follow-up (mean,
11.0 yr)
SNB 0.0006* 0.0011 –0.014 to 0.0027 1.00 0.99-1.00
SNA 0.0004* 0.0010 –0.0016 to 0.0024 1.00 0.99-1.00
ANB 0.0004* 0.0011 –0.00 to 0.003 1.00 0.99-1.00
Abbreviations: ANB, A point–nasion–B point; CI, confidence interval; F, female; HR, hazard ratio; M, male; SE, standard error;
SNA, sella–nasion–A point; SNB, sella–nasion–B point.
* Not statistically significant (P > .05).
Cillo and Dattilo. Severe Obstructive Sleep Apnea. J Oral Maxillofac Surg 2019.

surgical procedures as those that had a 90% chance
of a change of less than 2 mm at landmarks and
almost no chance of a change of more than 4 mm
during the first postsurgical year. In our study cohort,
loss of skeletal stability was experienced by up to
40% of patients and began to become apparent
approximately 8 years after surgery. Furthermore,
the data presented in this study showed that half of
the cohort maintained clinically significant skeletal
stability until approximately 13 years after surgery.
These were independent of the patient’s gender,
age at the time of surgery, amount of surgical manip-
ulation, time to follow-up, or bone grafting. Although
average HRs for these predictors were found to have
little to no influence on predictors of loss of clinical
skeletal stability, the 95% confidence intervals for the
cephalometric measurements were large, ranging
from 0.69 to 2.27. This finding might indicate that
there is some potential for the predictors of loss of
clinical stability to be influencing factors. In addition,
the progression to loss of skeletal stability between
the 3 cephalometric measurements (SNA, SNB, and
ANB) occurred essentially at the same rate. Finally,
these data allow for the acceptance of the hypothesis
that half of the patients who undergo MMA for severe
OSA will have long-term clinically significant cephalo-
metric skeletal stability at least 10 years after surgery.
MMA therefore may be considered a highly stable
long-term procedure in the management of OSA.
The shortfalls of this study include the inherent biases
in retrospective cohort analyses with a limited number
of patients. The low response rate may be due to the
length of time since last follow-up, as patients may
have either moved from the surrounding area, been un-
able or unwilling to undergo follow-up, died, or been
lost to follow-up. Future studies should include an
increased number of patients with more advanced
radiographic techniques such as cone-beam computed
tomography scans. Additional evaluation of the poten-
tial influence of predictors of skeletal stability as used
in this investigation will need to be completed to fully
ascertain their role in clinical skeletal stability.
Within the limitations of this retrospective cephalo-
metric cohort analysis of patients who underwent
MMA for severe OSA, loss of clinically significant skel-
etal stability of the maxillomandibular complex begins
to manifest almost 8 years after surgery, with half of the
cohort showing loss of stability almost 13 years after
surgery. Loss of clinically significant skeletal stability
was independent of gender, age at the time of surgery,
amount of surgical movement, length of follow-up, or
bone grafting. MMA appears to be a highly skeletally
stable long-term procedure in the treatment of severe
OSA.
1236
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