Change in Facial Profile in OSA

Ó 2013 CEO
Published by / Édité par Elsevier Masson SAS
Original article All rights reserved / Tous droits réservés
Article original
Changes in facial profile after

maxillomandibular advancement surgery
for obstructive sleep apnea syndrome

Evolution s chirurgie
du profil facial apre
d’avancee maxillomandibulaire dans le traitement
du syndrome d’apne es obstructives du sommeil
Julia COHEN-LEVYa,*, Boris PETELLEb, Estelle VIEILLEc, Marius DUMITRACHEd,

Bernard FLEURYe
a
Orthodontist, Private Practice, 255, rue Saint-Honore, 75001 Paris, France
b
MD, Ear Nose and Throat Department, Saint-Antoine Hospital, AP–HP, 184, rue du
Faubourg-Saint-Antoine, 75012 Paris, France
c
Dentist, Private Practice, 33, rue Capsulerie, 93170 Bagnolet, France
d
Orthodontist, Private Practice, 14, boulevard de la Reine, 78000 Versailles, France
e
MD, Saint-Antoine Hospital, h^opitaux universitaires est-parisiens, universite Paris VI, AP–HP,
184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
Available online: 9 February 2013 / Disponible en ligne : 9 fevrier 2013
Summary sume
Re
The aim of this study was to assess changes in the profile of
L’objectif de cette etude
etait
d’evaluer les modifications du
adult male patients treated for obstructive sleep apnea syndrome profil d’adultes atteints d’un syndrome d’apnees obstructives
(OSAS) with maxillomandibular advancement (MMA) surgery du sommeil (SAOS) traites par chirurgie d’avancee maxillo-
and to measure patient perception of changes compared with mandibulaire (AMM) et de mesurer la perception des patients
that of different panels. comparee à celle de differents
jurys.
Materials and methods: Fifteen consecutive apneic patients
Materiels
et methodes: Quinze patients apneiques
consecu-
displaying a wide variety of morphological types, mean age
tifs presentant une grande variet e morphologique, d’age ^
42 years (20–59), a BMI of 26.60 kg/m2 (22–29), a mean moyen 42 ans (20–59), indice de masse corporelle (IMC)
initial Apnea Hypopnea Index (AHI) of 50.9 (19–85), under- 26,60 kg/m2 (22–29), indice d’apnees
hypopnees (IAH)
went MMA. Assessment was done by facial photography, lateral moyen de 50,9 (19–8), ont et e oper es
d’AMM. Ils ont et e
cephalographs (Tweed analysis modified by Riley and Delaire
evalu par photographies faciales, tel
es eradiographies
de pro-
architectural analysis), polysomnographic records and a vali- fil (analyse de Tweed modifiee par Riley et analyse architec-
dated self-assessment questionnaire. Patients’ pre- and postop- turale de Delaire), polysomnographies et autoquestionnaire
erative profiles were taken from photographs using Photoshop valide. Les profils (pre- et postoperatoire)
des patients ont
7Ô software. Their darkened outlines were shown randomly in e extraits des photographies en utilisant le logiciel
et
positions A or B (pre- and postoperative) to panels composed of Photoshop 7Ô. Leurs ombres ont et e present
de façon
ees
orthodontists (n = 40), fine arts students (n = 50) and lay per-
aleatoire en position A ou B (pre- et postoperatoire)
à un jury
sons (n = 50) who were requested to choose the most attractive constitue d’orthodontistes (n = 40), d’etudiants
en art (n = 50)
profiles. ou de profanes (n = 50), qui devaient choisir la plus attrayante.
*
Correspondence and reprints / Correspondance et tires à part.
e-mail address / Adresse e-mail : juliacohenlevy@yahoo.fr (Julia Cohen-Levy)
International Orthodontics 2013 ; 11 : 71-92 71

doi:10.1016/j.ortho.2012.12.009
Julia COHEN-LEVY et al.
Results: The MMA success rate for OSAS was 80% (12/15) for
Resultats:
Le taux de reussite de l’AMM sur le SAOS etait de
an AHI less than 15, with no surgical complications. All 80 % (12/15) pour un IAH inferieur à 15, sans complication
patients reported a reduction of their symptoms and 14 out of chirurgicale. Tous les patients ont rapporte une reduction des
15 were satisfied with the esthetic outcome. Mean advancement ^
symptomes et 14 sur 15 ont et e satisfaits du resultat
esthe-
was 8.4 mm (3.0–10.0) for the maxilla and 10.8 mm (10.0– tique. L’avancee moyenne etait de 8,4 mm (3,0–10,0) pour le
13.0) for the mandible. Following MMA, 12 out of 15 exhibited maxillaire et 10,8 mm (10,0–13,0) pour la mandibule. Douze
maxillary protrusion and six out of 15 mandibular protrusion.
sur 15 presentaient une protrusion maxillaire et six sur 15 une
The mean change in the nasolabial angle was 5.7 ( 27 ; protrusion mandibulaire apres AMM. La reduction
moyenne
14 ). The postoperative profiles were preferred by 85% of the de l’angle nasolabial etait 5,7 ( 27 ; 14 ). Les profils
combined panels (P = < 0.001), showing no significant differ-
postoperatoires e pref
ont et er
es
par 85 % du jury gen eral

ence from one panel to another. No skeletal characteristic could (p < 0,001), sans difference significative entre les jurys.
be correlated with the esthetic preference. Upper lip retrusion,
Aucune caracteristique squelettique n’a pu etre^ correl ee
à la
open nasolabial angle and dolichofacial type emerged as pos- erence
pref
esthetique.
La retrusion
labiale superieure,
itive preoperative predictors of esthetic preference. l’ouverture de l’angle nasolabial et le type dolichofacial sont
apparus comme des predicteurs eratoires
preop positifs de
satisfaction.
Conclusion: The profile changes following MMA were favorably Conclusion: Les modifications faciales de l’AMM ont et e
perceived in the majority of cases. However, specific orthodontic
acceptees favorablement dans la majorite des cas.
preparation could be offered to patients with pronounced pre-
Cependant, une preparation
orthodontique specifique pour-
operative protrusion. ^
rait etre proposee dans les cas de protrusion preop eratoire

notable.
Ó 2013 CEO. Published by Elsevier Masson SAS. All rights Ó 2013 CEO. Édité par Elsevier Masson SAS. Tous droits
reserved réservés
Key-words s
Mots cle
·· Obstructive sleep apnea syndrome.
Maxillomandibular advancement surgery.
·· Syndrome d’apne es obstructives du sommeil.
Chirurgie d’avancee maxillomandibulaire.
· Facial esthetics. · tique faciale.
Esthe
Introduction Introduction
Obstructive sleep apnea syndrome (OSAS) is characterized by Le syndrome d’apne es obstructives du sommeil (SAOS) se
repeated collapse of the upper airways during sleep [1]. The caracte rise par un collapsus re pe
te
des voies ae riennes
commonest symptoms combine snoring broken by arrested supe rieures pendant le sommeil [1]. Les sympto ^mes les plus
breathing, daytime sleepiness and a feeling of not being communs associent un ronflement interrompu par des pauses
refreshed on wakening. The repercussions of untreated respiratoires, une somnolence diurne ou le sentiment d’un
OSAS are potentially serious with harmful impacts on cardio- sommeil non re parateur. Les conse quences d’un SAOS non
vascular morbidity and mortality (high blood pressure, infarct, sont potentiellement graves, avec des effets de
traite le
te
res
stroke, road accidents due to drowsiness at the wheel). OSAS sur la morbidite et la mortalite cardiovasculaires (hyperten-
is a genuine public health issue affecting 4% of the male sion, infarctus, accident vasculaire ce re
bral, accidents de la
middle-aged adult population and 2% of women [2]. route imputables à la somnolence). Le SAOS est un proble me
de sante publique, affectant 4 % d’une population masculine
adulte d’a ^ge moyen pour environ 2 % de femmes [2].
Continuous positive pressure ventilation (CPAP) is the stan- Le traitement de re fe
rence, la ventilation en pression positive
dard first-line treatment [3]. Despite its undeniable efficacy, continue (VPPC), est recommande en premie re intention [3].
the treatment involves constraints on patients which often lead Malgre son inde niable efficacite , son caracte re contraignant
to refusal and, in over 50% of cases, to inadequate long-term est parfois d’emble e à l’origine d’un refus et dans plus de 50 %
compliance with therapy [4]. Alternative conservative treat- de de faut d’observance à long terme [4]. D’autres traitements
ments can be offered such as hygiene- or diet-related mea- conservateurs peuvent e ^tre propose s, comme des mesures
sures (treatment for obesity, discontinuation of sleeping- hygienodie te
tiques (prise en charge de l’obe site
, arre^ t des
pills. . .) and/or a mandibular advancement appliance, which somnife res. . .) et/ou une orthe se d’avance e mandibulaire,
opens the pharynx mechanically [1]. A surgical solution can qui libere me caniquement le pharynx [1]. Une solution chirur-
also be considered in the event of unsuccessful attempts using gicale peut e ^tre envisage e apres un essai infructueux de ces
72 International Orthodontics 2013 ; 11 : 71-92

Changes in facial profile after maxillomandibular advancement surgery for obstructive sleep apnea syndrome

Evolution s chirurgie d’avance
du profil facial apre e maxillomandibulaire dans le traitement du syndrome d’apne
es obstructives du sommeil
the above-mentioned therapies, or immediately when a pha- prece dents traitements, ou d’emble e quand un obstacle
ryngeal blockage is observed [5,6]. pharynge est mis en e vidence [5,6].
Procedures directed at the soft tissues (tonsillectomy, uvulo- Les interventions portant sur les tissus mous (amygdalecto-
pharyngopalatoplasty, linguoplasty) have given limited results mie, uvulo/pharyngo/palatoplastie, linguoplastie) ont donne
in OSAS, most likely due to the simultaneous presence of des re sultats limites sur le SAOS, vraisemblablement du fait
several obstructions in the retrovelar and retrobasilingual de l’existence simultane e de plusieurs obstacles le long du
areas of the pharynx [7,8]. Maxillomandibular advancement pharynx, en situation re trovelaire et re trobasilinguale [7,8].
(MMA) is currently held to be the most effective surgical L’avance e maxillomandibulaire (AMM) est de crite aujourd’hui
treatment for OSAS in adult patients [9,10]. MMA consists comme le traitement chirurgical le plus efficace du SAOS chez
of a Le Fort I maxillary osteotomy and of a bilateral mandib- les patients adultes [9,10]. L’AMM consiste en une oste omie
ular sagittal split osteotomy together with significant advance- maxillaire de Le Fort I et d’une oste otomie sagittale mandibu-
ment (at least 10 mm) held in place by osteosynthesis. In this laire bilate rale, assorties d’une avance e conse quente, d’au
way, MMA widens the structures within the respiratory tract moins 10 mm, et maintenues par oste osynthe se. L’AMM
and reduces their propensity to collapse by tautening the largit ainsi structurellement les voies respiratoires et re
e duit
pharyngeal tissues attached to the maxilla, mandible and leur collapsibilite en ante riorisant les tissus pharynge s
hyoid bone. A CT-scan study has been able to show that attache s au maxillaire, à la mandibule et à l’os hyoı̈de. Une
MMA increases the cross-section of the airways in both the tude scanner a ainsi pu montrer que l’AMM ge
e ne
rait une
anteroposterior and transverse dimensions at different points augmentation de la section des voies ae riennes, dans le sens
along the pharynx [11]. ante roposte rieur mais e galement transversal, aux diffe rents
niveaux du phaynx [11].
According to the metaanalysis by Holty and Guilleminault [9] D’apre s la me ta-analyse de Holty et Guilleminault en 2010 [9],
in 2010 on 627 patients drawn from 22 studies, the MMA portant sur 627 patients extraits de 22 e tudes, le taux de
success rate is 86%, with a total cure for OSAS in 43.2% of succe s de l’AMM atteint 86 %, avec une gue rison totale du
cases (defined by an Apnea Hypopnea Index [AHI] per hour of SAOS dans 43,2 % des cas (de fini par un indice d’apne es
< 5). The systematic review by Pirklbauer et al. in 2011, hypopne es par heure, ou IAH < 5). La revue syste matique
representing the American Society of Maxillofacial surgery de Pirklbauer et al. en 2011, repre sentant la Socie te

[10], confirmed the efficacy of MMA in OSAS and attributed ame ricaine de chirurgie maxillofaciale [10], confirme
a high level of proof to the available studies, with grade A to B l’efficacite de l’AMM sur le SAOS et attribue un haut niveau
recommendations. Results appear to be stable over time (89% de preuve aux e tudes disponibles, avec des recommanda-
success rate for 56 patients followed up to 43.7 months), tions de grade A à B. Les re sultats apparaissent stables dans
excluding cases in which patients put on a lot of weight some le temps (89 % de succe s pour 56 patients suivis jusqu’à
time after the procedure [12–14]. Improvement of sleep ven- 43,7 mois), en dehors des cas où les patients connaissent
tilatory parameters is accompanied by a significant reduction une importante prise de poids à distance de l’intervention
in daytime drowsiness (evaluated using the Epworth question- [12–14]. L’ame lioration des parame tres ventilatoires du som-
naire) as well as by an enhanced quality of life [15], notably meil s’accompagne d’une re duction significative de la somno-
improved concentration and better social and intimate inter- lence diurne (e valuee par le questionnaire d’Epworth), mais
actions [16]. Close on 90% of patients are satisfied with the aussi d’une ame lioration de la qualite de vie [15], avec notam-
outcome of the procedure [17]. However, given the major ment une meilleure capacite de concentration, une meilleure
advancement of the maxillomandibular skeleton, facial interaction sociale et intime [16]. Pre s de 90 % des patients
changes are bound to occur following surgery [16–22]. sont satisfaits des re sultats de l’intervention [17]. Cependant,
Depending on the patient’s morphology and age, these compte tenu de l’importance de l’avance e du squelette
changes can be beneficial [22,23]. However, negative impacts maxillomandibulaire, une modification faciale accompagne
have also been reported, such as an excessively protrusive necessairement l’intervention [16–22]. En fonction de la mor-
profile [18–25], a bulging upper lip and widening of the nos- phologie et de l’a ^ge du patient, ces changements peuvent e ^tre
trils and nasal base [18–24]. It is advisable to adapt the MMA be nefiques [22,23] mais des effets de le
teres ont cependant
surgical technique [18,19,25–28], and to ensure orthodontic aussi e te
souligne s, comme la cre ation d’un profil exage re
-
preparation [24,29] in order to reduce unesthetic results of this ment protrusif [18–25], un aspect bombe de la le vre
kind. supe rieure et un e largissement de la base du nez et des
narines [18–24]. Une adaptation de la technique chirurgicale
de l’AMM est pre conise e pour re duire ces caracte res inesthe -
tiques [18,19,25–28], ainsi qu’une pre paration orthodontique
[24,29].
Some surgeons recommend a stringent selection of patients, Certains chirurgiens recommandent une stricte se lection des
admitting only those who are objectively retrognathic or doli- patients, qui doivent e ^tre objectivement re trognathes ou doli-
chofacial [30–33], while others have extended the indications chofaciaux [30–33], alors que d’autres ont e tendu les indica-
to patients with no skeletal anomalies [34,35]. tions aux patients exempts d’anomalie squelettique [34,35].

The aim of this study was to assess profile changes in a sample L’objectif de cette etude e tait d’e
valuer les modifications du
of consecutive apneic patients treated by MMA surgery in profil dans un e chantillon de patients apne iques conse cutifs
order to measure their perception regarding these changes s par chirurgie d’AMM, de mesurer leur perception de ces
traite
and to compare their opinions with that of several different modifications et de la comparer à celle de diffe rents jurys.
panels. Secondarily, the aim was to determine the existence of L’objectif secondaire e tait de determiner l’existence de fac-
skeletal, cutaneous or dental predictors regarding the esthetic teurs pre dictifs, squelettiques, cutane s ou dentaires, sur
outcome of the procedure as the patients exhibited a wide l’issue esthetique de l’intervention, car les patients pre
sentai-
range of morphologies. ent une grande varie te
morphologique.
Materials and methods riels et me

Mate thodes
The sample
Echantillon
Fifteen consecutive male patients suffering from OSAS (mean Quinze patients masculins conse cutifs atteints de SAOS (a ^ge
age: 42 [20–59], mean BMI: 26.60 kg/m2 [22–29], mean initial moyen 42 ans [20–59], d’IMC 26,60 kg/m2 [22–29], IAH
AHI of 50.9 [19–85]) underwent MMA by the same surgeon. moyen de 50,9 [19–85]) ont e te
ope re
s d’AMM, effectue es
They were assessed using digitalized photographs of the face, par le me ^me chirurgien. Ils ont e te
evalue s avec des photo-
lateral headfilms and pre- and post-surgery polysomnographic graphies nume rise
es du visage, des te le
radiographies de
recordings: electroencephalogram, electrooculogram, sub- profil et des enregistrements polysomnographiques pre - et
mental electromyography, measurements of chest and abdom- postope ratoires : electro-ence phalogramme, e lectro-oculo-
inal movements, respiratory inductance (plethysmography), gramme, e lectromyographie sous-mentonnie re, mesure des
arterial oxygen saturation and oronasal ventilation measure- mouvements thoraciques et abdominaux, inductance respira-
ments. Seven patients received orthodontic preparation before toire (plethysmographie), saturation arte rielle en oxyge ne et
the procedure. Two others had an orthodontic medical history mesure des flux ventilatoires oronasaux. Sept patients ont
with extracted premolars. be ne
ficie
d’une pre paration orthodontique pour l’intervention ;
deux autres patients pre sentaient des ante cedents orthodon-
tiques avec extraction de pre molaires.
Self-assessment questionnaires Autoquestionnaires
A validated questionnaire was sent out to all patients in order Un questionnaire valide ae te
envoye à tous les patients, pour
to assess their interpretation of the changes in their facial valuer leur interpre
e tation des changements de leur appar-
appearance and their feelings regarding the procedure (trans- ence faciale et leurs sentiments au sujet de la chirurgie (traduit
lated from Finlay et al. [36]). The questionnaire was sent at te
de Finlay et al. [36]). Il a e envoye au moins trois mois apre s
least 3 months after surgery to allow time for facial soft tissue la chirurgie, le temps de la cicatrisation des tissus mous
to heal and, above all, for the edema to subside. faciaux et notamment de la re gression de l’œde me.
Profile analysis ^te sur les profils

Enque
Patients’ profiles were obtained from digital photographs Les profils des patients ont e te
extraits de photographies
using the PhotoshopÔ (Windows) photography software nume riques, en utilisant le logiciel photographique
application. The profiles were enlarged and turned, avoiding Photoshop 7Ô (Windows). Les profils ont e te
agrandis et
distortion, in order to obtain exactly the same pre- and post- tourne s, sans de formation, afin d’atteindre exactement les
surgery scales and orientations (fig. 1). To prevent the differ- me ^mes e chelles et orientation du visage avant et apre s la
ent panels being influenced by changes of skin appearance or chirurgie (fig. 1). Pour que les diffe rents jurys ne soient pas
hairstyle between the two images, the soft-tissue profiles were influence s par l’apparence de la peau ou les modifications de
blackened and were superimposed on the posterior region of coiffure entre les deux prises de vue, les profils cutane s ont e
te

the skull of the initial photograph (fig. 2), parallel to the peints en noir et ont e te
superpose s sur la re
gion poste
rieure
Frankfurt plane in order to create composite images. du cra ^ ne de la photographie initiale (fig. 2), paralle lement au
plan de Francfort, pour cre er des images composites.
The darkened outlines of these profiles were shown in pairs, Les ombres de ces profils ont e te pre
sente es par paires, de
randomly in position A or B (pre- and post-surgery), to sepa- façon randomise e en position A ou B (pre - et postoperatoire)
rate juries comprising lay persons (n = 50), orthodontists à un jury de profanes (n = 50), d’orthodontistes (n = 40) et
(n = 40) and art students (students at the Fine Arts School in d’etudiants en art (e tudiants des Beaux-Arts de Paris,
Paris) (n = 50). For each pair of profiles, the panels were n = 50). Les jurys ont e te
invite
s, pour chaque paire de profils,


[(Fig._1)TD$IG]
Fig. 1: Facial changes associated with maxillomandibular advance-

ment (MMA) surgery on lateral photographs. Left: preoperative; right:
postoperative.
es à l’avance
Fig. 1 : Modifications faciales associe e maxillomandibu-
laire sur des photographies de profil. À gauche : pre ope ratoire, à
droite : postoperatoire.
[(Fig._2)TD$IG]
Fig. 2: Soft tissue profiles obtained from lateral photographs: a: pre-

operative; b: postoperative; c: superimposition of preoperative and post-
operative profiles; d: combination postoperative profile (blue circle) with
the same preoperative haircut and cervical outline (red circles).
Fig. 2 : Profils cutane s extraits des photographies de profil : a :
ope
pre ratoire ; b : postoperatoire ; c : superposition des profils pre- et
ratoires ; d : composite du profil postope
postope ratoire (cercle de bleu)
conservant la coiffure et le contour cervical preope ratoires (cercle
s de
rouge).
invited to tick the profile they found more pleasant (fig. 3) and cie
à cocher le profil le plus appre (fig. 3) et à de
finir de façon
to indicate which ones they found the most and the least globale le plus plaisant et le plus de plaisant de tous. Aucune
pleasant of all of them. No response was to be omitted even ponse ne devait e
re ^tre omise, me^me si aucun des deux profils
if they found neither of the two profiles attractive. The panels ne semblait beau. Les jurys n’e taient pas informe s de l’exis-
were not informed about the surgery or OSAS. The question- tence d’une chirurgie ou du SAOS. Les questionnaires e taient
naires were anonymous and bore only the age and gender of anonymes et ne mentionnaient que l’a ^ge et le sexe des juges.
the panelists.
Cephalometric analysis phalome

Analyse ce trique
In order to limit differences due to enlargement and inaccurate Afin de reduire les e
carts de grossissement et les erreurs de
head positions, the headfilms were obtained at a distance of positionnement de la te ^te, les te
le
radiographies ont e te
obte-
4 m (French standard) with the patients in an upright position nues à une distance de 4 m (norme française) avec les
in a cephalostat and looking straight ahead. patients en position debout, dans un ce phalostat et regardant
droit devant eux.
Two manually drawn tracings on acetate paper provided direct Des trace s manuels sur ace tate ont permis des mesures
measurements, using Tweed analysis as modified by Prinsell directes, selon l’analyse de Tweed modifie e par Prinsell [16]
[16](fig. 4) for landmark definitions, with values of angles (fig. 4) pour les de finitions reperes, avec les mesures des
SNA, SNB, ANB, FMA and MPH (distance from the hyoid angles SNA, SNB, ANB, FMA et les mesures millime tre
es

[(Fig._3)TD$IG]
Fig. 3: Profiles of 15 OSAS patients, randomized in relation to maxillomandibular advancement

(MMA) surgery, as presented in the survey.
s de 15 patients apne
Fig. 3 : Profils cutane iques conse
cutifs, pre
sente
s de façon randomise e en
position A ou B avant ou apre s la chirurgie d’avancee maxillomandibulaire, tels que pre sentes
tude.
dans l’e [(Fig._4)TD$IG]
Fig. 4: Tweed’s cephalometric analysis modi-

fied by Riley and Powell for OSAS patients,
using landmarks S (Sella), Na (Nasion), A, B,
angular measurements (SNA, SNB) and linear
measurements (PAS and MPH). Vertical diver-
gence is given by FMA angle value.
Fig. 4 : Analyse ce phalome trique de Tweed
e par Riley et Powell pour le SAOS, utili-
modifie
sant les points S (Sella), Na (Nasion), A, B, les
mesures angulaires de SNA, SNB et line aires
PAS et MPH. La mesure de la divergence faciale
est donnee par l’angle FMA.


[(Fig._5)TD$IG]
Fig. 5: Computerized architectural analysis according to Delaire used for maxillary and mandibular protrusion analysis (Tridim softwareÔ,
Orqual, France): a: cephalometric landmarks; b: customized skeletal frame.
Fig. 5 : Analyse architecturale informatise e de Delaire utilise
e pour l’e
valuation de la protrusion maxillaire et mandibulaire (logiciel TridimÔ,
res ce
Orqual, France), a : repe phalome
triques ; b : trace
architectural individualise
.
bone to mandibular margin) graduated in millimeters, PAS de MPH (distance de l’os hyoı̈de au bord mandibulaire), PAS
(distance between the walls of the pharynx at the narrowest (distance entre les parois pharynge es au niveau le plus e troit),
point), ANS-PNS (length of the palatal plane) and Go-GN ANS-PNS (longueur du plan palatin) et Go-GN (longueur du
(length of the mandibular body). Delaire’s computerized corpus mandibulaire). L’analyse architecturale informatise e
architectural analysis (TridimÔ, Orqual, France) was per- de Delaire (TridimÔ, Orqual, France) a e te
faite apres
formed following digitalization of the photos (Epson nume risation des cliches (scanner Epson Perfection V700)
Perfection V700 scanner) and positioning of the orthognathic et positionnement des points de l’analyse orthognathique
analysis points (fig. 5). The amount of skeletal protrusion and (fig. 5). Le degre de protrusion squelettique et de de calage
the sagittal discrepancy of the bases (in degrees) were des bases (en degre s) ont e
te
releves (fig. 6). La protrusion
recorded (fig. 6). Labial protrusion was assessed using the labiale a e te
evalue
e d’apres la ligne de Ricketts (distance en
Ricketts line (the distance in millimeters between line E millimetres entre la ligne E, passant par la pointe du nez
passing through the tip of the nose Pronasal and the cutaneous Pronasal et le Pogonion cutane ) et la mesure de l’angle naso-
Pogonion) and the nasolabial angle. All the manual and com- labial. Toutes les analyses, manuelles et informatise es, ont
puterized analyses were done by the same operator. te
e faites par le me^me ope rateur.
Statistics Statistiques
Patients’ morphological data and sleep recordings were trans- Les donne es morphologiques et les enregistrements de
ferred to a spreadsheet (Excel for Windows) and Wilcoxon sommeil des patients ont e te
transfe re
s dans un tableau
matched pairs tests were used to determine the significance (Excel for Windows), et les tests de Wilcoxon en se ries appa-
of pre- and post-surgery differences (software R version 2.15.1 riees ont e te
utilises pour de terminer le caracte re significatif
combined with TinnR Editor software, version 2.3.7). Chi2 des diffe rences avant et apre s chirurgie (logiciel R version
tests for homogeneity were done in order to analyze the cor- 2.15.1 associe au logiciel TinnR Editor version 2.3.7). Des
relation between the different panels and check on the impact tests de Khi2 d’homoge ne
ite
ont e te
re
alise
s afin d’e
tudier la
of panelists’ age (over/less than 30) and of their gender. For all corre lation qui existait entre les diffe rents jurys et ve rifier
tests, a first order error of a = 5% was selected. The Ho l’influence de leur a ^ge (plus ou moins de 30 ans) ou de leur
hypothesis (the two samples are homogenous) was then le sexe. Pour tous les tests, une erreur de premier ordre
retained when the probability was P > 0.05. The H1 hypoth- a=5 %a e te
choisie. L’hypothe se Ho (les deux e chantillons
esis (the two samples are not homogenous) was validated when sont homoge nes) e tait alors retenue lorsque la probabilite
P 0.05. p > 0,05. L’hypothe se H1 (les deux e chantillons ne sont pas
homoge nes) e tait valide
e lorsque p 0,05.
Results sultats
Re
Impact of MMA on OSAS Effets de l’AMM sur le SAOS
AHI dropped from 51.07 W 15.21 to 10.3 W 7.24 per hour L’IAH passait de 51,07 W 15,21 à 10,3 W 7,24 par heure apres
following MMA (P < 10 4) (Table I). Thus, the success rate AMM (p < 10 4) (Tableau I). Le taux de re ussite de l’AMM sur

[(Fig._6)TD$IG]
Fig. 6: Protrusion of maxilla before and after maxillomandibular

advancement (MMA).
s AMM (analyse de
Fig. 6 : Protrusion du maxillaire avant et apre
Delaire).
of MMA against OSAS was 80% in this series (12/15), success le SAOS e tait ainsi de 80 % dans cette se rie (12/15) conside r-
being defined as an AHI less than 15. The three other patients ant le succe s comme un IAH infe rieur à 15. Les trois autres
in the series presented a drop in AHI of at least 50%. Sleep patients de la se rie pre
sentaient une re duction de l’IAH d’au
efficacy was improved following MMA (P < 0.01), as was moins 50 %. L’efficacite de sommeil e tait ameliore
e apre s
oxygen saturation. The lowest oxygen saturation level rose AMM (p < 0,01), paralle lement à une meilleure saturation
from 79.5 W 13 to 82.2 W 5.4%. There was also a reduction en oxyge ne : augmentation de la saturation la plus basse
in the number of desaturations below 90% from 8.9 W 18 to (de 79,5 W 13 à 82,2 W 5,4 %) et re duction du nombre de
0.5 W 1.4. desaturations infe rieures à 90 % (de 8,9 W 18 à 0,5 W 1,4).
The drowsiness index, assessed using the Epworth scale, fell La somnolence, e valuee par l’e
chelle d’Epworth, passait d’un
from 12.3 W 5.0 to 3.9 W 2.8, thus marking a significant indice de 12,3 W 5,0 à 3,9 W 2,8, signant une ame lioration
improvement in daytime symptoms (P < 10 4). We noted a significative des sympto ^mes diurnes (p < 10 4). On observait
slight weight loss follows the procedure, with the BMI slipping ge
une le re re
duction ponde rale apre
s chirurgie, l’IMC passant
from 27.41 W 3.5 kg/m2 to 25 W 2.6 kg/m2 (NS). de 27,41 W 3,5 kg/m2 à 25 W 2,6 kg/m2 (NS).
Self-assessment questionnaires Autoquestionnaires
All patients were satisfied with the result of their surgery in Tous les patients ont e te
satisfaits du resultat de la chirurgie
terms of their OSAS (9/15 satisfied, 6/15 very satisfied). All sur le SAOS (9/15 satisfaits, 6/15 tre s satisfaits). Tous ont
stated that they enjoyed a better quality of life (better 10/15, clare
de une meilleure qualite de vie (meilleure 10/15, beau-
much better 5/15). Twelve out of 15 experienced improved coup mieux 5/15), 12 sur 15 notaient une meilleure capacite de
concentration. concentration.
All patients save one (14/15) were satisfied with their esthetic Tous les patients sauf un (14/15) ont e te
satisfaits du re
sultat
outcome. More precisely, three out of 15 either did not notice esthetique. Plus pre cise
ment, trois sur 15 n’ont pas remarque
or were not concerned about any change and 11 out of 15 noted ou ne se souciaient pas d’un changement et 11 sur 15 ont note
an improvement after the procedure. Improvements related to une ame lioration apre s chirurgie. L’ame lioration portait sur le
the nose (6/15), the upper lip (6/15) and the lower lip (4/15). nez (6/15), la le vre supe rieure (6/15) et la levre infe
rieure (4/
The dissatisfied patient noted a worse appearance of nose and 15). Le patient insatisfait notait une de te
rioration de l’aspect
upper lip. All the patients who had received orthodontic treat- du nez et de la le vre supe rieure. Tous les patients ayant suivi
ment found their result esthetically satisfactory, with the un traitement orthodontique se trouvaient esthe tiquement
exception of one who observed no change. ameliores, à l’exception d’un seul qui se trouvait inchange .


Table I Tableau I
Effects of maxillomandibular advancement (MMA) on sleep tres
Effets de l’AMM sur le sommeil et sur les parame
and morphological parameters in the studied sample. morphologiques dans l’e chantillon e
tudie
.
Before surgery/ After surgery/ P

eratoire
Preop
Postoperatoire
Mean/Moyenne Mean/Moyenne
SD/E cart-type SD/E cart-type

Sleep parameters/Parametres du sommeil
AHI (events/h)/IAH (h) 51.07 W 15.21 10.3 W 7.24 7.2 10 4**
Sleep efficiency (%)/Efficacite sommeil (%) 72 W 18 89 W 6 0.01*
LSAT (%) 79.5 W 13 82.2 W 5.4 0.3
Desat < 90% 8.9 W 18 0.5 W 1.4 0.11
ESS/Score Epworth 12.3 W 5.0 3.9 W 2.8 7.1 10 4**
Skeletal changes/Modifications squelettiques
SNA ( ) 82.80 W 3.31 89.13 W 3.31 6.8 10 4**
SNB ( ) 78.26 W 4.35 84.66 W 3.38 6.9 10 4**
ANB ( ) 4.53 W 1.92 4.40 W 1.42 0.69
FMA ( ) 23.13 W 7.19 20.27 W 8.04 0.03
MPH (mm) 25.44 W 4.41 18.33 W 2.90 0.001**
PAS (mm) 6.89 W 2.99 12.4 W 3.02 7.2 10 4**
Maxillary protrusion/Protrusion maxillaire ( ) 0.3 W 7.2 5.3 W 5.5 0.003*
Mandibular protrusion/Protrusion mandibulaire ( ) 4 W 6.3 0.5 W 4.09 0.002*
Soft tissue changes/Modifications T mous
NL Angle/Angle NL ( ) 96.7 W 18.7 91.0 W 22.8 73
Lower lip/E (mm) 0 W 2.0 mm/Levre inf./E (mm) 0 W 2,0 mm 3.46 W 2.53 2.26 W 2.37 0.024*
Upper lip/E (mm) - 1 W 2.0 mm/Levre sup./E (mm) - 1 W 2,0 mm 4.67 W 2.69 2.87 W 2.47 0.009*
BMI/IMC (kg/m2) 27.41 W 3.5 25 W 2.6 0.02
AHI: apnea hypopnea index (per hour of sleep); BMI: body mass index; ESS: Epworth sleepiness scale; MMA: maxillomandibular advancement; OSAS: obstructive sleep apnea
syndrome.
es hypopne
IAH : indice d’apne es (par heure de sommeil) ; IMC : indice de masse corporelle ; score Epworth : indice de somnolence d’apre
s le questionnaire d’Epworth ; AMM : avance
e
maxillomandibulaire ; SAOS : syndrome d’apne es obstructives du sommeil.
Five patients noted a change in the appearance of their teeth: Cinq patients ont note une modification de leur apparence
two found their dental situation was worse (no orthodontic dentaire : deux ressentaient une de te
rioration (non pre pare
s
preparation); three noted an improvement (of which only one orthodontiquement), trois notaient une ame lioration (dont un
had received orthodontic preparation). orthodontiquement).
seul traite
Morphological changes Modifications morphologiques
The mean surgical advancement was 9.3 mm, (3.0 to L’avance e chirurgicale moyenne a e te
de 9,3 mm (3,0
12.0 W 2.4) for the maxilla and 10.82 mm (10.0 to 14.0 W 1) à 12,0 W 2,4 mm) pour le maxillaire et 10,82 mm (10,0
for the mandible. One patient received advancement genio- à 14,0 W 1 mm) pour la mandibule. Un patient a be ne
ficie

plasty and another had a chin prosthesis removed. Within this d’une ge nioplastie d’avance e et un autre de l’ablation d’une
sample, nine patients had been orthodontically prepared (spe- prothe se mentonnie re. Au sein de cet e chantillon, neuf
cifically for the surgery, n = 7, orthodontic preparation alone, patients avaient e te
pre
pares orthodontiquement (spe cifique-
n = 2). Six patients had received premolar extractions in the ment pour la chirurgie, n = 7, ante cedents de pre paration,
course of orthodontic treatment. The other treated cases pre- n = 2). Des extractions de pre molaires avaient e te
re
alisees
sented with a Class II, division 2 and were decompensated pour six patients dans le cadre orthodontique. Les autres cas
without extractions. s pre
traite sentaient une malocclusion de Classe II division 2 et
leur decompensation a e te
re
alise
e sans extraction.
Tweed analysis showed that the maxilla was well situated D’apre s l’analyse de Tweed, le maxillaire e tait pluto
^t bien place
before surgery (SNA of 82.80 W 3.31, for a norm of avant chirurgie (SNA de 82,80 W 3,31, pour une norme de
81 W 3), and became significantly protrusive following 81 W 3) et devenait significativement protrusif apre s AMM

MMA (SNA of 89.13 W 3.31; P < 10 4). The mandible was (SNA de 89,13 W 3,31 ; p < 10 4). La mandibule e tait initia-
initially well located and even slightly posterior in relation to lement bien place e, voire le
ge rement reculee par rapport à la
the cranial base (SNB of 78.3 W 4.3 for a norm of base du cra ^ ne (SNB de 78,3 W 4,3 pour une norme de
79.0 W 3.0), and became protrusive following surgery (SNB
79,0 W 3,0) et devenait protrusive apre s chirurgie (SNB de
of 84.7 W 3.4; P < 10 4). The maxillomandibular sagittal 84,7 W 3,4 ; p < 10 4). Le de calage sagittal maxillomandibu-
discrepancy showed a Class II tendency (preoperative ANB laire e tait de tendance Classe II (ANB pre operatoire de
of 4.5 W 1.9 for a norm of 2 W 2) and remained generally the 4,5 W 1,9 pour une norme de 2 W 2), pour rester globale-
same after surgery (postoperative ANB of 4.4 W 1.4, a non- ment le me ^me apre s chirurgie (ANB postope ratoire de
significant difference). 4,4 W 1,4 diffe rence non significative).
According to Delaire’s architectural analysis, seven out of 15 D’apre s l’analyse architecturale de Delaire, sept sur 15
cases displayed maxillary retrusion prior to surgery, four out of presentaient une re trusion maxillaire avant l’intervention, dont
15 of which with 5 ; six out of 15 had a well-placed maxilla quatre sur 15 en deçà de 5 ; six sur 15 avaient un maxillaire
and two out of 15 already exhibited more than +5 of protru- bien place et deux sur 15 pre sentaient dejà une protrusion de
sion (fig. 6). Regarding the mandible, 11 out of 15 presented plus de +5 (fig. 6). Au niveau mandibulaire, 11 sur 15 pre sen-
with retrusion, eight out of 15 of whom with less than 5 fig. taient une re trusion, dont huit sur 15 en deçà de 5 (fig. 7).
7(fig. 7). Following surgery, 12 out of 15 displayed maxillary Apre s chirurgie, 12 sur 15 pre sentaient une protrusion max-
protrusion and six out of 15 mandibular protrusion. A illaire et six sur 15 une protrusion mandibulaire. La compa-
comparison of the sagittal discrepancies obtained using both raison des de calages sagittaux obtenus par les deux
methods of cephalometric analysis is shown in Table II. me thodes d’analyse ce phalome trique est presentee dans le
Tableau II.
Analysis of each individual case revealed that the changes in En analysant chaque cas particulier, la modification des
the maxillomandibular sagittal relationships were varied relations sagittales maxillomandibulaires e tait varie
e (fig. 8),
(fig. 8), as were vertical changes (approximate 3 reduction de me ^me que la modification verticale (re duction du FMA de
of FMA, only slightly significant at P = 0.03). Patients who l’ordre de 3 , faiblement significative, p = 0,03). Les patients
had been prepared orthodontically are shown by an asterisk ayant be ne ficie d’une pre paration orthodontique sont
and by the blue tracings. repre sente s avec un aste risque et en trace s bleus.
Posterior pharyngeal space increased significantly (PAS rose L’espace pharynge posterieur augmentait significativement
from 6.9 W 3 mm to 12.4 W 3 mm) and the hyoid bone was (PAS passant de 6,9 W 3 mm à 12,4 W 3 mm) et l’os
[(Fig._7)TD$IG]
Fig. 7: Protrusion of mandible before and after maxillomandibular

advancement (MMA).
s AMM (analyse de
Fig. 7 : Protrusion de la mandibule avant et apre
Delaire).


Table II Tableau II
Comparison of maxillomandibular protrusion as shown by Comparaison de la protrusion maxillomandibulaire avec les
Tweed’s and Delaire’s cephalometric analyses. phalome
analyses ce triques de Tweed et de Delaire.
Tweed analysis/Analyse de Tweed Delaire analysis/Analyse de Delaire

Maxillary protrusion Mandibular protrusion Maxillary protrusion Mandibular protrusion
normal to excessive/ normal to excessive/ normal to excessive/ normal to excessive/
Protrusion maxillaire Protrusion mandibulaire Protrusion maxillaire Protrusion mandibulaire
normale ou excessive normale ou excessive normale ou excessive normale ou excessive
Before surgery/ 9/15 7/15 2/15 4/15
Avant chirurgie 60% 46.6% 13.3% 26.6%
After surgery/ 14/15 13/15 12/15 6/15
chirurgie
Apres 93.3% 86.6% 73.3% 40%
higher following MMA, the mean distance from the mandibu- hyoı̈de e tait ascensionne apres AMM, la distance au bord
lar margin falling from 25.4 W 4.4 mm to 18.33 W 2.9 mm. mandibulaire passant en moyenne de 25,4 W 4,4 mm
à 18,33 W 2,9 mm.
Regarding facial soft tissue, the mean reduction of the nasio- Au niveau des tissus mous faciaux, la re duction moyenne de
labial angle was 5.7 ( 27 ; 14 ) and displayed wide var- l’angle nasolabial e tait 5,7 ( 27 ; 14 ) et montrait une
iability from one individual to another (fig. 9). grande variabilite entre les individus (fig. 9).
Before surgery, the majority of patients exhibited retrocheilia Avant chirurgie, les patients pre sentaient majoritairement une
of both lips, the mean distance from Ricketts’ esthetic line bire trocheilie, la distance moyenne par rapport à la ligne
being 3.5 W 2.5 mm for the lower lip (norm 0 W 2 mm, with esthe tique de Ricketts e tait de 3,5 W 2,5 mm pour la le vre
the lip flush with the line), and 4.7 W 27 mm for the upper rieure (norme 0 W 2 mm, la le
infe vre devant affleurer la ligne)
lip (norm 1 W 2 mm, with the lip behind the line). Major et de 4,7 W 2,7 mm pour la le vre supe rieure (norme
[(Fig._8)TD$IG]
Fig. 8: Sagittal skeletal discrepancy before and after maxilloman-

dibular advancement (MMA).
calage sagittal maxillomandibulaire avant et apre
Fig. 8 : De s AMM
(analyse de Delaire).

[(Fig._9)TD$IG]
Fig. 9: Nasolabial angle changes after maxillomandibular advance-

ment (MMA).
s AMM.
Fig. 9 : Modifications de l’angle nasolabial apre
disparities are observed with upper labial retrusion ranging 1 W 2 mm, la le vre devant e ^tre en retrait de la ligne). De
from 1 mm to 9 mm and lower lip retrusion from 0 to grandes disparite s existaient, avec une re trusion labiale
7 mm. supe rieure allant de 1 mm à 9 mm et une re trusion
rieure de 0 à 7 mm.
infe
After surgery, the mean changed, respectively, by Apres chirurgie, la moyenne passait respectivement de
2.3 W 2.4 mm for the lower lip and 2.9 W 2.5 mm for the 2,3 W 2,4 mm pour la le vre infe
rieure et 2,9 W 2,5 mm pour
upper. Four out of 15 patients exhibited noticeable procheilia vre supe
la le rieure. Quatre patients sur 15 pre sentaient une
after the procedure (No. 1, 2, 9 et 15). nette procheilie apre
s l’intervention (no 1, 2, 9 et 15).
Evaluation by different panels

Evaluation rents jurys
par diffe
Hundred and twenty questionnaires were completed and te

Cent vingt questionnaires ont e remplis et analyse
s.
analyzed.
Postoperative profiles were preferred by 85% of panel mem- Les profils postope ratoires ont e te pre
fe
re
s par 85 % du jury
bers overall (P < 0.001). Chi2 tests for homogeneity with 38 ge ne
ral (p < 0,001). Des tests de Khi2 d’homoge neite
à 38
degrees of freedom were performed on the choice of post- or degre s de liberte ont e te
effectues concernant le choix du
preoperative profiles between the orthodontists, artists and the profil post- ou pre ope ratoire, entre les orthodontistes, les
panel of lay people (Table III). In all the tests we kept a null artistes et le groupe de profanes (Tableau III). Pour tous les
hypothesis, H0: samples are taken from the same population, tests realises, nous avons garde l’hypothe se nulle H0 : les
the difference in choices between them is not significant. chantillons sont issus d’une me
e ^me population, la diffe rence
des choix entre eux n’est pas significative.
Two Fisher tests with 19 degrees of freedom were done to Deux tests de Fisher à 19 degre s de liberte ont e
te
effectue s
compare the choices made by men as opposed to women, pour confronter les pre fe
rences des hommes avec celles des
and by the “under 30s” versus the “over 30s”. Neither showed femmes et celles des « moins de 30 ans » avec celles des
any significant differences between the groups (P > 0.05). « plus de 30 ans » et n’ont pas montre de diffe rence signifi-
cative entre les groupes (p > 0,05).
Patients having undergone previous premolar extractions Les patients aux ante ce dents d’extraction de pre molaires
(9/15) were preferred post-surgery in 80% of cases. No (9/15) ont e te
pre
fe
re
s apre s chirurgie dans 80 % des cas.
skeletal predictors of esthetic outcome were found. Aucun facteur pre dictif squelettique de l’issue esthe tique n’a
However, it would appear, from examining the most attractive te
e trouve. Il apparaı̂t cependant, en examinant les ombres


Table III Tableau III

Comparison of profile preference according to different fe
Comparaison des pre rences en fonction des groupes de
panels. juges.

Compared groups/Groupes compares Probability/Probabilite Conclusion/Conclusion
Art students/Orthodontists P = 0.99 Ho: samples are no different
E tudiants en Art/Orthodontistes Ho : les echantillons sont homogenes
Art students/Lay persons P = 0.94 Ho: samples are no different
E tudiants en Art/Hommes de la rue Ho : les echantillons sont homogenes
Orthodontists/Lay persons P = 0.99 Ho: samples are no different
Orthodontistes/Hommes de la rue Ho : les echantillons sont homogenes
[(Fig._10)TD$IG]
Fig. 10: Most-liked postoperative profiles (red boxes). Note the

preoperative lip retrusion compared with the Ricketts E line, and
the normal-to-open nasolabial angle.
s postope
Fig. 10 : Profils cutane ratoires juge
s les plus beaux (dans les
cadres rouges). Noter la pre sence, en postope ratoire, d’une re
trusion
tique de Ricketts et un angle naso-
labiale par rapport à la ligne esthe
labial ouvert ou normal.

shaded profiles (fig. 10) and those deemed least attractive des profils les plus plaisants (fig. 10) et ceux juge s les plus
(fig. 11), that a number of cutaneous characteristics are deplaisants (fig. 11) que certaines caracte ristiques cutane es
unanimously preferred. soient unanimement pre fe
re
es.
The postoperative profile was systematically given preference Le profil postoperatoire etait systematiquement pre fe
re
par la
by the majority of the panelists in 12 out of 15 patients. majorite des juges pour 12 des 15 patients. Le profil post-
Globally speaking, the postoperative profile of patients operatoire des patients no 2, 9 et 10 e tait globalement moins
No. 2, 9 and 10 were given lower scores: bien note :
— the panel comprising orthodontists (n = 40) preferred the — le jury compose d’orthodontistes (n = 40) pre fe
rait dans
postoperative profile in 90% of cases but preferred the preop- 90 % des cas le profil postope ratoire mais s’accordait sur la
erative profile of patients No. 9 and 10 (75% and 60% of pre fe
rence du profil pre ope ratoire des sujets no 10 et 9
preferences, respectively); (respectivement 75 % et 60 % de pre fe
rence) ;
— the lay panel, i.e. comprising the man or woman in the — le jury de profanes, compose d’« hommes de la rue »
street (n = 40), gave preference in 90% of cases to the post- (n = 40), optait dans 90 % des cas pour le profil post-
operative profile. In contrast, the preoperative profiles of operatoire. En revanche, le profil pre operatoire des patients
patients No. 9 and 10 received clearly preference, with 75% no 10 et 9 e tait largement pre fe
re
, avec un pourcentage
and 63% of favorable opinions, respectively; respectif de 75 % et de 63 % ;
[(Fig._1)TD$IG]
Fig. 11: Most-disliked postoperative profiles (red boxes). Note the

preoperative lip protrusion according to Ricketts E line, and/or clo-
sure of nasolabial angle.
s postope
Fig. 11 : Profils cutane ratoires juge
s les moins beaux (dans
les cadres rouges). Noter la pre sence, en pre operatoire, d’une protru-
sion labiale par rapport à la ligne esthe tique de Ricketts (le vres au
contact) et/ou d’une fermeture de l’angle nasolabial.


— the panel comprising art students (n = 40) leaned in favor — le jury compose d’e tudiants en art (n = 40) penchait en
of the postoperative profile in 80% of cases. However, there faveur du profil postope ratoire dans 80 % des cas.
was a clear preference for the preoperative profile of patients Cependant, la pre fe
rence du profil pre operatoire etait nette
No. 2 and 10 with, respectively, 55% and 68% of preferences. pour les patients no 2 et 10 avec respectivement 55 % et
68 % des se lections.
Analysis of the three profiles which had been considerably En analysant ces trois profils particuliers, sensiblement
worsened by MMA revealed procheilia of both lips (touching aggrave s par l’AMM, on note qu’ils pre sentaient une
or exceeding the E line), visible closure of the nasolabial angle biproche ilie (au contact ou de passant la ligne E), une nette
and a nose which appeared fairly small. Prior to treatment, fermeture de l’angle nasolabial, le nez apparaissant assez
these patients were also characterized by a relatively short duit. Les patients avaient e
re galement comme caracte ristique
face. de pre senter une face assez courte avant traitement.
Those profiles which were held to be most attractive (patients Les profils les plus appre cie
s (patient no 1, no 3 et no 14)
No. 1, 3 and 14) were characterized by a fairly rectilinear avaient pour caracte ristique commune un profil sous-nasal
subnasal profile, with lips meeting virtually at a right angle assez rectiligne, les le vres s’affrontant quasiment à angle droit
to the nose, which was relatively pronounced. Analysis of their par rapport au nez, relativement marque . En analysant leur
preoperative profiles revealed distinct labial retrusion and/or ope
profil pre ratoire, ils pre
sentaient une nette re trusion labiale
an open nasolabial angle. et/ou une ouverture de l’angle nasolabial.
Discussion Discussion
Morphology and MMA-induced changes Morphologie et modifications induites par l’AMM
Since the 1980s, it has been shown that MMA surgery is À partir des anne es 1980, il a e te
montre que la chirurgie
considerably more effective than mandibular advancement d’AMM e tait nettement plus efficace que l’avance e mandibu-
alone in patients suffering from OSAS, thus pinpointing a laire isole e chez les patients atteints de SAOS, refle tant une
possible deficiency of the entire maxillomandibular complex possible de ficience de l’ensemble du complexe maxillomandi-
[11]. For this reason, and given the underlying obstructive bulaire [11]. Pour cette raison, et compte tenu de la sous-
pathology, patients presenting skeletal Class II discrepancies jacente pathologie obstructive, les patients pre sentant des
associated with mandibular retrusion underwent not only man- decalages de classe II squelettique avec re tromandibulie
dibular advancement osteotomy. Furthermore, the efficacy of n’ont pas seulement be ne
ficie
d’une oste otomie d’avance e
MMA on OSAS is likely correlated to the degree of maxillary mandibulaire. Plus encore, l’efficacite de l’AMM sur le SAOS
advancement, with an odds ratio of 1.97 per millimeter of serait me ^me corre le
e au degre d’avancement maxillaire, avec
advancement [10]. Although some authors initially advocated un Odds ratio (ou risque relatif rapproche ) de 1,97 par milli-
MMA only for patients with craniofacial anomalies [31,32], me tre d’avance e [10]. Si pour un certain nombre d’auteurs
most often Class II anomalies with retrognathia, this procedure l’AMM e tait initialement destine e aux patients atteints
can also be envisaged for dental and skeletal Class I patients d’anomalies craniofaciales [31,32], constitue es majoritaire-
with cephalometrically normal maxillomandibular protrusion ment d’anomalies de classe II avec re trognathie, cette inter-
[34,35]. vention peut aussi e ^tre propose e à des patients en classe I
dentaire et squelettique, avec une projection maxillomandibu-
laire ce phalome triquement normale [34,35].
In agreement with the data in the literature, MMA in this series En accord avec les donne es de la litte
rature, l’AMM a e te
dans
was extremely effective for the treatment of OSAS showing an cette se rie tre
s efficace dans le traitement du SAOS, avec une
improvement of sleep parameters and drowsiness scores. The ame lioration des parame tres de sommeil et des scores de
structures within the airways were enlarged (increased PAS) somnolence. Les voies ae riennes ont e te
structurellement
in parallel with the MMA and with the higher position of the largies (augmentation de PAS), paralle
e lement à l’AMM, et
hyoid bone, as a result of the tautening of the muscles at the à l’ascension de l’os hyoı̈de, te moin de la mise en tension
hyoid and base of the tongue [16]. des muscles hyoı̈diens et de la base de langue [16].
Using both conventional cephalometric and architectural Analyse s par une me thode ce phalome trique conventionnelle
analyses, it was observed that patients exhibited a marked et par une analyse architecturale, les patients pre sentaient un
difference in the extent of their maxillomandibular protrusion degre de protrusion maxillomandibulaire sensiblement diffe -
according to the type of analysis used, since the proportion of rent en fonction des analyses utilise es, puisque la proportion
patients considered to be retrusive before the procedure was de patients conside re
s comme re trus avant l’intervention
markedly lower using the Tweed method as opposed to Delaire tait nettement minore
e e par l’analyse de Tweed compare e
analysis (Table II): 74.4% of patients presented a mandibular à l’analyse de Delaire (Tableau II) : 74,4 % des patients
deficit (versus 54.4% with Tweed), and 87.3% showed a presenteraient un de ficit mandibulaire (contre 54,4 % pour

maxillary deficit (versus 40% with Tweed analysis), although Tweed) et 87,3 % un de ficit maxillaire (contre 40 % par l’ana-
the deficits were sometimes only slight. Following surgery, lyse de Tweed), me ^me si ces de ficits etaient parfois le gers.
protrusion was noticeable, particularly at the maxilla (93.3% Apre s l’intervention, la protrusion e tait claire, surtout au niveau
of maxillary protrusions with Tweed versus 73.3% with du maxillaire (93,3 % de protrusion maxillaire pour Tweed
Delaire). Similar differences in results have also been contre 73,3 % pour Delaire). Ces diffe rences de re sultats
described by Vezina et al. [37] in a series of 243 patients with ont e galement e te decrites par Vezina et al. [37], à propos
apnea. Moreover, the authors were able to correlate AHI with d’une se rie de 243 patients apne iques. Les auteurs avaient
the retrusion described by architectural analysis but not with en outre pu corre ler l’IAH avec la re trusion de crite d’apre s
Tweed-type analysis. l’analyse architecturale et non d’apre s l’analyse de Tweed.
These results are accounted for in several ways related to the Ces re sultats ame nent plusieurs explications, qui rele vent de
nature of cephalometric analyses. Delaire analysis assesses a la nature me ^me des analyses ce phalome triques. L’analyse de
subject’s proportions and balance with regard to the cranial Delaire e value les proportions et l’e quilibre de l’individu par
structures (base and vault), the cervical spine and the face rapport aux structures cra ^ niennes (base et voûte) du rachis
[38,39] and builds up an individual frame adapted to the cervical et de la face [38,39] et construit un cadre individuel,
subject’s gender and, in certain cases, their ethnic origin. adapte au sexe et e ventuellement à l’ethnie du sujet. Les
Conventional cephalometric analyses rely on linear and angu- analyses ce phalome triques conventionnelles s’appuient sur
lar measurements and take as their reference mean statistical des mesures line aires et angulaires, et se re fe
rent à des
values derived from large samples. It is possible they are valeurs statistiques moyennes, e tablies sur de grands
unsuitable for cohorts of patients suffering from apnea who chantillons. Elles ne seraient peut-e
e ^tre pas adapte es aux
could well present specific characteristics, notably related to populations de patients apne iques, qui pourraient pre senter
the cranial base [40]. des spe cificite
s, notamment basicra ^ niennes [40].
Furthermore, Delaire analysis uses deeper reference points in En outre, l’analyse de Delaire utilise des re fe
rences plus pro-
the facial skeleton than Tweed analysis [37–39]: M and FM as fondes dans le squelette facial que l’analyse de Tweed [37–
compared to N for the maxilla insertion point at the base of the 39] : M et FM en comparaison de N pour la re fe
rence d’inser-
anterior skull, NP as compared to A for the anterior maxillary tion maxillaire sur la base du cra ^ ne ante rieure, NP en compa-
reference point and Me as opposed to B or Pog for the anterior raison de A pour la re fe
rence maxillaire ante rieure, Me au lieu
mandibular reference point. It is thought that these deeper de B ou Pog pour la re fe
rence mandibulaire ante rieure. . . Ces
landmarks are less affected by cutaneous functional matrices refe
rences, plus profondes, seraient moins influence es par les
(platysma muscles, lips, cheeks) and are better suited to matrices fonctionnelles cutane es (peauciers, le vres, joues)
pinpointing pharyngeal anomalies. et seraient plus adapte es dans la mise en e vidence d’une
anomalie pharynge e.
Impact on soft tissues Effet sur les tissus mous
As a large proportion of OSAS sufferers are mature adult males Le SAOS touchant une grande proportion d’hommes d’a ^ge
[2], a number of patients requiring MMA surgery will present mûr [2], les patients candidats à la chirurgie d’AMM peuvent
with a face showing signs of ageing, in particular skeletal pre senter un visage marque de signes de vieillissement, avec
atrophy, a sagging tip of the nose, hollow cheeks and cervical notamment une atrophie squelettique, une chute de la pointe
ptosis. Since MMA brings forward the skeletal structures of du nez, un creusement des joues ou une ptose cervicale.
the mid and lower face and tautens the cutaneous soft tissues, L’AMM, projetant ante rieurement les structures squelettiques
the procedure can rejuvenate the patient’s appearance, a moyennes et infe rieures de la face, associe e à la mise en
phenomenon which some authors have termed a “reverse face tension des tissus mous cutane s, procurerait un effet de rajeu-
lift” [23]. Hence, the facial changes resulting from MMA are nissement, certains auteurs l’ayant me ^me qualifiee de « lifting
generally well received [17,25,30]. Nevertheless, a number of inverse » [23]. Les modifications faciales induites par l’AMM
patients find they are less attractive following the procedure sont ainsi globalement bien accepte es [17,25,30]. Un certain
(4/44, or 10% in the series of Li et al. [17], one subject in our nombre de patients se trouvent cependant moins beaux apre s
sample 1/15). These negative effects, which have also been l’intervention (4/44, soit 10 % dans la serie de Li et al. [17], un
described by other teams, are nonetheless considered to be of sujet dans notre e chantillon 1/15). Ces effets de le
te
res,
secondary importance by patients compared with the benefits de crits e
galement par d’autres e quipes, sont cependant con-
achieved by the surgery [21]. More research is required into side re
s comme secondaires par les patients, par rapport aux
these “esthetic failures” as a number of patients could well be ne
fices apportes par l’intervention [21]. L’analyse de ces
refuse surgery in order to avoid the risk of facial deformity. «e checs esthetiques » reste ne cessaire, car on peut estimer
This is especially true for young subjects with full faces or for qu’une proportion de patients pourrait refuser l’intervention
women with finer soft tissues which would not conceal their pour ne pas risquer une de formation faciale. On peut
skeletal contours. The mean 5 reduction of the nasolabial penser notamment aux sujets jeunes, pre sentant un visage
angle in our sample varied greatly from one individual to plein, ou aux femmes dont les tissus mous, plus fins, ne


another. The differences of angle were due, on the one hand, to masqueraient pas le relief squelettique. La re duction de l’angle
the forward movement of the maxilla and upper lip (the inter- nasolabial, de l’ordre de 5 dans notre e chantillon, e tait tre
s
action between the two is dependent on many factors, notably variable entre les individus. La modification de cet angle est
the surgical technique used) and, on the other, to the lifting of imputable, d’une part, à l’ante riorisation du maxillaire et de la
the tip of the nose. Among the various teams which have vre supe
le rieure (dont l’interaction de pend de nombreux fac-
published on this topic, Louis et al. [18] showed no correlation teurs, notamment de la technique chirurgicale) et, d’autre part,
between reduction of the nasolabial angle and the amount of à l’ascension de la pointe du nez. Parmi les autres e quipes
maxillary advancement, even though almost all the patients in ayant publie sur ce sujet, Louis et al. [18] n’ont pas montre de
their series (14/15) experienced a reduction approximating 5 corre lation entre la reduction de l’angle nasolabial et le degre
( 10 ; +7 ), on account of the advancement of the upper lip. d’avance e maxillaire, me ^me si quasiment tous les patients de
In the study by Conley et al. [19], the nasolabial complex leur se rie (14/15) avaient connu une re duction, de l’ordre de 5
underwent anticlockwise rotation with a reduction of the naso- ( 10 ; +7 ), imputable à l’avance e labiale supe rieure. Dans
labial angle of some 4 . tude de Conley et al. [19], le complexe nasolabial effectuait
l’e
une rotation antihoraire, avec une re duction de l’angle naso-
labial de l’ordre de 4 .
It has been demonstrated that, during MMA, the soft tissues te
Il a e montre qu’au cours de l’AMM les tissus mous suivaient
follow skeletal displacement to a large extent, by 80 to 90% in le de placement squelettique dans des proportions impor-
the anteroposterior dimension [18,19,22]. In order to reduce tantes, de 80 à 90 % dans le sens ante roposte rieur
the convexity of the upper lip, some surgeons systematically [18,19,22]. Pour re duire la convexite de la le vre supe rieure,
incorporate anticlockwise rotation into the maxillomandibular certains chirurgiens incorporent syste matiquement une rota-
complex during the advancement, recontour the piriform ori- tion antihoraire au complexe maxillomandibulaire lors de
fice and the anterior nasal spine area and advocate a VY l’avance e, remode lent l’orifice piriforme et la re gion de l’epine
mucosal suture technique [19,26,27,35]. Management of the nasale ante rieure, et pre conisent une technique de suture
soft tissues during surgery could thus modify the labial muqueuse en VY [19,26,27,35]. La gestion des tissus mous
advancement by between 60 and 90% [40,41]. lors de la chirurgie pourrait ainsi modifier l’avance e labiale de
60 à 90 % [40,41].
The close relationship between upper lip and maxillary Les relations intimes entre la le vre supe rieure et les incisives
incisors suggests that orthodontics has a role to play in maxillaires sugge rent un possible ro ^ le de l’orthodontie, face
patients displaying excessive protrusion. Moreover, a high à une protrusion excessive. En outre, en l’absence de pre para-
incidence of secondary malocclusions (> 44%) has been tion orthodontique, une forte incidence de malocclusions sec-
reported when orthodontic preparation was not performed ondaires (> 44 %) a e te
rapportee [16]. Selon Bettega et al.,
[16]. According to Bettega et al., reporting MMA results in rapportant les re sultats d’AMM sur 51 patients conse cutifs,
51 consecutive patients, a number of the technical problems certaines des difficulte s techniques rencontre es pouvaient
encountered in their sample could be attributed to the lack of ^tre rapproche
e es de l’absence de pre paration orthodontique
orthodontic preparation, which was difficult to perform in their dans leur e chantillon, difficile à mettre en place chez leurs
adult patients, as well as to poor quality dentition and bone patients adultes à la denture et au support osseux re duits en
support [26]. qualite [26].
Thus, individualized protocols could be offered to patients Des protocoles individualise s pourraient ainsi e ^tre propose s
requiring MMA depending on their occlusal and facial char- aux candidats à l’AMM, en fonction de leurs caracte ristiques
acteristics and the location of the pharyngeal obstacle [29]. occlusales, faciales et de la situation de l’obstacle pharynge
Numerous clinical studies, though not devoted specifically to [29]. De nombreuses e tudes cliniques, non spe cifiquement
apnea patients, have shown that premolar extractions signifi- applique es aux patients apne iques, ont ainsi pu montrer que
cantly reduce procheilia [42–44]. The use of bone anchorage des extractions de pre molaires permettent de re duire signifi-
can help maximize this retraction without lengthening treat- cativement la proche ilie [42–44]. Le recours à des ancrages
ment duration [45]. When making Class II decompensations, osseux permettrait de maximiser ce recul, sans augmenter
with or without extractions, mandibular advancement relative la dure e du traitement [45]. Lors des de compensations de
to the maxilla can be potentiated by creating incisal overjet, classe II, mene es avec ou sans extractions, la cre ation d’un
thus reducing the risk of widening the base of the nose or of surplomb incisif permettrait aussi de potentialiser l’avance e
bulging the upper lip (patients No. 4, 13 and 14). mandibulaire par rapport au maxillaire, re duisant le risque
d’etalement de la base du nez et de bombe de la le vre
(patients no 4, 13 et 14).
In this series of cases, patient N 8 displayed minimal facial Dans cette se rie de cas, le patient N 8 pre sente des modifica-
changes and had received specific orthodontic preparation, tions faciales minimes, et avait be ne
ficie
d’une pre paration
with extraction of four premolars and use of anchorage minis- orthodontique spe cifique, avec extraction de quatre pre mo-
crews (Dr. CFR). The patient refused to have his face modified laires et recours à des minivis d’ancrage (Dr CFR). Le patient

by MMA. Consequently, we sought to perform retraction refusait en effet de voir son visage modifie par l’AMM, aussi un
before the procedure. recul labial avait e te
recherche avant l’intervention.
The panel members unanimously preferred the preoperative Les juges ont ainsi unanimement pre fe
re
le profil pre
-
profile of the three patients who exhibited a marked procheilia ope ratoire des trois patients chez qui l’AMM avait cre e une
following MMA and a reduced nasolabial angle (fig. 11). In forte proche ilie avec reduction de l’angle nasolabial (fig. 11).
contrast, the different panels preferred the postoperative pro- Au contraire, les jurys ont pre fe
re
le profil postoperatoire des
file of patients who were initially retruded or who originally patients initialement re trus ou à l’angle nasolabial ouvert
displayed an open nasolabial angle (fig. 10). The most popular (fig. 10). Les profils pre fe
re
s e
taient relativement rectilignes.
profiles were relatively rectilinear.
These results are similar to those found by Czarnecki et al. [46] Ces re sultats sont similaires à ceux de l’e tude de Czarnecki,
for whom the worst situations are those with a markedly retru- Nanda et Currier [46] pour qui les pires situations sont celles
sive chin or an excessively convex face. According to the avec un menton nettement en retrait, ou une face excessive-
panel in their study (545 medical professionals), it was pref- ment convexe. Selon le panel qu’ils avaient e tudie (545 pro-
erable to display labial protrusion combined with a strong nose fessionnels), il e tait plus agre able d’avoir une protrusion
or chin. On the other hand, a small nose was deemed to be labiale associe e à un nez et un menton forts, alors qu’à
unsightly when combined with excessive labial protrusion l’inverse, un nez re duit apparaissait disgracieux face à une
and/or an excessively closed nasolabial angle. protrusion labiale excessive et/ou un angle nasolabial trop
ferme .
Interestingly, there was little difference in the assessment Il est inte ressant de noter le peu de diffe rences dans
made by the different panelists, whether medical professionals l’appreciation des juges, qu’ils soient professionnels ou pro-
or otherwise, irrespective of age and gender. All preferred the fanes, et ce quels que soient leur a ^ge et leur sexe. Ils s’accor-
postoperative profiles, with the exception of several patients dent sur la pre fe
rence des profils postope ratoires, sauf pour
who were always the same ones. The slight differences quelques individus, avec toujours les me ^mes exceptions. Les
observed between the artists and the orthodontists were not differences subtiles releve es entre les artistes et les orthodon-
significant and could simply reflect the more original mind- tistes ne sont pas significatives. Elles pourraient simplement
sets of the artists who tolerate more atypical profiles while refleter une plus grande originalite chez les artistes, qui tole -
remaining sensitive to overall facial harmony. rent des profils plus atypiques, et restent ne anmoins sensibles
à l’harmonie faciale ge ne
rale.
Also of interest, those patients with the profiles deemed to be De façon inte ressante e galement, les patients aux profils
protrusive did not necessarily find themselves unattractive juge s protrusifs ne se jugent pas ne cessairement disgracieux
(No. 2, 9, 10 and 15). The only patient who was dissatisfied (no 2, 9, 10 et 15). Le seul patient a avoir e te
insatisfait de
with the procedure (No. 11) had refused orthodontic prepara- l’intervention (no 11) avait refuse une pre paration orthodon-
tion in spite of his dental Class III and did not receive a tique malgre une Classe III dentaire et n’etait pas particulie re-
particularly bad assessment from the panelists. ment mal e value par les juges.
Limitations and prospects Limites et perspectives
This study, conducted on “cut-out”, blackened profiles, pre- Cette etude, mene e sur des profils de
toure s et colore
s en noir,
sented the advantage of simplifying the changes brought about presentait l’avantage de simplifier les modifications induites
by MMA in order to pinpoint the most striking morphological par l’AMM, afin de de gager des caracte ristiques morphologi-
features and to influence the judges as little as possible. This ques notables et d’influencer le jury le moins possible. Cette
so-called “silhouette technique”, validated for the study of me thode dite des « silhouettes » a e te
validee pour l’e
tude
soft-tissue profiles, notably following mandibular advance- des profils cutane s notamment apre s chirurgie d’avance e
ment surgery [47,48], clearly highlights the labial variables mandibulaire [47,48]. Elle permet de mettre clairement en
(extent of protrusion, competence and nasolabial vidence les variables labiales (degre
e de protrusion, compe -
relationships). tence et relations nasolabiales).
However, the method has a drawback in that it simplifies, La me thode pre sente cependant l’inconve nient de simplifier,
sometimes to the extreme, the esthetic assessment of the face, peut-e^tre à l’extre^ me, l’appre
ciation esthe tique du visage, où
which is expressionless. In addition, some of the nasal changes l’expression est absente. De plus, certaines des modifications
produced by MMA are masked as they are mostly apparent nasales ge ne re
es par l’AMM sont occulte es, car elles se
when viewed frontally (flattening of the nostrils and widening manifestent essentiellement de face (e talement narinaire
of the base of the nose, reduction of the nasogenial folds). et e largissement de la base, diminution des sillons
nasoge niens).
The cases in our series exhibited a wide range of soft-tissue Dans cette se rie de cas, qui pre sentaient une grande
and skeletal profiles on which a double cephalometric analy- de profils cutane
variabilite s et squelettiques, et pour qui
sis was conducted in parallel to the facial analysis. However, l’analyse faciale a e te
comple te
e d’une double analyse


no correlation was found between the cephalometric predic- cephalome trique, aucun caracte re predictif ce
phalome trique
tive elements and the esthetic outcome of surgery. The only n’a e te
corre
le
à l’issue esthetique de l’intervention. Seules
items which were common to the assessment of all the pane- des variables cutane es, et notamment la mesure de la protru-
lists were the soft-tissue variables, particularly the labial pro- sion labiale par l’analyse de Ricketts, prenant pour re fe
rence
trusion values provided by Ricketts analysis using the salient les structures saillantes faciales, ont pu montrer un caracte re
facial structures as reference points. commun dans l’appre ciation des juges.
Preoperative simulation of these soft-tissue changes using wax Une simulation pre ope ratoire de ces modifications cutane es,
conformers placed, for instance, under the lip would appear to par l’utilisation de conformateurs en cire place s sous la
be useful as it can assist the patient, the surgeon and even the vre par exemple, apparaı̂t inte
le ressante. Elle pourrait aider
orthodontist in the decisions to be made. In various studies, à la prise de de cision par le patient, le chirurgien, voire l’ortho-
Burstone [49,50] frequently questioned the skeletal standards dontiste. Dans diffe rents travaux de Burstone [49,50], les
applied to obtain esthetic results. Using superimpositions, he standards squelettiques ont souvent e te
remis en question
demonstrated that a beautiful skeleton did not systematically quant à l’obtention de re sultats esthe
tiques optimaux. Il a pu
entail a beautiful profile and concluded that our main objec- demontrer par le biais de superpositions qu’un beau squelette
tive should be to achieve a balanced soft tissue profile. ne donnait pas syste matiquement un beau profil, concluant
que l’e quilibre du profil cutane devait constituer l’objectif
majeur.
Conclusion Conclusion
The facial changes generated by MMA surgery for OSAS were Les modifications faciales engendre es lors de la chirurgie
assessed positively by both professional and non-professional d’AMM pour SAOS e taient appre cie
es positivement par un
panels, and were accepted by the patients themselves (14/15). jury naı̈f ou professionnel, et aussi bien accepte es par les
The evaluation of the soft-tissue profile by three different sets patients eux-me ^mes (14/15). L’e valuation du profil cutane
of judges composed of orthodontists, artists and “laymen” par trois jurys diffe rents (orthodontistes, artistes et « hommes
demonstrated great homogeneity. In 85% of cases, the lay de la rue ») a montre une grande homoge ne
ite
; ces derniers
panel preferred the postoperative profile of the operated ont pre fe
re
dans 85 % des cas le profil postope ratoire des
patients despite their bi-maxillary protrusion. patients ope re
s, malgre la protrusion maxillomandibulaire.
Prior existence of retrocheilia and of an open nasolabial angle L’existence pre alable d’une re troche
ilie et d’un angle nasola-
emerged as determining factors for the achievement of an bial ouvert apparaı̂t e ^tre de terminante dans l’obtention d’une
improved profile following MMA for OSAS. In some cases, ame lioration du profil au cours d’une AMM pour SAOS.
orthodontics would appear to minimize the risk of procheilia of L’orthodontie pourrait permettre dans certains cas de minimi-
the upper lip by creating anterior overjet to potentiate the ser le risque de proche ilie supe rieure, en creant un surplomb
mandibular advancement or by closing diastemas or extrac- anterieur pour potentialiser l’avance e mandibulaire, ou en
tion spaces in order to retract the lips. An orthodontic work-up obtenant un recul des le vres par fermeture d’espaces (dia-
could be performed during the presurgical check-up of mes, extractions). Un bilan orthodontique pourrait ainsi
ste
patients about to receive MMA for the treatment of OSAS, ^tre propose
e au cours de l’e valuation pre chirurgicale des
whether an obvious malocclusion is present or not. patients candidats à une AMM pour le traitement du SAOS,
qu’une malocclusion e vidente soit pre sente ou non.
Disclosure of interest claration d’inte

De re
^ts
The authors declare that they have no conflicts of interest Les auteurs de clarent ne pas avoir de conflits d’inte
re
^ ts en
concerning this article. relation avec cet article.
Acknowledgements Remerciements
We would like to thank Dr. M. Bijaoui for collecting satisfac- Nous souhaitons remercier le Dr M. Bijaoui pour la collecte
tion questionnaires and Pr. Robert Garcia for his support. des questionnaires de satisfaction, et le Pr Robert Garcia
Thanks to Dr. C. Fauquet Roure for completion of the ortho- pour avoir soutenu ce travail. Merci au Dr C. Fauquet Roure
dontic treatment of four of the presented cases. alise
pour avoir re le traitement orthodontique pre
paratoire de
quatre des patients pre sente
s.

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Change in Facial Profile in OSA

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Ó 2013 CEO

Published by / Édité par Elsevier Masson SAS

Original article All rights reserved / Tous droits réservés

Changes in facial profile after

Julia COHEN-LEVYa,*, Boris PETELLEb, Estelle VIEILLEc, Marius DUMITRACHEd,

Available online: 9 February 2013 / Disponible en ligne : 9 fevrier 2013

International Orthodontics 2013 ; 11 : 71-92 71

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International Orthodontics 2013 ; 11 : 71-92 73

Materials and methods riels et me

Self-assessment questionnaires Autoquestionnaires

Profile analysis ^te sur les profils

74 International Orthodontics 2013 ; 11 : 71-92

Fig. 1: Facial changes associated with maxillomandibular advance-

Fig. 2: Soft tissue profiles obtained from lateral photographs: a: pre-

Cephalometric analysis phalome

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Fig. 3: Profiles of 15 OSAS patients, randomized in relation to maxillomandibular advancement

Fig. 4: Tweed’s cephalometric analysis modi-

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Impact of MMA on OSAS Effets de l’AMM sur le SAOS

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Fig. 6: Protrusion of maxilla before and after maxillomandibular

Self-assessment questionnaires Autoquestionnaires

78 International Orthodontics 2013 ; 11 : 71-92

Before surgery/ After surgery/ P

Morphological changes Modifications morphologiques

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Fig. 7: Protrusion of mandible before and after maxillomandibular

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Tweed analysis/Analyse de Tweed Delaire analysis/Analyse de Delaire

Fig. 8: Sagittal skeletal discrepancy before and after maxilloman-

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Fig. 9: Nasolabial angle changes after maxillomandibular advance-

Evaluation by different panels

Hundred and twenty questionnaires were completed and te

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Table III Tableau III

Fig. 10: Most-liked postoperative profiles (red boxes). Note the

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Fig. 11: Most-disliked postoperative profiles (red boxes). Note the

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Morphology and MMA-induced changes Morphologie et modifications induites par l’AMM

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Impact on soft tissues Effet sur les tissus mous

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Limitations and prospects Limites et perspectives

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Disclosure of interest claration d’inte

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