Research Original Investigation Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea A Meta-analysis Soroush Zaghi, MD; Jon-Erik C. Holty, MD, MS; Victor Certal, MD; Jose Abdullatif, MD; Christian Guilleminault, DM, MD, DBiol; Nelson B. Powell, MD, DDS; Robert W. Riley, MD, MS, DDS; Macario Camacho, MD Supplemental content at IMPORTANCE Maxillomandibular advancement (MMA) is an invasive yet effective surgical jamaotolaryngology.com option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. OBJECTIVE To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies. DATA SOURCES The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea. STUDY SELECTION Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngo- plasty, and partial glossectomy) were excluded. DATA EXTRACTION Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015. MAIN OUTCOMES AND MEASURES The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h. RESULTS Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were −47.8 (25.0) and −44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced Author Affiliations: Author large and substantial net improvements despite modest surgical cure rates. affiliations are listed at the end of this article. CONCLUSIONS AND RELEVANCE Maxillomandibular advancement is an effective treatment for Corresponding Author: Soroush OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical Zaghi, MD, Department of Head and procedures for OSA are likely to benefit from MMA. Neck Surgery, David Geffen School of Medicine at UCLA, 10833 LeConte Ave, Room 62-132, Center for Health JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2015.2678 Sciences, Los Angeles, CA 90095 Published online November 25, 2015. ([email protected]). (Reprinted) E1 Copyright 2015 American Medical Association. All rights reserved. Downloaded From: http://archotol.jamanetwork.com/ by a UNIVERSITY OF SYDNEY LIBRARY User on 12/21/2015 Research Original Investigation Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea axillomandibular advancement (MMA) is an inva- Figure 1. PRISMA Flow Diagram sive yet potentially effective surgical option in the treatment of obstructive sleep apnea (OSA) for pa- M 1280 Records identified through tients who have difficulty tolerating continuous positive air- database searching (after removal of duplicates) way pressure and whose OSA has been refractory to other surgical modalities.1 Maxillomandibular advancement 1163 achieves enlargement of the nasopharyngeal, retropalatal, Excluded after review of abstracts and hypopharyngeal airway by physically expanding the 106 Other surgical modalities facial skeletal framework via Le Fort I maxillary and sagittal 286 Oral appliances 11 Imaging study split mandibular osteotomies. Advancements of the maxilla 727 Pediatrics and mandible increase tension on the pharyngeal soft tissue, 24 Review article 9 CPAP thereby enlarging the medial-lateral and anteroposterior dimensions of the upper airway.2 A previous meta-analysis3 117 Potentially relevant demonstrated a mean decrease in the apnea-hypopnea index articles retrieved for (AHI) from 63.9 to 9.5 events/h with a pooled surgical success detailed evaluation rate of 86.0% and OSA cure rate of 43.2% using study-level data. Despite a large number of studies reporting excellent 5 Additional studies 77 Articles excluded after full-text identified from review outcomes on the cohort level, baseline individual variables reference lists 21 No preoperative and/or that might be associated with a highly effective outcome postoperative PSG data 43 No individual patient data remain to be elucidated. Indeed, assessment of whether any 4 MMA combined with other preoperative factors could be consistently associated with surgery 9 Reviews or editorials postoperative outcomes could help to shape patient selection criteria and to counsel patients regarding their chances to 45 Included in meta-analysis achieve a significant improvement with MMA. after full-text review We performed a systematic review of the literature and meta-analysis of studies reporting individual patient data The meta-analysis included 518 unique patients undergoing 518 unique among adults who underwent MMA for the treatment of OSA. procedures. CPAP indicates continuous positive airway pressure; The purpose of our meta-analysis was to use aggregated indi- MMA, maxillomandibular advancement; and PSG, polysomnography. vidual patient-level data from a large number of studies to assess whether any baseline preoperative factors might be pre- operative and postoperative quantitative outcomes for the AHI dictive of postoperative AHI and respiratory disturbance in- and/or RDI; and (3) reports of individual patient data. We ex- dex (RDI) outcomes, surgical success, and/or OSA cure. Our spe- cluded studies of patients who underwent adjunctive proce- cific aim was to elucidate factors associated with outcome dures at the time of MMA (including tonsillectomy, uvulopala- effect size and the likelihood of surgical success and cure. topharyngoplasty, and partial glossectomy). Methodologic Quality of Included Studies Methods We screened 1280 MMA studies for potential relevance, and 117 nonduplicated articles were downloaded for detailed evalu- Three of us (V.C., J.A., and M.C.) independently performed a lit- ation (Figure 1). An effort was made to include all available stud- erature search to identify potentially relevant studies via search ies in all languages, including library requests and direct con- of the Cochrane Library, Scopus, Web of Science, and MEDLINE. tact with the authors. Five more articles were added based on These same three of us came to a consensus as to which stud- a review of references. After reviewing the full-text versions ies met the inclusion criteria and submitted these to another one of 122 articles, a total of 45 studies were included. One of these of us (S.Z.), who independently reviewed each article to en- was a randomized clinical trial.4 The other 77 articles were ex- sure that they met the inclusion and exclusion criteria. cluded because preoperative and/or postoperative polysom- nographic data were missing (n = 21), individual patient data Search Strategy were not available (n = 43), MMA was combined with other sur- The 4 databases were searched from June 1, 2014, through geries (n = 4), or the articles were reviews or editorials (n = 9). March 16, 2015. The Medical Subject Heading keywords and The 45 included studies were written in English (n = 40), phrases searched included maxillomandibular advancement, French (n = 2), German (n = 1), Dutch (n = 1), and Chinese orthognathic surgery, maxillary osteotomy, mandibular ad- (n = 1). A quality control questionnaire was developed to evalu- vancement, sleep apnea, surgical, surgery, sleep apnea syn- ate the methodologic quality of each study (eAppendix in the drome, and obstructive sleep apnea. Supplement). Results of the questionnaire are given in eTable 1intheSupplement. Study Inclusion Criteria We included studies in all languages of (1) adult patients (aged Data Abstraction >18 years) who underwent MMA (with or without genial tu- Individual patient data from each article were abstracted into bercle advancement) as a treatment for OSA; (2) reports of pre- a spreadsheet (Excel 2013; Microsoft Corporation). Abstracted E2 JAMA Otolaryngology–Head & Neck Surgery Published online