Maxillomandibular Advancement for Obstructive Sleep Apnea: Is It Right For You?
November 11, 2009
With all the surgical options for obstructive sleep apnea, maxillomandibular advancement (or the MMA) is not mentioned too often as a first line treatment option. Historically, it’s thought to be a big procedure with lots of potential complications, and a long recovery.
The MMA involves cutting the upper and lower jaws and pushing it forward 1 cm or more and fixing it in place using plates and screws. It’s typically reserved for patients that can’t tolerate CPAP, or who’ve failed other soft tissue procedures.
A recent paper published in Otolaryngology – Head & Neck Surgery reported on the complications of 59 patients that underwent this procedure. They reported an 80% success rate with no serious complications. Minor complications included 6 cases of fixation plate infection requiring removal, 2 cases of minor bleeding and one case of vein inflammation. Ninety-four percent reported numbness of the lip area immediately after the procedure, and after 18 months, 52% still complained of numbness.
Despite these complications, the vast majority (94%) were happy with the overall results and would recommend the procedure to family and friends. Many patients were also happy that although their facial appearance changed (usually for the better), they also looked younger, which is due to the facial stretching effect of the procedure.
Overall, success rates for the MMA are reported to be from 80% up to 97%. This is much better than multi-level soft tissue surgeries which are no better than 80%. In this particular study, the average distance the jaws were moved was .7 cm, which is much less than what’s typically achieved (over 1 cm). Also, many of the patients that “failed” had large tonsils and bulky soft palate tissues, in addition to being more overweight.
Perhaps one way of increasing the overall chances of success if to address any soft tissue areas of obstruction first, and of the 20 or so percent that don’t respond, offer them the MMA procedure. It’s also important to move the jaws the maximum distance possible, but that’s not as easy as it sounds.
Granted this procedure is not for everyone, but once you begin to look at surgical options, you should at least know about what’s involved the the MMA.
To listen to an interview with Stanford University surgeon Dr. Kasey Li, click here.
14 Responses to “Maxillomandibular Advancement for Obstructive Sleep Apnea: Is It Right For You?”
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Dr. Park,
How long does the surgery take and how long is the recovery period?
thanks
David
Anywhere from 3-6 hours, and full recovery can take 4-6 weeks. You may also need further orthodontic work afterwards to better align your teeth. Different surgeons have widely different approaches and outcomes.
I recently had MMA surgery. The surgeons advanced the upper and lower jaw 7.5 mm. He said he initially tried 10 mm but this stretched the soft tissues too much. He also cut through two nerves. I was hoping for more. What really is getting me down is that my lower lip and chin, and part of the left side of my face is numb. From reading postings on this subject, it seems that the majority of patients that have gone through this procedure have permanent numbness. I did not know this bad side effect was so common. I am hoping that it is not permanent, and it is causing me to be depressed. In addition, I may have put myself through this ordeal and still not have my sleep apnea cured. Any comments?
Mr. Ralston,
Your disappointment is understandable after the results that you’ve just experienced. The MMA is not a completely benign procedure. Numbness is a common complication. Sometimes, the bigger the potential for success, the higher the risk.
In some cases it can take 6-12 months for the numbness to improve, so give it more time. See what the sleep study shows 6-12 months after the procedure, and have a discussion with your surgeon about the results, as well as other options.
I recently had MMA surgery. The surgeon had to approximate two nerves. It has been two and a half weeks and I am experience tingling, pulsing in the areas that are numb, which is the lower lip and chin. Does this mean the nerve is regenerating. It is hard to sleep since this never seems to stop.
Check out this website http://www.sleepnet.com under the non-cpap options message board. many people who have had the mma surgery post on these message boards including an mma surgeon named Dr. Kasey Li whom Dr. Park has interviewed in the past. The people on the board are very nice and helpful. They even have an annual mma surgery meetup in Northern California.
I am surprised that you suggest that the recovery period is 4-6 weeks. I presume that you are referring to the period before you can resume chewing properly again. I had this procedure and I was told that the complete recovery period was 4-6 months. By complete recovery I mean when the tingling/numbness stops and the face muscles become fully functional (in my experience, it was the face muscles which took the longest to recover (given that they are stretched around your face during the operation) but even that was no big issue.
5- 10 years ago this procedure involved having your jaws wired together for 6 weeks and only after that period could the recovery process begin. So advancements in this area have made this a move less traumatic experience (and definitely worth thinking about if you face a life of using a CPAP … unless the apnea is weight related).
Also, in my experience the tingling is a sign of nerve regeneration and will stop (although I didn’t have it to the degree that it interfered with my sleep, it was just slightly annoying for me).
Mr. Callan,
Thanks for pointing out that complete recovery and healing is different from post-operative recovery, which is what I quoted. Even with the soft tissue procedures that I perform, I usually order a sleep study about 4-6 months later, when everything has settled down.
This procedure has been recommended for me, along with about five other ones, even before I have had a sleep study because of anatomical features. Frankly, it scares me, and for more than one reason. As a telephone triage RN, I talk for a living, and I have to speak clearly and concisely. A prolonged period of not being able to speak clearly could permanently disable me. I am going to have to think long and hard before I could even accept the co-morbid risks of the procedure itself.
I am 4 weeks post op MMA . I still have major speech problems that I wasn’t even told about, and my sleep apnea is not gone. My preop AHI was 89 with minimum o2 60 percent. Now, my oximeter goes down to 87 (lowest I have recorded) and I recorded a heartrate of 135 (one spike). Needless to say, I have gone back on CPAP. MMA may not cure. Read the technical journals. Most patients have significant improvements but not a cure.
Glen,
Sorry to hear about your disappointing results so far. Since you’re only 4 weeks post-op, it’s too early to assess whether or not your procedure was “successful” or not. Typically, a post-op sleep study is performed anywhere from 4 to 6 months after the procedure. There’s a lot more healing that can happen along with resolution of swelling in the next few months. Your improved O2 saturation shows that there was significant improvement, from levels (60%), to 87%, which is much better. Please note that I never state in any of my articles or posts that an option is a “cure” (except for a tracheotomy). There’s no such thing in medicine. All surgical procedures, even the better ones, have some degree of failure, or in your case, possibly less than optimal results. But again, it’s way too early to assess it’s effectiveness at 4 weeks. Hopefully, you’ll improve even further over the next few months. Good luck.
I am curious about whether this procedure would offer an advantage over mandibular advancement surgery for someone who has a receding chin. It seems to me that, if the upper and lower jaws are advanced an equal distance, the oral cavity may expand sufficiently to help counteract obstructive sleep apnea, but any existing dental alignment problems would remain. Advancing the lower jaw still more, to bring the lower and upper front teeth into alignment, might put a large strain on the nerves in the lower jaw, not to mention the muscles which move the jaw. In the (unlikely?) event of other conditions being equal, might mandibular advancement alone be a worthwhile alternative in the case of a significantly receding chin?
For the past year, I’ve been using a BiPAP machine for treatment of OSA, but haven’t seen any readily noticeable benefit. Out of frustration with the ineffective therapy, I had a consultation late last month with a local ENT physician regarding possible surgery. He recommended UPPP surgery to help enlarge the airway opening, and described the relationship between the tongue and the chin I raised the subject of mandibular advancement (recommended by an orthodontist years earlier), which the physician agreed could serve to help move the tongue away from the back of the throat during sleep. Since then, I’ve scheduled a consultation (early next month) with a local oral surgeon who performs the mandibular surgery, and have listened to Dr. Li’s presentation on MMA. I’m not anxious to go to surgery, but I am gathering information so that I can make an informed decision on what action to take. At this time, I don’t expect to escape CPAP (my untreated AHI is 103), but something needs to help it work.
I have the same question about orthodontic work and mandibular advancement for individuals with an underdeveloped lower jaw.
With weight loss and moving to a lower altitude I have lowered my AHI from 40 (NREM) and 60 (REM) to 18 (NREM) and about 30(REM). Cannot tolerate CPap, and developed bite problems from long term use of mandibular advancement device (which worked pretty well!) Am looking at multilevel airway surgery, and possible follow up, if needed, with orthodontics and mandibular advancement.
Your thoughts, Dr. Park?
Rachel,
I can’t be very specific without examining you, but it sounds like you’re on the right course. You have to deal with both the jaws and the soft tissues for maximum effectiveness. Practitioners of the DNA appliance state that they can get significant upper and lower jaw expansion with their device, but it can take 1-2 years to fully treat obstructive sleep apnea. There are no long-term studies using this for obstructive sleep apnea, but it does sound promising. Good luck.