Maxillomandibular advancement (MMA)
Sleep apnea is a very common chronic disease. Estimates are as high as 1/3 of the adult population has sleep apnea and many are untreated or undertreated. The most common way sleep apnea is managed is through PAP therapy. This involves wearing a mask at night every night from now on. For many people, particularly young people, PAP therapy is not a reasonable option.
The surgery with the highest rate of success is a tracheotomy. This is a hole in your neck, which again, for many people is unreasonable. The next best is MMA. This is jaw surgery to open the upper airway. The idea of this surgery is to move both the upper and lower jaws to create as much space as possible for you to breathe. This surgery has a success rate of 86% for people with moderate to severe OSA. While moving the lower face may sound more invasive than a tracheotomy, it is the same surgery we use to help orthodontists treat people whose teeth don’t fit well. This surgery is used in cosmetic surgery for jawline enhancement and gender affirmation. MMA is just upper and lower jaw surgery with the goal of creating space to breathe.
MMA is carried out through a lefort osteotomy and a mandibular osteotomy (most commonly a BSSO). Here are common questions we hear.
The best literature as the surgical success rate at 86% and the cure rate at 43%. These terms have meanings as success is a 50% reduction in AHI and reducing the AHI less than 15. Cure is AHI less than 5. These numbers are in people with moderate to severe sleep apnea. Success and cure are seen more often in younger people, women, and in people with smaller jaws. Other sleep surgeries have success rates of 10-50% with cure rates much lower.
One of the big advantages of MMA over nonsurgical approaches to OSA is that you don’t have to do anything to breathe better. No more masks, appliances or positioning devices.
Sleep apnea is more complicated than just the bony anatomy of the face. Sleep physiology – specifically loop gain and arousal threshold – is different in each of us. Unfavorable physiology can lead to no to minimal response to surgery. Another common cause of residual apnea after MMA is that other things cause apnea. Weight loss is often helpful as is establishing nasal breathing. We have also seen people with long palates, floppy epiglottis, or tonsils that are still in the way following MMA. We know ear nose and throat docs to refer you to.
The biggest risk is that you still have sleep apnea after MMA. This was addressed before. The next most common risk is numbness. Surgery is through bones and the feeling of your teeth, gums and maybe lip and chin can be different after surgery. Most people have temporary numbness while some have permanent sensory changes.
MMA changes your lower facial structure. A risk is that this change is unfavorable. Widening of the base of the nose is a common unfavorable change. We customize all of our plans to you to minimize unfavorable face change.
Need for more surgery is another problem. No one wants one surgery let alone two! Luckily, if a second surgery is needed, it is to remove some of the plates and screws. These are removed due to infection or pain. Other times the bones do not set right, causing either the bones to heal in an unfavorable position or not heal at all. This can lead to a revision surgery.
Other risks like infection and bleeding are manageable. This is a safe surgery but there are risks. We look forward to discussing them in more detail with you.
MMA surgery takes 2-3 hours. Many times, this is outpatient surgery but other times you spend a night in the hospital.
A misconception of MMA is that the recovery will be terrible. It is a long recovery but most people need 1-2 weeks off from work. Your teeth are not wired shut following surgery. Unfortunately, we do not want you using your teeth to eat after surgery. For 6 weeks you use a blender or fork and knife to do the chewing for you. This is to allow the upper and lower jaws to heal. Pain is typically not the biggest issue after surgery. Most people find nasal and sinus congestion to be difficult. This improves after a week or two. Pain medication is prescribed for 7-10 days after surgery to help with the discomfort.
Many people find that facial swelling takes 2 months to go away completely. The more impressive swelling lasts for 1-2 weeks. We don’t want you working out or lifting heavy things so many people find recovery to be boring. This can take a toll on your mental health so we want you to be as prepared as you can be for surgery.
We typically meet with people three or four times before MMA surgery. During those visits, we discuss the recovery process in detail. We have videos to learn more about it now if you would like!
Sometimes braces (orthodontics) can help set you up for a better final surgical outcome. Other times braces are needed to correct any changes in the way the teeth fit following surgery.
The best candidates for MMA are people with small jaws. Advancing those people with surgery often has favorable benefits on facial esthetics. Chin projection, improved jaw line, better facial balance, and improved lip support are all things that people notice.
We often find that people notice the increase in upper airway size during the day. This makes breathing at rest or with exercise easier. While these reports are anecdotal, it makes sense that breathing takes less effort with more space.
If your teeth don’t fit ideally, MMA can improve this too. Underbites, overbites, cross bites, open bites can all improve dramatically with MMA.
The last benefit is head position. People with upper airway restriction have a chin up head forward head posture. This causes tension in the posterior neck. MMA improves posture through pulling on the anterior neck musculature and opening the upper airway.
Many insurances provide coverage for MMA to treat sleep apnea. Here are common criteria that insurance companies want us to show in order for them to provide coverage.
- moderate to severe OSA
- intolerance of pap therapy (6 month trial)
- reasons why other treatments won’t work
Contemporary MMA uses various surgical adjuncts to improve the final outcome.
The animated surgical simulation prior to this section is a surgery that Dr. Bobek refers to as MMAW. The upper and lower jaws are advanced and widened at the same time. He is a pioneer in this surgery as the complexity is high. Widening the arches at the time of MMA or as a first stage surgery (midline distraction) is thought to decrease the risk of persistent sleep apnea after MMA. Widening of the upper and lower arches gives more tongue space and nasal breathing. It does change the face more in that the jawline becomes wider. We find this procedure to be useful in people comfortable with a more traditionally masculine jawline.
Counterclockwise rotation refers to an increase in the occlusal plane’s pitch when viewing the head from the right profile. This allows for a better opening of the upper airway and for improved facial aesthetics. MMA can be associated with negative esthetics in some people. The classic negative face change is too much fullness under the nose giving a simian appearance. Counterclockwise rotation of the upper and lower jaws helps minimize face change.
While surgery on your chin may not seem helpful for breathing, the tongue attaches to the inner aspect of your chin. This area is referred to as the genial tubercles. Moving the genial tubercles forward pulls the base of the tongue forward. This surgery is known as Genial Tubercle Advancement (GTA). Dr. Bobek performs this along with a traditional genioplasty. By doing a genioplasty, the genial tubercles can be better visualized and there is no need to twist the tubercles as classically described in GTA. Chin esthetics can be addressed at the same time – whether it is to minimize the change with MMA or it is to maximize the change.
Often, nasal breathing is much improved with MMA. This has to do with the increased nasal airway space associated with this procedure. Additional things can be done at the time of MMA including a septoplasty or turbinate reduction. The floor of the nose (alar base) is often widened during MMA to help with nasal breathing.
Airway changes typical of MMA
Here are typical changes seen with MMA. These are 3 dimensional pictures of the upper airway before and after surgery. First pictures are from the side and the second are from the front. A doubling in total airway space and tripling in minimum area is to be expected. Here are some superimposed airway changes. The little black circle is before surgery and the larger circle is after surgery. The lower images are a little different way to visualize things.
