Effects of mandibular setback surgery on upper airway dimensions and their influence on obstructive sleep apnoea – A systematic review

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Abstract

Background

Mandibular setback used to be the traditional treatment of choice for correcting mandibular prognathism. Nowadays, bimaxillary surgery is preferred. Several authors have asserted that mandibular setback causes a relative narrowing of the upper airway (UA) that could trigger obstructive sleep apnoea (OSA); however, its potential role in OSA development is still much debated. Another controversial subject is whether changes in airway space caused by the procedure are permanent.

Objectives

To ascertain the consequences for UA size and shape of mandibular setback surgery in comparison with bimaxillary surgery (maxillary advancement with Le Fort I and mandibular setback), and to analyse the changes in oximetric indices and their relationship with OSA.

Search methods

A systematic review was made of the bibliography in 4 databases: Medline, Scopus, Embase and Cochrane.

Selection criteria

Systematic reviews, meta-analyses, clinical trials and cohort and case–control studies of adults published in the past 15 years were included.

Data collection and analysis

The initial search yielded 668 articles, of which 498 were eliminated because of duplication and 123 on the basis of their titles and abstracts or summaries. The remaining 47 papers were read in their entirety, and 14 were included in the final selection.

Results

According to our observations, the nasopharyngeal space does not undergo significant changes after either of the two surgical procedures. In the oropharynx and hypopharynx, none of the measurements changed significantly with maxillary advancement; however, persistent and significant decreases in the area, horizontal linear dimensions, and volume of these spaces are encountered after mandibular setback alone. No long-term changes in oximetric indices were found.

Conclusions

Morphological changes are more pronounced following exclusively mandibular surgery. A decrease in the UA does take place but appears not to affect the patient's sleep quality. This study found no evidence to confirm that bimaxillary or mandibular orthognathic surgery predisposes to obstructive sleep apnoea development.

Introduction

Traditionally, the surgical procedure of choice to correct mandibular prognathism has been mandibular setback (Kawamata et al., 2000), but nowadays this is used in only 10% of cases (Degerliyurt et al., 2009). Some authors have indicated that it leads to a relative narrowing of the upper airway (UA) (Turnbull and Battagel, 2000, Foltán et al., 2009, Mattos et al., 2011, Gokce et al., 2012). The preferred choice currently is bimaxillary surgery (Gokce et al., 2012), as it achieves a better aesthetic effect and the airway anatomy is affected to a lesser degree (Park et al., 2012, Lee et al., 2013, Gonçales et al., 2014, Lee et al., 2012). Narrowing of the airway is expected after mandibular setback, and some authors have pointed to this as a factor triggering obstructive sleep apnoea (OSA) (Park et al., 2010). However, the potential role of this narrowing in OSA development remains a much-debated subject (Demetriades et al., 2010). It must not be forgotten that a physiological postural response to prevent airway collapse takes place after this surgery (Gokce et al., 2012, Panou et al., 2013, Kawamata et al., 2000, Jakobsone et al., 2010). Other controversial questions are whether the changes in the airway brought about by the surgery are permanent (Kim et al., 2013a, Park et al., 2010) and whether they also affect skeletal stability (Gonçales et al., 2014, Park et al., 2012).

The objectives of this review are to ascertain the consequences for UA size and shape of mandibular setback surgery in comparison with bimaxillary surgery (maxillary advancement with Le Fort I and mandibular setback), and to analyse the changes in oximetric indices and their relationship with OSA.

Section snippets

Materials and methods

The bibliography on UA alteration by mandibular setback and bimaxillary surgery (maxillary advancement with Le Fort I and mandibular setback) was subjected to a systematic review. It was carried out by two independent reviewers who followed the CONSORT criteria (Schulz et al., 2010). The 4 data bases searched were Medline, Scopus, Embase, and Cochrane. The search was made and updated on 15 April 2014. The following search limitations were set: type of publication: articles, articles in press

Characteristics of the imaging studies and of the measurements

Each of the studies refers to different anatomical planes in the upper airway. The eight studies recognise nine anatomical landmarks from which to construct planes at different levels of the UA (Table 2). The area, antero-posterior, and lateral dimensions and volume are measured on these planes, forming an image of the spatial morphology of the airway.

Results following bimaxillary surgery (BS)

The changes observed with bimaxillary surgery are less noticeable than with mandibular surgery. As regards the area measurements, no significant

Discussion

The evidence collected on morphological and volumetric changes in the airway following orthognathic surgery is scarce. The rigorous screening of methodologically acceptable articles undertaken for this systematic review had consequences for the number of articles included. In addition, different anatomical planes were used in each of the studies, causing difficulties in compiling and comparing the results.

Conclusions

Based on our study findings, we conclude the following:

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    In the medium term, the only significant change in UA morphology following bimaxillary surgery is an increase in horizontal area on the plane passing through the first cervical vertebra (C1) and a decrease in horizontal area on the plane passing through the fourth vertebra (C4).

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    After mandibular setback surgery alone, there is a significant decrease in area in the UA in general that persists in the medium and long term.

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    Comparison of the

Funding

This work was not supported by any external funding.

Acknowledgements

The authors wish to thank Mary Georgina Hardinge for translating the manuscript into English.

References (25)

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