Effects of mandibular setback surgery on upper airway dimensions and their influence on obstructive sleep apnoea – A systematic review
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)
- et al.
A comparative CT evaluation of pharyngeal airway changes in class III patients receiving bimaxillary surgery or mandibular setback surgery
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2008) - et al.
The effect of mandibular setback or two-jaws surgery on pharyngeal airway among different genders
Int J Oral Maxillofac Surg
(2009) - et al.
Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders
J Oral Maxillofac Surg
(2010) - et al.
Comparison of CBCT parameters and sleep questionnaires in sleep apnea patients and controls
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2010 February) - et al.
The impact of Le Fort I advancement and bilateral sagittal split osteotomy setback on ventilation during sleep
Int J Oral Maxillofac Surg
(2009) - et al.
Changes in posterior airway space, pulmonary function and sleep quality, following bimaxillary orthognathic surgery
Int J Oral Maxillofac Surg
(2012) - et al.
Changes in oropharyngeal airway and respiratory function during sleep after orthognathic surgery in patients with mandibular prognathism
Int J Oral Maxillofac Surg
(2011) - et al.
Three-dimensional analysis of pharyngeal airway volume in adults with anterior position of the mandible
Am J Orthod Dentofacial Orthop
(2011) - et al.
Three-dimensional changes in pharyngeal airway in skeletal class III patients undergoing orthognathic surgery
J Oral Maxillofac Surg
(2011) - et al.
Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of class III malocclusion
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
(2010)
Three-dimensional computed tomographic evaluation of morphologic airway changes after mandibular setback osteotomy for prognathism
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
Effects of mandibular setback surgery on oropharyngeal airway and arterial oxygen saturation
Int J Oral Maxillofac Surg
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