Effects of transverse maxillomandibular distraction osteogenesis on obstructive sleep apnea syndrome and on the pharynx

  • Pedro Pileggi VinhaEmail author
  • Ana Célia Faria
  • Mariana Christino
  • Francisco Veríssimo de Mello-Filho
Sleep Breathing Physiology and Disorders • Original Article



To assess the effects of transverse maxillomandibular distraction osteogenesis (TMDO) on the treatment of obstructive sleep apnea (OSA) and on the morphology of the pharynx.


A clinical trial was conducted with seven patients with OSA and with transverse maxillomandibular deficiency, two women and five men aged on average 41.16 ± 10.9 years on the day of surgery. All participants were submitted to computed tomography (CT) and full-night polysomnography (PSG) before and approximately 9 months after surgery. A 95% confidence interval was defined.


The AHI and RDI of the participants were reduced by about 62% (from 27.65 ± 36.65 to 10.73 ± 11.78, p = 0.031 and from 41.21 ± 32.73 to 15.30 ± 13.87, p = 0.015, respectively). The airway showed a surprising mean reduction in volume of 10% (from 5.78 ± 2.53 to 4.71 ± 1.42, p = 0.437, for the upper pharynx; from 6.98 ± 2.23 to 6.23 ± 2.05, p = 0.437, for the lower pharynx; and from 12.76 ± 1.56 to 10.94 ± 2.42, p = 0.625, for the total pharynx). However, the site of the smallest area of the pharynx was considerably increased both in the anteroposterior and transverse direction and in its total area (from 0.88 ± 7.11 to 0.99 ± 0.39, p = 0.625; from 1.78 ± 0.81 to 2.05 ± 0.61, p = 0.812; and from 0.99 ± 0.74 to 1.40 ± 0.51, p = 0.180, respectively).


TMDO proved to be efficient in reducing or curing OSA, producing modifications of upper pharynx morphology with an increase of the smallest area of the pharynx.


Surgically assisted rapid maxilla expansion Adults Middle age Sleep apnea syndrome Maxillary transverse distraction osteogenesis Mandibular transverse distraction osteogenesis Maxillomandibular transverse distraction osteogenesis 



Transverse maxillomandibular distraction osteogenesis


Transverse maxillary distraction osteogenesis or surgically assisted rapid

maxillary expansion


Posterior nasal spine


Upper pharynx


Lower pharynx


Total pharynx


Obstructive sleep apnea


Computed tomography


Full-night polysomnography


Funding information

This study received financial support from FAPESP (Fundação de Amparo à Pesquisa do Estado de São Paulo), no. 2011.50305-7.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Statement of informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Tufik S, Santos-Silva R, Taddei JA, Bittencourt LRA (2010) Obstructive sleep apnea syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med 11:441–446. CrossRefGoogle Scholar
  2. 2.
    Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, Martínez-Alonso M, Carmona C, Barceló A, Chiner E, Masa JF, Gonzalez M, Marín JM, Garcia-Rio F, Diaz de Atauri J, Terán J, Mayos M, de la Peña M, Monasterio C, del Campo F, Montserrat JM, Spanish Sleep and Breathing Network (2012) Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. JAMA 307:2161–2168. CrossRefGoogle Scholar
  3. 3.
    Botros N, Concato J, Mohsenin V, Selim B, Doctor K, Yaggi HK (2009) Obstructive sleep apnea as a risk factor for type 2 diabetes. Am J Med 122:1122–1127. CrossRefGoogle Scholar
  4. 4.
    Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235. CrossRefGoogle Scholar
  5. 5.
    Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, Stubbs R, Hla KM (2008) Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 31:1071–1078CrossRefGoogle Scholar
  6. 6.
    Cistulli PA (1996) Craniofacial abnormalities in obstructive sleep apnoea: implications for treatment. Respirology 1:167–174CrossRefGoogle Scholar
  7. 7.
    Flores-Mir C, Korayem M, Heo G, Witmans M, Major MP, Major PW (2013) Craniofacial morphological characteristics in children with obstructive sleep apnea syndrome: a systematic review and meta-analysis. J Am Dent Assoc 144:269–277. CrossRefGoogle Scholar
  8. 8.
    Faria AC, da Silva-Junior SN, Garcia LV, dos Santos AC, Fernandes MRF, de Mello-Filho FV (2013) Volumetric analysis of the pharynx in patients with obstructive sleep apnea (OSA) treated with maxillomandibular advancement (MMA). Sleep Breath 17:395–401. CrossRefGoogle Scholar
  9. 9.
    Faria AC, Garcia LV, Dos Santos AC, Diniz PRB, Ribeiro HT, De Mello-Filho FV (2012) Comparison of the area of the pharynx during wakefulness and induced sleep in patients with obstructive sleep apnea (OSA). Braz J Otorhinolaryngol 78:103–108CrossRefGoogle Scholar
  10. 10.
    Vinha PP, Eckeli AL, Faria AC, Xavier SP, de Mello-Filho FV (2016) Effects of surgically assisted rapid maxillary expansion on obstructive sleep apnea and daytime sleepiness. Sleep Breath 20:501–508. CrossRefGoogle Scholar
  11. 11.
    Liu SY-C, Guilleminault C, Huon L-K, Yoon A (2017) Distraction osteogenesis maxillary expansion (DOME) for adult obstructive sleep apnea patients with high arched palate. Otolaryngol Neck Surg 157:345–348. CrossRefGoogle Scholar
  12. 12.
    Palmisano RG, Wilcox I, Sullivan CE, Cistulli PA (1996) Treatment of snoring and obstructive sleep apnoea by rapid maxillary expansion. Aust NZ J Med 26:428–429. CrossRefGoogle Scholar
  13. 13.
    Cistulli PA, Richards GN, Palmisano RG, Unger G, Berthon-Jones M, Sullivan CE (1996) Influence of maxillary constriction on nasal resistance and sleep apnea severity in patients with Marfan’s syndrome. Chest 110:1184–1188. CrossRefGoogle Scholar
  14. 14.
    Vinha PP, Faria AC, Xavier SP, Christino M, de Mello-Filho FV (2016) Enlargement of the pharynx resulting from surgically assisted rapid maxillary expansion. J Oral Maxillofac Surg 74:369–379. CrossRefGoogle Scholar
  15. 15.
    Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA (2008) Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep 31:543–547CrossRefGoogle Scholar
  16. 16.
    Cistulli PA, Palmisano RG, Poole MD (1998) Treatment of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep 21:831–835CrossRefGoogle Scholar
  17. 17.
    Abdullatif J, Certal V, Zaghi S, Song SA, Chang ET, Gillespie MB, Camacho M (2016) Maxillary expansion and maxillomandibular expansion for adult OSA: a systematic review and meta-analysis. J Cranio-Maxillofacial Surg 44:574–578. CrossRefGoogle Scholar
  18. 18.
    Guerrero CA, Bell WH, Contasti GI, Rodriguez AM (1997) Mandibular widening by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg 35:383–392CrossRefGoogle Scholar
  19. 19.
    Bell WH, Harper RP, Gonzalez M, Cherkashin AM, Samchukov ML (1997) Distraction osteogenesis to widen the mandible. Br J Oral Maxillofac Surg 35:11–19CrossRefGoogle Scholar
  20. 20.
    Guilleminault C, Li KK (2004) Maxillomandibular expansion for the treatment of sleep-disordered breathing: preliminary result. Laryngoscope 114:893–896. CrossRefGoogle Scholar
  21. 21.
    Bonetti GA, Piccin O, Lancellotti L, Bianchi A, Marchetti C (2009) A case report on the efficacy of transverse expansion in severe obstructive sleep apnea syndrome. Sleep Breath 13:93–96. CrossRefGoogle Scholar
  22. 22.
    Nie P, Zhu M, Lu X-F, Fang B (2013) Bone-anchored maxillary expansion and bilateral interoral mandibular distraction osteogenesis in adult with severe obstructive sleep apnea syndrome. J Craniofac Surg 24:949–952. CrossRefGoogle Scholar
  23. 23.
    Iber C, Ancoli-Israel S, Chesson JRA, Quan S. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications 2007Google Scholar
  24. 24.
    Seeberger R, Kater W, Davids R, Thiele OC (2010) Long term effects of surgically assisted rapid maxillary expansion without performing osteotomy of the pterygoid plates. J Craniomaxillofac Surg 38:175–178. CrossRefGoogle Scholar
  25. 25.
    Suri L, Taneja P (2008) Surgically assisted rapid palatal expansion: a literature review. Am J Orthod Dentofac Orthop 133:290–302. CrossRefGoogle Scholar
  26. 26.
    Laudemann K, Petruchin O, Mack MG, Kopp S, Sader R, Landes CA (2009) Evaluation of surgically assisted rapid maxillary expansion with or without pterygomaxillary disjunction based upon preoperative and post-expansion 3D computed tomography data. Oral Maxillofac Surg 13:159–169. CrossRefGoogle Scholar
  27. 27.
    Koudstaal MJ, Poort LJ, van der Wal KGH, Wolvius EB, Prahl-Andersen B, Schulten AJM (2006) Surgically assisted rapid maxillary expansion (SARME): a review of the literature. Int J Oral Maxillofac Surg 34:709–714. CrossRefGoogle Scholar
  28. 28.
    Weissheimer A, De Menezes LM, Sameshima GT, Enciso R, Pham J, Grauer D (2012) Imaging software accuracy for 3-dimensional analysis of the upper airway. Am J Orthod Dentofac Orthop 142:801–813. CrossRefGoogle Scholar
  29. 29.
    Rosset A, Spadola L, Ratib O (2004) OsiriX: an open-source software for navigating in multidimensional DICOM images. J Digit Imaging 17:205–216. CrossRefGoogle Scholar
  30. 30.
    Guijarro-Martínez R, Swennen GRJ (2011) Cone-beam computerized tomography imaging and analysis of the upper airway: a systematic review of the literature. Int J Oral Maxillofac Surg 40:1227–1237. CrossRefGoogle Scholar
  31. 31.
    Chang Y, Koenig LJ, Pruszynski JE, Bradley TG, Bosio JA, Liu D (2013) Dimensional changes of upper airway after rapid maxillary expansion: a prospective cone-beam computed tomography study. Am J Orthod Dentofac Orthop 143:462–470. CrossRefGoogle Scholar
  32. 32.
    Ota M, Neo M, Aoyama T, Ishizaki T, Fujibayashi S, Takemoto M, Nakayama T, Nakamura T (2011) Impact of the O-C2 angle on the oropharyngeal space in normal patients. Spine (Phila Pa 1976) 36:E720–E726. CrossRefGoogle Scholar
  33. 33.
    Ataka H, Tanno T, Miyashita T, Isono S, Yamazaki M (2010) Occipitocervical fusion has potential to improve sleep apnea in patients with rheumatoid arthritis and upper cervical lesions. Spine (Phila Pa 1976) 35:E971–E975. CrossRefGoogle Scholar
  34. 34.
    Caples SSM, Rowley JA, Prinsell JJR, Pallanch JF, Elamin MB, Katz SG et al (2010) Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep 33:1396–1407CrossRefGoogle Scholar
  35. 35.
    Kartalian A, Gohl E, Adamian M, Enciso R (2010) Cone-beam computerized tomography evaluation of the maxillary dentoskeletal complex after rapid palatal expansion. Am J Orthod Dentofac Orthop 138:486–492. CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculty of Medicine of Ribeirão PretoUniversity of São PauloRibeirão PretoBrazil

Personalised recommendations