Maxillomandibular Advancement for Obstructive Sleep Apnoea
1. What is Maxillomandibular Advancement?
2. Why is Maxillomandibular Advancement performed?
3. What happens before the surgery?
4.
5.
What is Maxillomandibular Advancement?
Maxillomandibular advancement (MMA), also known as double jaw or bimaxillary advancement surgery, is a highly effective treatment for obstructive sleep apnea (OSA) in patients with skeletal abnormalities who cannot tolerate CPAP or mandibular advancement devices. By surgically advancing the upper and lower jaws, MMA enlarges the airway, particularly behind the soft palate and tongue base, reducing airway collapse during sleep. Used clinically for over 35 years, MMA has a long-term success rate of ~90% and improves sleep, cognitive function, mood, and cardiovascular health.
Before Surgery
The airway is constricted due to the posterior position of the jaws, leading to breathing difficulties during sleep.
After Surgery
Advancement of the maxilla and mandible results in an expanded airway, reducing obstructions and improving breathing.
Why is Maxillomandibular Advancement performed?
Untreated obstructive sleep apnoea has serious consequences:
Quality of Life
• Poor sleep quality with frequently interrupted sleep
• Excessive daytime sleepiness and fatigue
• Memory and cognition impairment
• Disruption of sleep quality for bed partners
Health Risks
• Increased risk of motor vehicle accidents due to daytime sleepiness
• High blood pressure (hypertension)
• Diabetes
• Abnormal heart rhythm (arrhythmias)
• Heart attack (myocardial infarction)
• Stroke
• Dementia
Important considerations for MMA
• Surgery duration: 6–8 hours
• First 4 weeks of recovery are the most challenging and social support is important
• Most patients return to work after 1 month
• Lip and facial numbness is common; may take up to 1 year to resolve
• Facial appearance will change slightly but remain natural as jaw advancement is carefully planned for facial balance and airway improvement
• Temporary dietary restrictions may lead to weight loss
What happens before the surgery?
Initial Consults
• Ear, Nose & Throat Surgeon, Oral & Maxillofacial Surgeon and Orthodontist
Medical & Sleep History
• Medical and sleep history will be reviewed.
• Sleep questionnaires will be completed.
• Sleep study (polysomnography) will be arranged.
Physical Examination and Airway Evaluation
• Clinical assessment of the face and oral cavity.
• Nasoendoscopy will be performed in the clinic to examine the upper airway.
• Drug-Induced Sleep Endoscopy (DISE) may be performed to conduct an airway examination under sedative anesthesia (done in operating theatre) to simulate sleep conditions.
Treatment Planning
• Medical and surgical treatment options will be discussed.
• If MMA (Maxillomandibular Advancement) is recommended, the following will be arranged:
▪ Pre-operative photographs
▪ Dental X-rays, Cone Beam Computed Tomography (CBCT) or standard CT scan
▪ Dental impressions or intraoral scans
Orthodontic Preparation
• Begin orthodontic treatment (braces) to align teeth before surgery.
• Dental extractions may be needed.
• You'll learn to use rubber bands on brackets as required
• Expect multiple visits up to 1 to 1.5 years.
• MMA surgery is scheduled when orthodontic treatment is nearly or fully complete.
Note: Orthodontic treatment is billed separately from the surgery.
Maxillomandibular Advancement for Obstructive Sleep Apnoea
Virtual Surgical Planning (No attendance required)
• Conducted 14–21 days before surgery.
• CBCT/CT scans and dental models/intraoral scans will be used to create a 3D model of your jaws and skull.
• Surgical cuts (osteotomies) and jaw movements are precisely planned on the 3D model
• 3D-printed splints are created to accurately position the jaws and bite during surgery.
Return Consult
• The virtual surgical plan, surgical process and post-operative recovery will be discussed.
• Informed consent will be obtained during this visit.
• Ample opportunities for you to ask questions will be given.
Pre-operative
Visit with Anesthesia (Within 4 weeks of surgery)
• The primary goal is to ensure that you are fit for surgery.
• Blood-thinning medications must be stopped at least 7 days prior to surgery (depending on anesthetist’s advice).
• Avoid traditional medicines and supplements (e.g., gingko, ginseng, goji, wolfberry, fish oils).
The Day Before Surgery
• You will receive a call with reminders and instructions.
• Begin fasting from 12 midnight on the day before surgery.
• Information on when and where to report on the day of surgery will be provided.
3D model of skull before osteotomy After osteotomy & bone repositioning
What
Pre-Operative Preparation
Upon arrival, you will settle into the pre-operative area, where you’ll meet the anesthesia and surgical team. We will answer last-minute questions and address any concerns to ensure you are informed and comfortable.
During Surgery
Once asleep, a breathing tube will be gently placed to support your airway, and a temporary urinary catheter will be inserted. You won’t feel or remember this. The surgical team will proceed with your procedure. While surgery duration varies, it will be approximately 6 to 8 hours from the time you enter the operating theatre till the time you leave.
Post-operative recovery
After surgery, our surgical team will update your family or designated guardian on how the procedure went and discuss the next steps in your recovery. You will be closely monitored in the Post Anesthesia Care Unit (PACU) until the effects of anesthesia wear off, ensuring your comfort and safety. From pain management to follow-up care, every aspect of your recovery is planned to support your healing and well-being.
What happens after surgery?
In-hospital care
After waking up in the Post Anesthesia Care Unit (PACU), you will be transferred to the ward where you will stay to recover after surgery.
Patients are normally hospitalised for 1-2 nights. If more time is required, our team will discharge you accordingly. The post-operative instructions will be reviewed with you and your family prior to discharge. You will be discharged when you are comfortable caring for yourself at home. Post-operative blood tests and a post-operative CT scan may be performed prior to discharge.
Goals prior to discharge
• Able to walk about and urinate on your own
• Able to self-feed with a liquid diet (for ~ 1 week) and take medications as instructed
• Able to perform oral rinsing as demonstrated
• Able to change jaw dressing and apply ice packs on your own
• Pain is well controlled
• No nausea or vomiting
When are my follow up appointments and what happens at these appointments?
1 week after surgery
• You will receive the date and time for this appointment before hospital discharge.
• This is the first post-operative visit.
• Your healing and bite will be assessed.
• Dental X-rays or CBCT/CT scans may be acquired.
• Instructions on dental elastics wear and diet will be provided.
• Typically, after the first week, you may transition to a pureed or soft diet (such as porridge with minced meat, mashed potatoes, yoghurt, smooth soup).
2-4 weeks after surgery
• We will continue evaluating your healing (swelling, surgical sites and bite) during weekly appointments.
• Please begin light physical activity (e.g. short walks) as tolerated, gradually increasing the intensity based on your comfort.
• Mouth opening exercise should be started with instructions from your surgeon.
• Patients generally return to eating a more regular diet 1 month after surgery while avoiding hard foods (e.g. steak, nuts) and those requiring significant mouth opening (e.g. whole apples).
• You will be referred to our orthodontist to continue the fine tuning of your bite.
3 months after surgery
• A comprehensive anatomic evaluation including a nasoendoscope of your airway will be performed.
• A sleep study will be done to evaluate the outcome of your surgery.
• At this time, your jaws should have fully healed which allows you to return to a normal diet.
6 months after surgery
• You will be reviewed in the clinic and post-operative x-rays will be acquired.
12 months after surgery
• You will be reviewed in the clinic and post-operative x-rays will be acquired.
• Yearly clinical reviews will be conducted for up to 5 years or as required.
What are the Side Effects of MMA Surgery?
While Maxillomandibular Advancement (MMA) is highly effective in Obstructive treating Sleep Apnoea (OSA), like any major surgery, it comes with certain temporary side effects Below is a detailed breakdown of the most common side effects and what patients can expect can expect during recovery.
Pain
You can expect some pain, but it is uncommon to experience extreme pain. With the use of pain medication, patients generally complain of dull, achy pain and a feeling of discomfort. Some patients also experience nerve-related pain (described as a “burning” or “electric shock-like”) during recovery. These symptoms can be managed with special nerve-pain medication.
Nausea and vomiting
Some patients experience nausea and vomiting following completion of the surgery. This commonly occurs as a reaction to the anaesthetic medications and resolves in 1-2 days. Nausea and vomiting are managed with anti-nausea medications. If vomiting does occur, the dental elastics should be cut immediately.
Bleeding
Oozing is common for the first 1-3 days following surgery. To help manage this, you are encouraged to remain inclined (with the head of bed elevated to at least a 30-degree angle). A suction tube (similar to when you are at the dentist) will be provided in the hospital for use in the oral cavity to help with secretions.
Swelling
This is expected following surgery. It is most prominent in the lips and will become more pronounced over the first post-operative week. Using the jaw bra with icepacks will help reduce swelling. The vast majority of swelling will resolve within the first month. However, most of the swelling will take up to 6 months to resolve.
Weight loss
Due to dietary restrictions following surgery, , most patients lose at least 5kg in the first 3 months after surgery. Generally, some of this weight will return over time (unless lifestyle changes are made).
Sensory changes
All patients will have numbness or altered sensation in a distribution covering the low face, surrounding and including the lips following the surgery. This is a result of stretching of the nerves caused by the movement of the upper and lower jaws forward. These sensory changes are often noticed when kissing one’s partner, trying to enunciate certain sounds, smiling widely, rinsing, eating or drinking. This numbness improves slowly (over several weeks to a few months) and returns fully in the most of our patients. For patients that are older (greater than 60 years old) or have medical problems that slow healing (diabetes), return of sensation can take much longer or may only partially return. Some patients experience nerve-related pain during the healing process (usually described as an electric shock-like or burning sensation). This can be managed by using nerve medications prescribed by our team.
Changes in occlusion (your bite)
The goal of MMA surgery is to preserve your original bite or achieve a stable bite. Minor bite changes are common and typically self-correct. Orthodontic treatment, if needed, will refine the bite over 6–12 months. In rare cases of significant misalignment, additional surgery may be required.
Trismus (limited mouth opening)
After MMA surgery, your mouth opening will be reduced due to tissue stretching. Physiotherapy will begin 3–6 weeks post-op as directed. Once cleared by your surgeon, perform mouth opening exercises: open as wide as possible without pain, holding for 10 seconds, 10 times per set, 10 sets per day. Continue daily for 6 months or until normal opening returns.
Changes in facial appearance
MMA will change your facial appearance, but it won’t look unnatural. Your facial and jaw positions are taken into consideration during planning to balance airway expansion and facial aesthetics. In general, advancing the jaws results in a more favourable appearance as patients who are good candidates for this procedure tend to have retruded lower jaws.
Sleep symptoms
The occurrence of vivid dreams post-surgery is not uncommon due to deep sleep rebound phenomenon and tends to wear off in a matter of weeks. Persistent or worse snoring can also occur in the first 2 weeks until post operative swelling subsides.
What are the Possible Complications of MMA Surgery?
Infection
To reduce infection risk, you will receive antibiotics during and after surgery. Healing will be closely monitored. If infection occurs, it is usually treated with antibiotics and follow-up. In some cases a minor surgery may be required to remove plates and screws that may be the cause of infection. This complication occurs in about 10% of cases.
Damage to Teeth
Tooth discoloration, tooth devitalisation, damage to dental roots and dental crowns can occur.
Bony Non-Union (failure of the bony cuts to heal)
Rarely, and more often in patients with poor wound healing, the bone segments may not heal and fuse properly after surgery. This can lead to infection, mobility between bone segments, and may require revision surgery. The risk is under 5%.
Unintended Fracture of the Mandible
Occasionally, the lower jaw may fracture in an unintended area during surgery, requiring a reconstructive plate. This occurs in about 10% of cases. Bone healing takes up to 6 months, so avoid facial trauma (getting hit in the face) and hard foods during recovery. If you experience pain or bite changes, please contact our team promptly.
Permanent or longstanding numbness
Sensory nerves to the mid and lower face are at risk during surgery. If a nerve is accidentally cut, it may be repaired, but recovery of sensation can be slow or incomplete.
Nasal obstruction
One of the goals of this surgery is to improve nasal breathing. In some cases, nasal blockage can occur post-operatively, which may need to be corrected with a minor procedure depending on the severity. The risk of this complication is roughly 5%.
Temporomandibular Joint Problems
Shifting the lower jaw forward can strain the temporomandibular joint (TMJ), potentially causing long-term discomfort or joint issues. In rare cases, the TMJ may deteriorate over time, requiring further surgery. The risk of TMJ complications is about 3–5%.
Maxilla and Dentoalveolar Necrosis
In very rare cases (less than 1%), MMA surgery may disrupt blood flow to the upper jaw or dental segments, especially with segmental surgery. This can lead to tissue loss and require additional surgery.
Frequently Asked Questions (FAQ)
What is the chance that MMA will treat my sleep apnoea?
MMA surgery has been shown to improve obstructive sleep apnoea (OSA) or convert it to a mild form in nearly 90% of patients.
Will there be any visible external scarring?
There may be small incisions (5mm to 10mm) on your cheeks and chin which heal with minimal or no scarring.
Will I look different?
Yes, your jaws will assume a more forward position. While your loved ones will likely notice a difference, strangers will not perceive your appearance as unusual.
Is this surgery very painful?
No, pain is to be expected, but it is uncommon to experience extreme pain after the operation. By comparison, this surgery is less painful than having your tonsils removed. With the use of pain medications, patients generally complain of a dull, achy pain and a feeling of discomfort in the face.
Can I eat and talk after the operation?
Yes. Your jaw will not be wired shut but held in place with elastic bands. Your diet should be entirely liquid while the elastics are in place (~ 7 days). A pureed or soft diet can be started 1 week after surgery (such as porridge with minced meat). A more regular diet can usually be started 1 month after surgery while avoiding hard foods (e.g. steak, nuts) and those requiring significant mouth opening (e.g. whole apples) till 2 months after surgery.
How much time should I take off work?
Depending on the nature of your job, you will require between 3 to 6 weeks to return to full duty.
How long after the surgery can I start doing sports and other physical activities?
You can start jogging or lifting weights 2 to 4 weeks after surgery, provided that care is taken not to traumatise your face. Contact sports are not allowed until 6 months after surgery when bony healing is complete.
The Sleep Team
Otolaryngologist
Dr Leonard Soh Jie Min
Oral & Maxillofacial Surgeon
Dr Lee Chee Seng
Orthodontist
Dr Ng Yao Xuan Adabelle
Contact us
MBBS, MRCS (Edin), MMed (Otorhinolaryngology)
Clinical Fellow in Sleep Medicine and Sleep Surgery at University of Pennsylvania, United States
