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Counterclockwise maxillomandibular advancement: a choice for Chinese patients with severe obstructive sleep apnea

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Maxillomandibular advancement (MMA) is an effective alternative for treating severe obstructive sleep apnea (OSA). However, the promotion of MMA in China is limited by many Chinese patients having a convex facial profile. To achieve maximal upper airway enlargement without an esthetic disaster, we added counterclockwise rotation of the maxillomandibular complex (MMC) in the routine MMA. In this paper, we have evaluated the objective and subjective outcomes of this technology.


In total, 33 severe OSA patients who accepted counterclockwise maxillomandibular advancement (CMMA) were investigated in this study. Genioplasty, uvulopalatopharyngoplasty (UPPP), and turbinate reduction were also performed on selected patients. Polysomnography (PSG) and Epworth sleepiness scale (ESS) were chosen to evaluate the effectiveness of this technology in treating OSA. Patients’ facial appearances were evaluated by cephalometric analysis and 5-point Likert scales.


After CMMA, the apnea-hypopnea index (AHI) decreased from 59.3 ± 14.6 to 10.2 ± 6.7 (P < 0.001), minimum SpO2 (pulse oxygen saturation, %) increased from 74.0 ± 11.7 to 88.8 ± 4.4 (P < 0.001), and ESS decreased from 12.5 ± 2.3 to 7.3 ± 2.1. It is encouraging that soft-tissue cephalometric measurements such as facial convexity angle, nasolabial angle, and labiomental fold were not worsening after surgery. The Likert scales revealed that 28 patients (85%) were satisfied or very satisfied with their facial changes. In addition, no patient complained about dental function after surgery.


These findings indicate that CMMA is an effective way to achieve a balance between airway enlargement and facial appearance for Chinese patients with severe OSA.

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The authors acknowledge the financial support received from the Science and Technology Commission Foundation of Shanghai Municipality (16140903900).

Author information

Correspondence to Hua Zhang or Xiaofeng Lu.

Ethics declarations


This study was funded by the Science and Technology Commission Foundation of Shanghai Municipality (16140903900).

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures involving human participants were approved by the Institutional Board of Ethics of the hospital.

Informed consent

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

Additional information


The authors here propose and validate a method to enhance esthetic outcomes after maxillary mandibular advancement surgery for OSA in their specific Asian cohort. The results submitted are highly encouraging and I congratulate the authors on their work.

Soroush Zaghi


Silong Wei and Yong Zhang are co-first author

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Wei, S., Zhang, Y., Guo, X. et al. Counterclockwise maxillomandibular advancement: a choice for Chinese patients with severe obstructive sleep apnea. Sleep Breath 21, 853–860 (2017). https://doi.org/10.1007/s11325-017-1484-7

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  • Counterclockwise rotation
  • Maxillomandibular advancement
  • Obstructive sleep apnea
  • Esthetics