Counterclockwise rotation of the occlusal plane in the treatment of obstructive sleep apnea syndrome.

Maxillofacial surgeons are increasingly involved in the surgical management of patients affected by severe obstructive sleep apnea syndrome (OSAS) because of the high success rate of maxillomandibular advancement (MMA).1, 2 This increase has occurred in the absence of a correlation between the dimensions of the upper airways corresponding to a resolution of OSAS. There is also no mathematical correlation between bimaxillary advancement and resulting change in dimensions of the posterior airway space (PAS).3 Most surgeons now agree that the best results are achieved by advancing the jaw as much as possible, maintaining an acceptable functional and esthetic result.4, 5 The criteria for patient selection included severe OSAS patients unsuitable for undergo conventional procedures and able to receive a maximum advancement. Although MMA is a life-saving treatment in severe OSAS patients, esthetic considerations cannot be neglected, because these patients usually exhibit normal craniofacial skeletal morphology. Therefore the limit of the MMA is represented by that beyond which an unacceptable deformity would be created. Technical improvements are necessary to make extreme bimaxillary advancements more esthetically acceptable. Recent review of opinions held for the last decade regarding the treatment of facial deformity has led us to exploit a method from the past, the counterclockwise rotation of the occlusal plane,6 which was previously used in correcting severe Class II skeletal deformity, called the bird-face deformity. The results achieved from mandibular advancement with counterclockwise rotation of the occlusal plane overcome those of sagittal bimaxillary movement. This method achieves esthetic goals and fulfills the main objective in the treatment of OSAS, which is to increase PAS. Rotation of the occlusal plane has been shown to produce significant modifications of the upper airways.7 Counterclockwise rotation of the occlusal plane in the correction of severe OSAS is an effective technique for increasing airway function in selected cases while preventing deformity. This article aims to highlight the importance of this technique and its association with reverse planning (performing mandibular osteotomy first). Because these movements are relatively unstable, we discuss ways of achieving stability using screws, plates, and interpositional bone graftin