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Rinnakkaistallenteet Terveystieteiden tiedekunta
2019
Effect of Maxillomandibular
Advancement Surgery on Pharyngeal Airway Volume and Polysomnography
Data in Obstructive Sleep Apnea Patients
Niskanen, I
Elsevier BV
Tieteelliset aikakauslehtiartikkelit
© American Association of Oral and Maxillofacial Surgeons
CC BY-NC-ND https://creativecommons.org/licenses/by-nc-nd/4.0/
http://dx.doi.org/10.1016/j.joms.2019.04.001
https://erepo.uef.fi/handle/123456789/7732
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Accepted Manuscript
Effect of maxillo-mandibular advancement surgery on pharyngeal airway volume and polysomnography data in obstructive sleep apnea patients
Iiro Niskanen., DDS, Jukka Kurimo., DDS, Jorma Järnstedt., DDS, Sari-Leena Himanen., MD. PhD, Mika Helminen., MSc, Timo Peltomäki., DDS. PhD
PII: S0278-2391(19)30365-9
DOI: https://doi.org/10.1016/j.joms.2019.04.001 Reference: YJOMS 58736
To appear in: Journal of Oral and Maxillofacial Surgery Received Date: 17 December 2018
Revised Date: 31 March 2019 Accepted Date: 1 April 2019
Please cite this article as: Niskanen. I, Kurimo. J, Järnstedt. J, Himanen. S-L, Helminen. M,
Peltomäki. T, Effect of maxillo-mandibular advancement surgery on pharyngeal airway volume and polysomnography data in obstructive sleep apnea patients, Journal of Oral and Maxillofacial Surgery (2019), doi: https://doi.org/10.1016/j.joms.2019.04.001.
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Effect of maxillo-mandibular advancement surgery on pharyngeal airway volume and polysomnography data in obstructive sleep apnea
patients
Iiro Niskanen (corresponding author). DDS. Research Fellow. Department of Ear and Oral Diseases, Tampere University Hospital, Tampere, Finland.
Postal Address: Tampereen yliopistollinen sairaala, Suu- ja leukasairauksien poliklinikka, PL 2000, 33521 Tampere, FINLAND.
Telephone: +358 505476242 Email: iiro.niskanen@fimnet.fi
Jukka Kurimo. DDS. Specialist of Orthodontics. Department of Ear and Oral Diseases, Tampere University Hospital, Tampere, Finland. Email: jukka.kurimo@pshp.fi
Jorma Järnstedt. DDS. Specialist of Oral and Maxillofacial Radiology. Department of Radiology, Medical Imaging Center, Tampere University Hospital, Tampere, Finland. Email: jorma.jarnstedt@pshp.fi
Sari-Leena Himanen. MD. PhD. Department of Clinical Neurophysiology, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Finland. Email: sari-leena.himanen@tuni.fi
Mika Helminen. MSc. Biostatistics Specialist. M.Sc., Biostatistician. Research, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland and Faculty of Social Sciences, Health Sciences, Tampere University, Tampere, Finland. Email: mika.helminen@tuni.fi
Timo Peltomäki. DDS. PhD. Specialist of Orthodontics. Department of Ear and Oral Diseases, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University and Institute of Dentistry, Faculty of Health Sciences, University of Eastern Finland. Email: timo.peltomaki@pshp.fi
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Effect of maxillo-mandibular advancement surgery on pharyngeal airway volume and polysomnography data in obstructive sleep apnea
patients
Abstract
Purpose
To study volumetric changes in the upper airway in obstructive sleep apnea (OSA) patients after maxillo- mandibular advancement (MMA) and compare findings to polysomnography (PSG) data of the same patients.
Patients and Methods
Study consisted of 20 OSA patients (mean age 48 years, range 31-59 years, 1 female, 19 male). Mean SNB and SNA angles before surgery indicated mandibular and maxillary retrognathia. All were treated with MMA including pre- and post-operative orthodontics. Pre- and post-treatment cone-beam computed tomograms (CBCT) were used to measure upper airway volume and PSG data to examine apnea-hypopnea index (AHI), oxygen desaturation index (ODI3/ODI4). In addition, Epworth Sleepiness Scale (ESS), General Health Questionnaire (GHQ-12) and amount of MMA was collected from patient´s files.
Results
Mean maxillary and mandibular advancement was 4.6±1.9 mm and 9.3±1.7 mm, respectively. Statistically significant increase (mean 64.1%) in the airway volume was found with large individual variation.
ODI3/ODI4 and AHI values improved statistically significantly from pre- to post-surgery. ODI3/ODI4 reduced from 12.3±9.8 to 4.0±4.2 and AHI 21.4±13.8 to 5.8±7.2. ESS scores improved (lower scores) post-surgery for majority of patients (n=15) while GHQ-12 scores improved (lower scores) in only six patients.
Conclusion
Maxillo-mandibular advancement increases upper airway volume and reduces OSA symptoms studied by PSG. MMA can be considered as curative treatment for OSA; however, residual AHI can be found in many patients.
Introduction
Maxillomandibular advancement (MMA) surgery is used to correct congenital (and acquired) craniofacial growth disorders. These disorders often lead to compromised facial esthetics and problems in occlusion. Several investigators 1 have shown the efficacy of MMA surgery in
improving quality of life of patients suffering from such conditions. In recent years MMA surgery has been advocated as a highly effective and curative method for the treatment of obstructive sleep apnea (OSA)2,3,4.
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OSA is a sleep-related breathing disorder characterized by partial or total collapse of the
pharyngeal airway during both rapid eye movement (REM) and non-REM sleep5. Epidemiological data suggests OSA prevalence to be between 9-24% in adults with up to 80% of individuals
remaining undiagnosed 6,7. If left untreated OSA can increase the risk of several conditions such as cardiovascular diseases, hypertension, stroke, headaches, daytime sleepiness and traffic accidents.
Continuous positive airway pressure (CPAP) therapy is considered the first-line and gold standard treatment for OSA8. Often mandibular advancement therapy (MAD) is offered as the second stage treatment, particularly if the patient does not tolerate CPAP and the OSA is mild. Both of these treatment methods reduce OSA symptoms but are not curative. MMA surgery, on the other hand, is a corrective treatment and a good option especially if the patient also suffers from an
unfavorable maxillo-mandibular relationship9.
Previous studies suggest that the mechanism by which MMA surgery may cure OSA is the expansion of pharyngeal airway due to advancement of the maxillo-mandibular complex and its muscles. Patients with diagnosed (moderate to severe) OSA and unfavorable skeletal maxillo- mandibular relationship may benefit from MMA surgery twofold since MMA with related orthodontics usually corrects the existing skeletal malocclusion and at the same time may cure OSA. Success rates for MMA surgery for the treatment of OSA have been reported to range from 65-100%10,11,12. While the efficacy of MMA surgery for the surgical treatment of OSA is well established13 only limited data exists on actual volumetric changes in the pharyngeal airway after MMA surgery. Additionally, there are only a few publications14 that compare the findings of the volumetric 3D cone beam computed tomogram (CBCT) analysis of the pharyngeal airway to polysomnography (PSG) data, which is the main diagnostic tool for the identification of OSA.
The purpose of this study was to analyze volumetric changes in the pharyngeal airway after maxillomandibular advancement surgery and compare these findings to the polysomnography data of the same patients.
1. Materials and methods
This retrospective study consisted of 20 patients diagnosed with OSA and treated with
maxillomandibular advancement at the Oral and Maxillofacial Unit, Tampere University Hospital, Tampere, Finland, in 2008-2016. This study followed the Declaration of Helsinki on medical protocol and ethics, and the regional ethical review board of the Tampere University Hospital approved the study. Pretreatment and post-treatment CBCTs were used for the pharyngeal airway analyses. Pre- and post-treatment lateral cephalograms were used for patients´ diagnoses and to study changes at the operation. PSG data, including apnea-hypopnea index (AHI), oxygen desaturation index (ODI-3 or ODI-4) and other variables such as age, sex, Epworth Sleepiness Scale (ESS), General Health Questionnaire (GHQ-12), body mass index (BMI), and amount of mandibular and maxillary advancement were used and collected manually from the patient files.
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1.1 Patient selection
An initial database search of the Tampere University Hospital patient archives yielded a total of 83 patients diagnosed with OSA and treated with MMA surgery between in 2008-2016. The following additional inclusion criteria were then applied: good quality (anatomical landmarks for volume analyses had to be clearly visible) pre- and postoperative (max. 1 year after surgery) CBCT images, pre- and post-operative polysomnography data and orthodontic treatment performed at Tampere University Hospital. Finally, 20 patients (19 males and 1 female) met the criteria and were included in the study.
1.2 CBCT images and volumetric analyses of the pharyngeal airway
CBCT scans were obtained before and after MMA surgery using a Scanora 3D (Soredex, Finland) or ProMax 3D Max (Planmeca, Finland) CBCT machine. The following imaging settings were used:
voxel size 400µm, 96kV, 8-11mA, 8-13s. Digital Imaging and Communications in Medicine (DICOM) data of axial batches (0.8mm slices) of the CBCT scans were imported into an analyzing software (Planmeca Romexis, Planmeca Inc. Finland). Using the software’s region growing tool (algorithm, threshold set to software default for air cavity 300) pre- and post-operative (max. 1 year after surgery) scans were analyzed. Anatomical landmarks used as borders for volume estimation (cm3) were maxilla superiorly and the most inferior part of the second vertebrae (Figure 1). All analyses were performed by the same operator (IN) using the same version (4.4.1.R) of the Romexis software. To assess intra-investigator error, ten randomly selected scans were measured again eight months after the first examination.
The mean (sd) intra-investigator error was 0.03 (0.28) cm3 for pre-op volume and 0.24 (0.46) cm3 for post-operative volume, with a maximum error of 0.90 cm3. Single measures Intra Class Correlation (absolute agreement) were 0.998 and 0.988 for pre- and postoperative volume.
1.3 Sleep recordings and polysomnography variables
Sleep recordings were cardiorespiratory polysomnographies performed at the sleep laboratory of the Tampere University Hospital. During 2008-2012 respiratory events were scored according to standard rules (hypopnea rule 4b15) and from 2012 onwards the updated rules were followed 16. In some pre-op recordings the ODI-4 index was used describe the number of desaturations per hour of sleep. Therefore, if ODI-4 was used in the pre-op recording and ODI-3 in the post-op recording, the post-op recording was re-analyzed and the ODI-4 was calculated. In this way only one ODI index (either ODI-3 or ODI-4) was taken into account for each patient. In addition to ODI, apnea- hypopnea indices were included in the analyses.
1.4 Surgical advancement of the maxillo-mandibular complex
The amount of maxillary and mandibular advancement (mm) in the horizontal plane was determined from surgery planning files. The majority of the surgeries were planned (and
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executed) using traditional models and splints, although in recent years digital surgery planning had mostly replaced traditional planning. Thus, part of the data was collected directly from the surgery planning software (Materialise ProPlan CMF, DePuy Synthes, Belgium). Pre- and post- treatment lateral cephalograms were used to study changes at the operation.
1.5 Additional variables
Demographic parameters included: sex, age, and BMI. Additionally, ESS and GHQ -12 were used to evaluate the patients’ subjective experiences.
1.6 Statistical analyses
Correlation analyses were performed using Spearman’s rank correlation and changes from pre- to post-treatment were analysed using Wilcoxon Signed Ranks Test. The level for statistical
significance was set to p<0.05. Statistical analyses were done with the IBM SPSS Statistics software (International Business Machines Corporation, Released 2015. IBM SPSS Statistics for Windows, Version 23.0 Armonk, NY: IBM Corp.)
2. Results
The study population consisted of 20 patients (19 males and 1 female) with a mean age of 48 years (range 31-59 years). Based on the lateral cephalometric study (Table 1) mean SNB angle before surgery was 76.9° indicating mandibular retrognathia. Mean SNA angle was 78° indicating
maxillary retrognathia. Measurement of the facial vertical proportions showed slight dolichofacial pattern (Sella-Nasion/Mandibular plane angle mean 34.9°). Standard cephalometric values for caucasians17 are presented for comparison. A total of 36% (n=8) of the patients were diagnosed with mild OSA (AHI < 5-14.9/h), 36% (n=8) with moderate OS (AHI 15-29.9) and 18% (n=4) with severe OSA (AHI >30) pre-operatively. Post-operatively 11 patients had an AHI lower than 5 and were not diagnosed with OSA post-surgery. Five patients had mild OSA and 3 patients moderate OSA. Two patients did not have their post-operative AHI measurements taken and their post-op OSA status thus could not be determined.
2.1 Volumetric data
Pre- and post-operative airway volumes were analyzed and mean, median and standard deviations were calculated. Mean airway volume before surgery was 10.97±4.29 cm3 and post-surgery
17.36±7.86 cm3. There was a statistically significant increase in airway volume following MMA - surgery. The mean increase in airway volume was 64.1%. However, there was also high variation in airway volumes between the patients (Table 2).
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2.2 Maxillo-mandibular advancement
The mean maxillary advancement was 4.6±1.9 mm and mandibular advancement 9.3±1.7 mm. All measurements were taken in the horizontal plane (Table 2). Nine patients had a decrease in S- NA/Mand angle, which indicated some counterclockwise rotation of the mandible at the operation. For the whole sample no statistically significant difference was noted in the facial vertical proportions (Table 1).
2.3 Sleep recordings and polygraphy data
Pre- and post-operative AHI and ODI-3/ODI-4 were analyzed and mean, median and standard deviations were calculated. Mean ODI-3/ODI-4 before surgery was 12.3±9.8 and post-surgery 4.0±4.2. Mean AHI pre-surgery was 21.4±13.8 and post-surgery 5.8±7.2. Changes in ODI and AHI were statistically significant (Table 3, Figure 2).
2.4 Additional variables
Mean, median and standard deviations were calculated for BMI, ESS and GHQ-12. ESS scores improved (lower scores) post-surgery for majority of patients (n=15) while GHQ-12 scores improved (lower scores) in only six patients. Mean BMI (25.5±3.3 vs. 26.6±2.3) increased slightly post-surgery although there was variation in the timing of the post-surgery BMI recording from a few months to 2 years after the surgery (Table 3).
2.5 Correlation analyses
Association between the amount of maxillary and mandibular advancement and other parameters (AHI, ODI-3/ODI-4, ESS, age) was studied. Spearman correlation analysis revealed three statistically significant correlations (rs=-0.56, rs=0.56, rs=-0.67), which were between the amount of maxillary advancement and post-op BMI, between post-op GHQ-12 and mandibular advancement and between post-op GHQ-12 and maxillary advancement. All other correlations were between -0.40 and 0.40 and not considered statistically significant (Table 4). Eventhough airway volume increase and AHI decrease following MMA surgery were statistically significant, no statistically significant correlation between these two parameters was found (rs=-0.36, p=0.14, n=19). Cephalometric angle change (Sella-Nasion/Mandible, pre- and postoperative measurements) was used to study correlation to change in AHI and ODI3/ODI4 and a statistically significant correlation was found (rs=-0.61, p=0.007, n=18).
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In this study, pre- and post-operative CBCT scans of 20 patients with OSA who had been treated with MMA-surgery were analyzed. A statistically significant increase in the 3D airway volume of the pharynx was found, which concurs with previous studies 18,19,20. There was, however, great individual variation between patients: airway volume increased in every patient, but in some patients the increase was very significant, whereas in others only slight improvement occurred. In this study the mean mandibular advancement was 9.3±1.7mm and mean maxillary advancement was 4.6±1.9 mm. In theory, the more the maxilla-mandibular complex is advanced the greater the airway volume should increase.
CBCT scans were used for the airway volume measurements. Previous studies have compared 2D cephalograms to CBCT scans for the evaluation of pharyngeal airway (volume estimation and minimum cross-section area) and concluded CBCT scans to be significantly more accurate 21. The main advantages of 3D imaging over 2D imaging are reconstruction and visualization of areas of interest in various planes. 3D CBCT also offers independent visualization of internal anatomical structures, such as the airway, by sculpting (=3D -render modeling of airway, Figure 1)22. However, CBCT imaging also has its disadvantages regarding pharyngeal airway evaluation. Since CBCT is a static, non-dynamic imaging method it may correlate poorly with OSA parameters studied by polysomnography. Furthermore, most CBCT images are taken awaken in an upright position which causes problems due to differences in upper airway geometry and functionality compared to the supine position at sleep 23.
Airway volume estimation from CBCT scans using region growing algorithms are fairly accurate if a) the quality of a CBCT scan is adequate, b) anatomical landmarks are chosen precisely and in the same way in each scan and c) the same threshold sensitivity protocol is followed in every
measurement. If these requirements are not met, there is a high chance of measurement error. To assess intra-investigator error, 10 randomly selected scans we re-measured 8 months after the first evaluation. Mean (sd) intra-investigator error was 0.03 (0.28) cm3 for pre-op volume and 0.24 (0.46) cm3 for post-op volume, which confirms that the measurement technique used is
repeatable and can be used for estimation of pharyngeal airway volume.
Zimmerman et al24 concluded in their systematic review that CBCT imaging has excellent reliability to asses airway volume, but they emphasize that only limited aspects of airway analysis
(methodological limitations, lack of manual orientation of images and selection of sensitivity threshold) have been evaluated, indicating further research is required to adequately establish the reliability of upper pharyngeal airway assessment of patients using dental CBCT.
There is evidence 2,12,25 that AHI decreases significantly following MMA-surgery, indicating MMA- surgery to be a highly effective surgical treatment for OSA. Depending on the success criteria of MMA surgery to treat OSA, 65 -100% success rates have been reported 10,11,12. In our study nearly all patients had lower AHI values post-surgery. Mean pre-surgical AHI 21.4±13.8 decreased to mean 5.8±7.2 post-surgery. 55% (n=11) of patients had a postsurgical AHI of less than five, which can be considered a complete success. Similar to airway volume change, there was also individual variation in the polysomnography findings.
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Patients´ subjective experience studied by ESS improved post-surgery for the majority of patients, while CHQ-12 scores changed only very little. This seems to indicate that most patients
subjectively benefitted from MMA surgery concerning sleepiness, but at the same did not notice improvement in their general health. According to Makowska et al.26, values over 3 in GHQ-12 indicate psychological stress. In our study 45% (9/20) of patients reported 3 or higher GHQ-12 values pre-operatively but only 25% (5/20) of patients reported these values post-operatively. The difference is not statistically relevant but is nevertheless of interest.
Only limited amount of MMA is possible due to patient-specific anatomy.Clinically, however, it would be of great importance to know how much MMA is needed individually to optimize
treatment outcomes for OSA. Many authors27,28 suggest achieving maximum advancement, i.e. by normalizing the cephalometric measurements on a lateral radiograph and producing a minimum advancement of 10 mm at the level of the mandible, and the same or less (5-10 mm) in the maxilla. The length of mandibular advancement usually varies from 10 to 12 mm. Maxillary advancement is the same or less (5-10 mm) taking into account that the mandible does a
counterclockwise rotation during the advancement. In our study counterclockwise rotation of the mandible was recorded in 9 patients, however, no statistically significant association was found between mandibular rotation and PSG-values in these subjects. Due to small variation in the amount of MMA in the present study, the association between airway volume increase and amount of advancement could not be studied.
A statistically significant increase in BMI was found, which agrees with the long-term Finnish study in OSA patients treated with MMA 29 and highlights the importance of weight control in OSA patients. As it is widely accepted that weight gain during OSA treatment worsens the final
outcome it is imperative that surgical intervention should increase the airway as much as possible.
We think this clearly suggests that MMA, as opposed to only mandibular advancement surgery, is indeed beneficial in the treatment of OSA patients.
The association between the amount of maxillary and mandibular advancement and other parameters (AHI, ODI3/ODI4, ESS, CHQ-12, age) was also studied (Spearman Correlation analysis) but was found to be statistically weak.
4. Conclusions
In line with previous studies our study indicates that MMA is an effective means of increasing upper airway and reducing AHI and ODI in OSA patients. Considerable individual variation was found regarding both increase in airway and improvement in polysomnographic findings. While patients´ subjective feeling of sleepiness as studied by ESS seemed to reduce, their feeling of general healthiness does not necessarily concurrently improve.
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5. References
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9. Dicus Brookes CC, Boyd SB. Controversies in Obstructive Sleep Apnea Surgery. Oral Maxillofac Surg Clin North Am. 2017 29:503, 2017.
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26. Makowska, Z., D. Merecz, A. Moscicka, W. Kolasa. 2002. The validity of general health questionnaires, GHQ-12 and GHQ-28, in mental health studies of working people. Int J Occup Med Environ Health 15:353, 2002.
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advancement as the initial treatment of obstructive sleep apnea: five years follow-up of the Pori experience. J Oral Maxillofac Res. 3:e5, 2012.
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TABLE 1. Cephalometric measurements
Pre- and postoperative lateral cephalometric values for the study group (n=19) with standard values for Caucasians17
Before surgery After surgery p* Standard value
Mean Range Mean Range
SNA 78.0 71-84 81.2 75-88 <0.0001 82
SNB 76.9 70-84 81.3 74-89 <0.0001 80
ANB 2.9 0-8 2.7 0-7 0.887 2
S-Na/Mand 34.9 25-47 34.9 29-47 0.992 32
*P-values were calculated using Wilcoxon Signed Ranks Test. TABLE 2. Airway volume and maxillo-mandibular advancement Airway volume measurements (n = 20) in cm3 Before Surgery After Surgery P* mean ± SD 10.97±4.29 17.36±7.86 <0.001 median 9.2 16.8 min 5.6 7.9 max 18.6 33.6 Maxillo-mandibular advancement (n = 20) in mm Maxillary Mandibular p* mean ± SD 4.6±1. 9 9.3±1.7 <0.001 median 4 10
min 2 4
max 8 11
*P-value calculated using Wilcoxon Signed Ranks Test
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TABLE 3. Demographic and polysomnographic data
Demographic (BMI n = 20, ESS n = 19, GHQ-12 n = 18) and polygraphic (AHI n=19, ODI n = 15) variables
Before surgery After surgery p*
Median Range Median Range
BMI 26.0 21.0-34.6 26.6 22.1-31.3 0.007 ESS 9 1-19 4 0-19 0.001 GHQ-12 1 0-11 0 0-11 0.308 AHI/h 22.7 5.3-46.9 3.0 0-25 <0.001 ODI/h 8.0 0-33 2.6 1-16 <0.001
*P-values calculated using Wilcoxon Signed Ranks Test
TABLE 4. Spearman correlation analyses
BMI pre-op
BMI post- op
Pre- op AHI
Post- op AHI
ODI pre- op
ODI post- op
ESS pre- op
ESS post- op
GHQ- 12 pre-op
GHQ-12 post-op
Age
Maxillary advancement
rs
p-value n rs
p-value n
-.397 .083 20 .098 .681 20
-.561 .010 20 -.079 .740 20
.037 .878 20 -.004 .986 20
-.080 .745 19 -.008 .973 19
-.153 .572 16 -.213 .429 16
.011 .966 17 -.230 .374 17
.152 .522 20 -.252 .284 20
.107 .664 19 -.404 .086 19
.242 .318 19 -.304 .206 19
.558 .013 19 -.673 .002 19
.131 .582 20 -.224 .343 20 Mandibular
Advancement
Statistically significant correlations are bolded
