Virtual Guided and Customized Orthognathic Surgery in Patients with Obstructive Sleep Apnea Syndrome: Accuracy and Clinical Outcomes

<b>Background:</b> This preliminary case series aimed to evaluate the clinical and morphometric outcomes of maxillomandibular advancement (MMA) surgery in patients with severe obstructive sleep apnea (OSA) using virtual surgical planning (VSP), patient-specific cutting guides, and customized titanium plates. Primary outcomes included changes in the Apnea-Hypopnea Index (AHI), airway dimensions, surgical accuracy, and quality of life. <b>Methods</b>: In this preliminary case series, six patients with severe OSA underwent MMA surgery planned using three-dimensional VSP, and executed with the aid of CAD-/CAM-generated surgical guides and patient-specific osteosynthesis. Clinical variables included AHI, Epworth Sleepiness Scale (ESS), and computed tomography-based airway morphometry. Surgical accuracy was assessed by comparing planned and achieved skeletal movements. Statistical analysis was performed using Wilcoxon signed-rank tests and Spearman's correlation. <b>Results</b>: The mean preoperative AHI decreased significantly from 48.8 ± 23.6 to 12.4 ± 10.0 (<i>p</i> = 0.035), and ESS scores improved from 14.5 ± 4.6 to 7.8 ± 2.1 (<i>p</i> = 0.029). Mean airway area increased significantly from 51.8 ± 9.0 mm² to 91.8 ± 26.6 mm² (<i>p</i> = 0.035). A strong but non-significant correlation was observed between airway gain and ESS improvement (<i>p</i> = 0.754, <i>p</i> = 0.084). No patients required CPAP at 6-month follow-up, and all were asymptomatic. The anteroposterior accuracy of skeletal movements was high: 82.6% for the maxilla and 85.8% for the pogonion, with mean absolute errors of 1.25 mm and 1.95 mm, respectively. Vertical accuracy was lower, particularly in the chin region, where error analysis showed greater variability. No statistically significant differences were found between planned and achieved movements in any vector. <b>Conclusions</b>: MMA surgery performed with VSP, cutting guides, and customized titanium plates offers a highly effective, safe, and precise treatment modality for selected OSA patients. This approach leads to a significant reduction in AHI, expansion of the upper airway, and improvement in patient-reported daytime functioning. High accuracy in skeletal repositioning-particularly in anteroposterior vectors-supports the reliability and reproducibility of digitally guided orthognathic surgery. These findings reinforce the role of technologically assisted MMA as a definitive treatment for severe OSA.