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Assessment of nasal septum after Le Fort I osteotomy with computer tomography
Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7
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Assessment of nasal septum after Le Fort I osteotomy with computer tomography Akinori Moroi*, Kunio Yoshizawa, Takamitsu Tsutsui, Yuriko Saida, Asami Hotta, Kenichi Fukaya, Ryota Hiraide, Akihiro Takayama, Tatsuya Tunoda, Yuuki Saito, Koichiro Ueki Department of Oral & Maxillofacial Surgery (Chief: Prof. Koichiro Ueki, DDS, PhD), Division of Clinical Medicine, Graduate Faculty of Interdisciplinary Research, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 4 February 2016 Accepted 31 May 2016 Available online xxx
The purpose of this study was to evaluate the effects of Le Fort I osteotomy on nasal septum deviation and differences in left and right airway sizes, and to determine whether the nasal septum was affected by differences in the direction of movement. Forty patients underwent conventional Le Fort I osteotomy, and computed tomography (CT) was performed preoperatively, and 1 week and 1 year postoperatively. The nasal septum angle and airway area were measured at the anterior, middle, and posterior positions on the CT images Patients were divided into 2 groups depending on each difference in movement (impaction 5 mm or other; anterior movement or other; and impaction asymmetry or other). There were no significant differences in the nasal septum angle and the airway of all patients. Among the patient groups, there were no significant differences in the nasal septum angle and airway. We concluded that conventional LI osteotomy did not influence the nasal septum deviation or the left and right airway asymmetry. Differences in the method of moving the maxilla have not been shown to affect changes in the nasal septum. © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Nasal septum Computer tomography Le Fort I osteotomy
1. Introduction The nasal septum is an important part of what constitutes the form of a nose. It divides the nasal airway symmetrically, and defines the position and height of the nose apex. Deflection of the large nasal septum inhibits the nasal ventilation function (Haarmann et al., 2009). Therefore, extensive damage of the nasal septum is likely to impair both aesthetics and function. Perforation or deviation of the nasal septum has been reported as one of the complications of Le Fort I (LI) osteotomy (Erbe et al., 2001). In these cases, the nasal septum deviation was rectified using surgery (Ibrahim et al., 2014). There have been many reports of the nasal ventilation and the nasal form after orthognathic surgery, although few reports examined the effects on the nasal septum. The effects of LI osteotomy on the midface soft and hard tissue have been investigated in previous studies. In particular, changes of the nasal airway in function and form have been evaluated from various measurement points. It has been reported that nasal airflow increased, while nasal airway resistance and total nasal volume * Corresponding author. Tel.: þ81 55 273 9673; fax: þ81 55 273 8210. E-mail address: [email protected] (A. Moroi).
decreased (Pourdanesh et al., 2012). Advancement of the maxilla by LI osteotomy can improve nasal respiratory function; however, maxillary impaction reduces nasal respiratory function (Ghoreishian and Gheisari, 2009). On the other hand, there have been no reports of nasal airway changes after LI osteotomy impaction and advancement (Erbe et al., 2001). The different types of LI osteotomy and the maxillary multidirectional movements of LI osteotomy result in these contradictory nasal outcomes (Pourdanesh et al., 2012). These effects on the nasal septum may also occur after orthognathic surgery; however, there have been no reports on the differences of bone movement in LI osteotomy influencing the nasal septum after surgery. The purpose of this study was to evaluate the effects of LI osteotomy on the nasal septum form and on both sides of the nasal cavity, as well as to investigate the differences in directions in LI osteotomy and their influence on the nasal septum. 2. Materials and methods 2.1. Patients This retrospective study included 40 patients (14 men and 26 women; mean age: 24.6 years; range: 16e49 years). All patients
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Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
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A. Moroi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7
Table 1 Patient data. SSRO: sagittal split ramus osteotomy, L1: Le Fort I osteotomy, PLLA: poly-L-lactic acid (absorbable) plate. uHA/PLLA: uncalcined and unsintered hydroxyapatite and poly-L-lactic acid (absorbable) plate. Case number
Diagnosis
Age
Sex
Procedures
#1 #2
Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Open bite Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry Mandibular prognathia, open bite Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Open bite Mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Open bite Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Open bite Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Mandibular prognathia Open bite
19 19
F F
LI,SSRO LI,SSRO
7 3
23
M
LI,SSRO
24 19 37
F F F
23 18
#3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19 #20 #21 #22 #23 #24 #25 #26 #27 #28 #29 #30 #31 #32 #33 #34 #35 #36 #37 #38 #39 #40
Setback right (mm)
Plate
Maxillary movement
5 8
uHA/PLLA uHA/PLLA
Left 5 mm up Right 5 mm up
5
3
uHA/PLLA
Right 6 mm up, left 2 mm up
LI,SSRO LI,SSRO LI,SSRO
3 11 9
3 2 1
uHA/PLLA uHA/PLLA uHA/PLLA
Whole 4 mm up Left 8 mm up Right 3 mm up and 2 mm advance
M F
LI,SSRO LI,SSRO
0 9
1 4
uHA/PLLA uHA/PLLA
Right 10 mm up Right 7 mm up
44 28
M M
LI,SSRO LI,SSRO
8 2
7 5
uHA/PLLA uHA/PLLA
22 27 19
F F M
LI,SSRO LI,SSRO LI,SSRO
11 1 13
10 2 8
uHA/PLLA uHA/PLLA uHA/PLLA
Whole 1 mm down and 1 mm advance Right 3 mm up, advance 3 mm, and 4 mm side shift to the left Advance 5 mm Right 10 mm up Advance 3 mm
24
M
LI,SSRO
9
9
uHA/PLLA
Left 5 mm up and 2 mm setback
19
M
LI,SSRO
6
4
uHA/PLLA
18
F
LI,SSRO
10
7
uHA/PLLA
23
F
LI,SSRO
5
3
uHA/PLLA
Left 6 mm up, 2 mm advance, and 2 mm side shift to the left Whole 2 mm up, 2 mm advance, and 2 mm side shift to the left Right 7 mm up
25 20 26 34 20
F M F F M
LI,SSRO LI,SSRO LI,SSRO LI,SSRO LI,SSRO
4 5 11 5 11
5 6 9 2 8
uHA/PLLA uHA/PLLA uHA/PLLA uHA/PLLA uHA/PLLA
Whole 5 mm up Whole 4 mm up and 1 mm advance Whole 4 mm up Left 6 mm up and 2 mm side shift to the left Right 4 mm up
17 19
F F
LI,SSRO LI,SSRO
2 5
4 4
uHA/PLLA PLLA
Whole 4 mm up Right 6 mm up
30
M
LI,SSRO
11
11
uHA/PLLA
Right 8 mm up and Left 4 mm up
20
F
LI,SSRO
5
11
PLLA
Left 4 mm up
19
M
LI,SSRO
7
3
uHA/PLLA
2 mm side shift to the left
17 16 20 27
F F M M
LI,SSRO LI,SSRO LI,SSRO LI,SSRO
2 8 13 2
4 8 8 4
uHA/PLLA uHA/PLLA uHA/PLLA PLLA
4 mm setback and anterior 3 mm down Whole 4 mm up 4 mm advance Right 7 mm up, left 3 mm up, and 2 mm advance
28
F
LI,SSRO, Genioplasty
8
7
uHA/PLLA
Right 8 mm up, left 3 mm up, and 4 mm setback
21 23
M F
LI,SSRO LI,SSRO
10 7
10 2
PLLA uHA/PLLA
Whole 4 mm down Right 4 mm up and 3 mm advance
30 28 49
F F F
LI,SSRO LI,SSRO LI,SSRO
11 10 6
2 10 10
uHA/PLLA uHA/PLLA uHA/PLLA
Whole 4 mm up 3 mm advance Right 4 mm up
36 34 19
F F F
LI,SSRO LI,SSRO LI
4 2
2 3
PLLA uHA/PLLA uHA/PLLA
Left 2 mm up and 5 mm setback Whole 4 mm up and 2 mm advance 5 mm advance
underwent LI osteotomy performed between December 2008 and January 2015. Informed consent was obtained from all patients in accordance with the Declaration of Helsinki, and the study was approved by the ethics committees of Yamanashi University Hospital, Yamanashi Prefecture, Japan. 2.2. Surgical procedure All patients underwent a standard LI osteotomy, following a periodontal incision at the anterior teeth and a vestibular incision
Setback left (mm)
at the posterior teeth to prevent postoperative scars at the labial gingival tissue, with inter-maxillary fixation screws (Stryker LEIBINGER, Freiburg, Germany, or Jeli Medical, Seoul, Korea) implanted in the maxillary anterior alveolar bone. The alar base width was measured at the start of surgery. The lateral wall of the maxillary sinus was cut using a reciprocating saw, and the nasal septum and lateral nasal walls were sectioned with a chisel. A bone separator was fixed in a thick bony area of the lateral wall of the maxillary sinus, attached with screws implanted in the maxilla, and wired to fracture and pull down the maxillary segment. The posterior wall of
Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
A. Moroi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7
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Fig. 1. A: Measurement of nasal septum angle and airway area at anterior region. B: Measurement of nasal septum angle and airway area at middle region. C: Measurement of nasal septum angle and airway area at posterior region. Yellow line indicates nasal septum line. Range surrounded by the green line indicates airway area. D: Yellow line indicates zygomatic frontal suture line.
the maxillary sinus, the maxillary tuberosity, and the pterygoid process were exposed. The maxillary segment was pulled down and pushed forward, and the sonopet UST-2001™ ultrasonic bone curette (Miwatec Co., Ltd., Kawasaki, Kanagawa, Japan) was used to remove interference between the pterygoid process and the posterior part of the maxilla without damaging either the descending palatine artery or other vessels and nerves. “Artificial fracture” of the pterygoid plate facilitated movement of the maxilla (Ueki et al., 2004 and Ueki et al., 2009). The maxillary segment was then repositioned with an intermediate occlusal split and fixed with mini-plates and monocortical screws. For 5 patients, we used 2 L-type absorbable plates at the site of the piriform rim, 2 L-type absorbable plates at the site of the zygomatic buttress, and screws (poly-L-lactic acid (PLLA): NEOFIX®, Gunze, Kyoto, Japan); for 35 patients, we used other absorbable plates and screws (uncalcined and unsintered hydroxyapatite (uHA) and PLLA: super FIXSORB®MX, Takiron Co. Ltd, Osaka, Japan) in the same manner (Table 1). A cinch suture was placed at the alar base using a 2/0 nonabsorbable suture and a cutting needle. The suture was placed through the vestibular incision and passed through the perinasal musculature in a lateral to medial direction. This suturing technique made it possible to grasp a lot of soft tissue. It was placed superficial to the alar base, and passed through the perinasal musculature and fibroareolar tissue on the opposite side in a lateral to medial direction. A hole was made the anterior nasal spine through lateral to lateral using a 2.0-mm diameter drill. The free ends of the sutures were then passed through the hole in the nasal
spine. Making a knot of the suture repositioned the alar base medially and adjusted the measured distance to that of just before maxillary osteotomy surgery. 2.3. Computed tomography (CT) measurements A CT was performed preoperatively, 1-week postoperatively, and 1-year postoperatively.
Fig. 2. Deformation of the nasal septum.
Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
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Table 2 Patients divided by the difference of moving direction. More than 5 mm group or Less than 4 mm group More than 5 mm group
Less than 4 mm group
#1.2.3.5.7.8.12.14.15.17.18.21.24.25.31.32
#4.6.9.10.11.13.16.19.20.22.23.26.27.28.29.30.33.34.35.356.37.38.39.40
Anterior group or Not anterior group Anterior group
Not anterior group
#6.9.10.11.13.15.16.19.29.30.31.34.36.39.40
#1.2.3.4.5.7.8.12.14.17.18.20.21.22.23.24.25.26.27.28.32.33.35.37.38
Asymmetry impaction group or Symmetry impaction group Asymmetry movement group
Symmetry movement group
#1.2.3.5.7.8.12.14.15.17.21.22.23.24.25.26.31.32.34.37
#4.6.9.10.11.13.16.18.19.20.27.28.29.30.33.35.36.38.39.40
The patients were placed in the gantry with the tragal-canthal line perpendicular to the ground for CT scanning. They were instructed to breathe normally and to avoid swallowing during the scanning process. The CT scans were obtained in our radiology department by skilled radiology technicians: 19 patients received high-speed, advantage-type CT generator (Light Speed Plus; GE Healthcare, Milwaukee, WI), with each sequence taken 1.25-mm apart (120 kV; average: 150 mA; 0.7 s/rotation; and helical pitch: 0.75), and 21 received a high-speed, advantage-type CT generator (Aquilion One; Toshiba Medical Systems Corp, Tochigi, Japan), with each sequence taken 0.5-mm apart (80e120 kV; 280 mA; 0.5 s/ rotation; and helical pitch: 0.75). 2.4. Measurement using CT The CT images were reconstructed using computer software (SimPlant 2011; Materialise Dental, Leuven, Belgium). Measurements by CT were in the coronal 3 across sections, and a number of landmarks were set on each. The anterior coronal section contained the anterior nasal spine, the middle coronal section contained the natural ostium, and the posterior coronal section contained the posterior nasal spine (Fig. 1AeC). The measurements were calculated on the screen at double enlargement using ImageJ (ImageJ; Research Services Branch, National Institute of Mental Health, Bethesda, MD). All CT images were measured by an author (M.A). All patients were measured again 10 days later using a paired t-test (P > 0.05). The zygomatic frontal suture line was defined as passing through 2 points on the right and left zygomatic frontal sutures (Fig. 1D); the nasal septum line as passing through the upper end of the nasal septum and the narrowest part of the nasal septum; and the nasal septum angle as between the right end of zygomatic frontal suture line and the nasal septum line. An inferior angle of the septum line of less than 150 was considered to indicate deformation of the nasal septum (Fig. 2). If the septum was crooked, the septum line was passed through the upper end of the nasal septum and the point of the crooked septum. The airway area was defined as surrounding the upper end of the inferior nasal concha and nasal surface, with fewer than zero Hounsfield units. Grouping by the difference in movement
1. Impaction more than 5 mm or less than 4 mm All patients were divided into 2 groups based on the amount of impaction in LI. The larger-than-5-mm group consisted of those for whom the amount of impaction was more than 5 mm (n ¼ 24), and the smaller-than-4-mm group consisted of those for whom the amount of impaction was smaller than 4 mm (n ¼ 16) (Table 2). 2. Movement anterior or not anterior All patients were divided into 2 groups based on the direction of movement in LI. The anterior group consisted of those who displayed anterior movement in LI (n ¼ 15), and the not-anterior group consisted of those who did not (n ¼ 25) (Table 2). 3. Impaction asymmetry or symmetry All patients were divided into 2 groups on the asymmetry movement in LI. The asymmetry movement group consisted of those for whom the amount of impaction differences were more than 4 mm between the left and the right side (n ¼ 20), and the symmetry movement group consisted of those for whom the amount of impaction differences were less than 3 mm between the left and right side (n ¼ 20) (Table 2).
2.5. Statistical analysis Septum angle and airway area values were analyzed statistically using StatView version 4.5 software (Abacus Concepts Inc., Berkeley, CA). Differences in the airway area between right and left were analyzed using an unpaired t-test. Time-dependent changes were examined using repeated-measures analysis of variance (ANOVA). Differences of rate of occurrence to deformation of the nasal septum between preoperative and 1 year were analyzed using the Fisher exact test.
Table 4 The nasal septum angle in the >5 mm or <4 mm impaction groups. Preoperatively
Table 3 The nasal septum angle in all patients.
Anterior Middle Posterior
Pre
1w
1y
89.3 ± 3.1 87.9 ± 5.7 89.6 ± 2.7
89.0 ± 7.9 89.0 ± 7.9 89.4 ± 2.9
87.8 ± 8.8 88.3 ± 6.3 89.6 ± 2.8
More than 5 mm impaction Anterior 89.5 ± 3.2 Middle 89.6 ± 5.0 Posterior 89.7 ± 3.6 Less than 4 mm impaction Anterior 89.1 ± 3.1 Middle 86.7 ± 6.0 Posterior 89.5 ± 1.9
1-week
1-year
88.9 ± 9.4 89.4 ± 8.5 89.5 ± 4.1
84.9 ± 11.6 88.5 ± 5.5 89.9 ± 3.3
89.0 ± 6.9 88.8 ± 7.5 89.4 ± 1.8
90.0 ± 5.4 88.3 ± 6.9 89.4 ± 2.4
Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
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Table 5 The nasal septum angle in the movement anterior or not anterior groups. Preoperatively Right More than 5 mm impaction Anterior 770.2 ± Middle 745.8 ± Posterior 504.9 ± Less than 4 mm impaction Anterior 835.3 ± Middle 678.7 ± Posterior 430.8 ±
1-week Right
Left
Right
Left
162.4 203.6 215.0
664.4 ± 283.7 705.5 ± 271.5 409.5 ± 148.3
525.9 ± 232.1 204.1 ± 211.5 224.9 ± 211.2
589.8 ± 360.6 187.1 ± 226.3 171.2 ± 192.5
562.9 ± 227.4 441.7 ± 277.0 311.6 ± 147.8
572.8 ± 322.2 487.8 ± 275.4 418.0 ± 208.1
255.3 205.6 183.7
704.3 ± 337.1 641.3 ± 299.1 462.3 ± 188.6
781.2 ± 307.0 262.9 ± 218.5 278.8 ± 200.0
717.0 ± 421.3 303.2 ± 289.1 242.6 ± 177.7
768.6 ± 207.3 621.5 ± 295.0 406.9 ± 184.0
776.2 ± 522.0 658.2 ± 313.9 443.4 ± 226.3
Table 6 The nasal septum angle in the impaction asymmetry or symmetry groups. Preoperatively Anterior movement Anterior 88.9 Middle 86.1 Posterior 90.2 Non anterior movement Anterior 89.5 Middle 89.0 Posterior 89.2
1-year
Left
1-week
Table 8 The airway area in the movement anterior or not anterior groups.
1-year
Preoperatively
± 3.9 ± 6.9 ± 2.9
89.1 ± 7.5 89.2 ± 8.3 90.3 ± 3.3
90.0 ± 5.9 87.5 ± 6.4 89.5 ± 2.5
± 2.6 ± 4.6 ± 2.6
88.8 ± 8.3 89.0 ± 7.8 88.9 ± 2.6
86.4 ± 10.0 88.9 ± 6.3 89.7 ± 3.0
3. Results Intra-operatively, there were no unfavorable fractures or severe damage to the nasal septum in any cases. Postoperatively, no patient experienced wound infections. In the nasal septum angle of all cases, the time-course change was not found to be significant by repeated-measures ANOVA (between subjects: F ¼ 0.687, df ¼ 2, and P ¼ 0.5052; within subjects: F ¼ 0.437, df ¼ 2, and P ¼ 0.6464) (Table 3). Deformities of the nasal septum were observed in 8 (20%) of 40 patients. 3.1. Impaction larger than 5 mm or less than 4 mm The time-course change was not significant by repeatedmeasures ANOVA (between subjects: F ¼ 0.918, df ¼ 5, and P ¼ 0.4722; within subjects: F ¼ 0.858, df ¼ 2, and P ¼ 0.4252) (Table 4). In both groups, there was no significant difference in the airway area between the right side and the left side at anterior, middle, and posterior positions preoperatively, at 1 week, and at 1 year (Table 5). The rate of occurrence of deformities of the nasal septum also showed no significant difference (P ¼ 0.2290).
Asymmetry impaction Anterior 89.2 Middle 89.4 Posterior 89.5 Symmetry impaction Anterior 89.4 Middle 86.5 Posterior 89.6
1-week
1-year
± 3.2 ± 4.7 ± 3.2
87.7 ± 8.8 89.1 ± 7.6 89.4 ± 3.5
85.6 ± 11.0 88.4 ± 4.9 90.0 ± 2.9
± 3.1 ± 6.3 ± 2.3
90.2 ± 7.0 89.0 ± 8.3 89.5 ± 2.3
90.0 ± 5.4 88.3 ± 7.6 89.2 ± 2.6
P ¼ 0.5521; within subjects: F ¼ 0.859, df ¼ 2, and P ¼ 0.4251) (Table 6). The 2 groups showed no significant difference in the airway area between the right side and the left side at anterior, middle, and posterior positions preoperatively, at 1 week and 1 year postoperatively (Table 7). No significant difference was seen in the rate of occurrence of deformities of the nasal septum (P ¼ 0.6857). 3.3. Impaction asymmetry or symmetry The time-course change was not significant by repeatedmeasures ANOVA (between subjects: F ¼ 0.848, df ¼ 5, and P ¼ 0.5197; within subjects: F ¼ 0.539, df ¼ 2, and P ¼ 0.5842) (Table 8). In the 2 groups, there was no significant difference in the airway area between the right side and the left side at the anterior, the middle, and the posterior positions preoperatively, at 1 week and 1 year postoperatively (Table 9). There was also no significant difference in the rate of occurrence of deformities of the nasal septum (P ¼ 0.7025). 4. Discussion
3.2. Movement anterior or not anterior The time-course change was not significant by repeatedmeasures ANOVA (between subjects: F ¼ 0.800, df ¼ 5, and
The use of CT allowed us to investigate the various sites that could not be seen until after orthognathic surgery. Some studies have reported a relationship between orthognathic surgery and the
Table 7 The airway area in the impaction >5 mm or <4 mm groups. Preoperatively Right Anterior movement Anterior 744.7 Middle 669.9 Posterior 404.3 Not anterior movement Anterior 845.4 Middle 729.6 Posterior 497.1
1-week
1-year
Left
Right
Left
Right
Left
± 216.8 ± 188.9 ± 189.1
565.3 ± 199.5 573.3 ± 311.1 408.0 ± 185.8
640.7 ± 222.1 265.2 ± 215.3 213.9 ± 191.4
694.3 ± 342.6 347 ± 313.4 218.1 ± 188.8
677.9 ± 180.3 614.7 ± 308.0 344.4 ± 180.3
646.1 ± 295.1 644.0 ± 256.2 423.4 ± 197.5
± 218.4 ± 214.6 ± 199.4
760.6 ± 347.0 725.8 ± 259.4 459.0 ± 165.1
691.8 ± 345.0 221.5 ± 217.3 281.1 ± 210.8
644.1 ± 431.9 197.9 ± 224.2 208.7 ± 186.8
683.2 ± 268.6 503.3 ± 289.7 379.6 ± 172.7
716.0 ± 532.1 550.8 ± 333.3 438.1 ± 230.8
Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
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A. Moroi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7
Table 9 The airway area in the impaction asymmetry or symmetry groups. Preoperatively Deviation side Asymmetry impaction Anterior 740.3 ± 311.0 Middle 679.1 ± 253.5 Posterior 439.9 ± 217.0 Preoperatively Right Symmetry impaction Anterior 836.4 ± 247.6 Middle 681.9 ± 206.2 Posterior 471.7 ± 183.4
1-week
1-year
Non-deviation side
Deviation side
Non-deviation side
Deviation side
Non-deviation side
733.9 ± 210.5 748.6 ± 229.3 446.9 ± 140.2
656.8 ± 391.1 219.9 ± 237.5 263.2 ± 218.1
618.8 ± 342.1 195.6 ± 241.4 161.1 ± 165.9
656.3 ± 497.8 575.5 ± 324.8 370.7 ± 173.9
714.9 ± 314.6 591.6 ± 355.4 443.2 ± 214.6
Left
1-week Right
Left
1-year Right
Left
686.6 ± 326.4 623.7 ± 300.9 451.2 ± 207.7
732.2 ± 296.3 268.4 ± 202.1 282.8 ± 198.8
685.8 ± 373.9 326.5 ± 276.9 244.5 ± 181.9
740.8 ± 260.6 496.6 ± 195.5 361.5 ± 153.3
629.9 ± 294.5 585.2 ± 289.4 417.2 ± 243.5
maxillary sinus using the LundeMackay rhinologic staging scale, which is a method of evaluating the maxillary sinus using CT images (Sharp et al., 1999; Basu et al., 2005). Additionally, some studies have assessed the oropharyngeal airway after LI and investigated the correlation between this change and surgical maxillary movement (Almuzian et al., 2016). These reports revealed complications following orthognathic surgery that have not thus far been recognized. One of these complications was deformation or deflection of the nasal septum. Nocini et al. examined anatomic defects or surgery-induced alternations that could lead to paranasal homeostasis disruption (2016). In addition, it has been reported that postoperative findings indicate the presence of septal perforations in 3 out of 20 cases (Erbe et al., 2001). While similar nasal septum issues have been reported, there are no reports involving statistically analysis of nasal septum issues. A possible reason for a cartilaginous septum deviation or perforations after maxillary osteotomy is dislocation by a partially deflated cuff during extubation (Acebal-Bianco et al., 2000; Kramer et al., 2004). This is the one of the most important factors in deviation of the septum; it is also considered that LI osteotomy itself will affect the nasal area in terms of the moving direction and moving method. A number of reports related to maxillary orthognathic surgery and the nasal area cited the moving direction and moving method as factors that influence the nasal area (Kim and Park, 2007). In this study, we evaluated the nasal septum by using not only the angle of nasal septum but also both of the nasal airways into which the nasal septum is divided. This was more useful than septum angles in assessing its influence on the nasal cavity and nasal function. It has been reported that after maxilla orthognathic surgery, nasal volume decreased in all cases; it showed remarkable decreases in maxillary impaction cases (Pourdanesh et al., 2012). In addition, clinically significant advancement of the maxilla results in a significant increase in the airway dimension at the nasopharynegeal level (Jakobsone et al., 2011). These studies evaluated the overall nasal area both pre- and post-operatively; however, they did not assess left-right differences. Many studies have compared the nasal or nasopharyngeal airways before and after orthognathic surgery using CT analysis (Jakobsone et al., 2010; Kaur et al., 2014). Compared to diverse evaluation methods, such as 3D construction, CT analysis enables internal and external evaluation of the form and physicality of objects both (Zheng et al., 2014). On the other hand, it is very difficult to ensure reproducibility with CT imaging, as it can be affected by reproducibility of the scanning position, body movement during scanning, and the settings of the CT imaging apparatus. Although measurement of the angle or the length can be modified by calibration, the measurement of the area and volume cannot be modified. Therefore, in our study, evaluation of the area
has been carried out only on the same screen; longitudinal evaluation was not carried out in this study. However, the nasal septum angle measurement from the reference line was carried out to evaluate the time course. The internal width and sectional area at the Isthmus nasi increased significantly in impactions of the maxilla up to 5 mm (Erbe et al., 2001); the maxillary impaction reduced total nasal resistance up to 5 mm, and thus improved the total nasal air flow (Pourdanesh et al., 2012). These reports suggest a close relationship between impaction of maxilla in LI and nasal form and function, in addition to using 5 mm as the reference value. In our study, the deviation of the nasal septum and the airway area were investigated using a reference value of 5 mm; there was no difference between the 2 groups in this study. We found that the anterior movement of maxilla increased the volume of the nasopharyngeal and the hypopharyngeal airway spaces (Greco et al., 1990). Although it was expected that preventing the change would increase volume, there was no significant difference between the advance group and the not-advance group in this study. In terms of improvement of asymmetry, it has been reported that asymmetrical soft tissue was corrected using the jawbone for the asymmetric correction (Moroi et al., 2014). In this study, there was no significant difference between the 2 groups for either the nasal septum angle or the airway area. These results suggest that the nasal septum adapts to the new maxilla and nasal form. In our study, the nasal septum angle larger than 5-mm impaction group at 1 year was 84.9 ± 11.6, and the rate of occurrence of deformation of the nasal septum was 8 (20%) of 40 patients. Excursion or deformation in the nasal septum may occur as a complication; therefore, there is a need for patients' informed consent regarding the nasal septum prior to LI osteotomy surgery. 5. Conclusion In this study, we concluded that conventional LI osteotomy did not influence nasal septum deviation and did not cause left and right asymmetry in the airway. Differences in the methods of moving the maxilla have been shown not to cause changes in the nasal septum. Funding None. References Acebal-Bianco F, Vuylsteke PL, Mommaerts MY, De Clercq CA: Perioperative complications in corrective facial orthopedic surgery: a 5-year retrospective study. J Oral Maxillofac Surg 58: 754e760, 2000
Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
A. Moroi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7 Almuzian M, Almukhtar A, Ju X, Al-Hiyali A, Benington P, Ayoub A: Effects of Le Fort I osteotomy on the nasopharyngeal airway-6-month follow-up. J Oral Maxillofac Surg 74: 380e391, 2016 Basu S, Georgalas C, Kumar BN, Desai S: Correlation between symptoms and radiological findings in patients with chronic rhinosinusitis: an evaluation study using the Sinonasal Assessment Questionnaire and Lund-Mackay grading system. Eur Arch Otorhinolaryngol 262: 751e754, 2005 €de U, Wigand ME, Neukam FW: Nasal airway changes after Le Erbe M, Lehotay M, Go Fort Ieimpaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg 30: 123e129, 2001 Ghoreishian M, Gheisari R: The effect of maxillary multidirectional movement on nasal respiration. J Oral Maxillofac Surg 67: 2283e2286, 2009 Greco JM, Frohberg U, Van Sickels JE: Cephalometric analysis of long-term airway space changes with maxillary osteotomies. Oral Surg Oral Med Oral Pathol 70: 552e554, 1990 Haarmann S, Budihardja AS, Wolff KD, Wangerin K: Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery: a prospective study. Int J Oral Maxillofac Surg 38: 321e325, 2009 Ibrahim A, Balakrishnan R, Ebenezer V, Padmanabhan A, Muthlingam V: Combating nasal septum deviation in Le Fort 1 orthognathic surgery complications, with submental intubation. J Clin Diagn Res 8: 46e48, 2014 Jakobsone G, Neimane L, Krumina G: Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of Class III malocclusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110: 234e242, 2010 Jakobsone G, Stenvik A, Espeland L: The effect of maxillary advancement and impaction on the upper airway after bimaxillary surgery to correct Class III malocclusion. Am J Orthod Dentofacial Orthop 139: 369e376, 2011 Kaur S, Rai S, Kaur M: Comparison of reliability of lateral cephalogram and computed tomography for assessment of airway space. Niger J Clin Pract 17: 629e636, 2014
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Kim SG, Park SS: Incidence of complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 65: 2438e2444, 2007 Kramer FJ, Baethge C, Swennen G, Teltzrow T, Schulze A, Berten J, et al: Intra- and perioperative complications of the LeFort I osteotomy: a prospective evaluation of 1000 patients. J Craniofac Surg 15: 971e977, 2004 Moroi A, Ishihara Y, Sotobori M, Nakazawa R, Higuchi M, Nakano Y, et al: Evaluation of soft tissue morphologic changes after using the alar base cinch suture in Le Fort I osteotomy in mandibular prognathism with and without asymmetry. J Craniomaxillofac Surg 42: 718e724, 2014 Nocini PF, D'Agostino A, Trevisiol L, Favero V, Pessina M, Procacci P: Is Le Fort I osteotomy associated with maxillary sinusitis? J Oral Maxillofac Surg 74: 400.e1e400.e12, 2016 Pourdanesh F, Sharifi R, Mohebbi A, Jamilian A: Effects of maxillary advancement and impaction on nasal airway function. Int J Oral Maxillofac Surg 41: 1350e1352, 2012 Sharp HR, Rowe-Jones JM, Mackay IS: The outcome of endoscopic sinus surgery: correlation with computerized tomography score and systemic disease. Clin Otolaryngol Allied Sci 24: 39e42, 1999 Ueki K, Nakagawa K, Marukawa K, Yamamoto E: Le Fort I osteotomy using an ultrasonic bone curette to fracture the pterygoid plates. J Craniomaxillofac Surg 32: 381e386, 2004 Ueki K, Hashiba Y, Marukawa K, Okabe K, Alam Nakagawa K, Yamamoto E: Assessment of pterygomaxillary separation in Le Fort I osteotomy in Class III patients. J Oral Maxillofac Surg 67: 833e839, 2009 Zheng ZH, Yamaguchi T, Kurihara A, Li HF, Maki K: Three-dimensional evaluation of upper airway in patients with different anteroposterior skeletal patterns. Orthod Craniofac Res 17: 38e48, 2014
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Assessment of nasal septum after Le Fort I osteotomy with computer tomography Akinori Moroi*, Kunio Yoshizawa, Takamitsu Tsutsui, Yuriko Saida, Asami Hotta, Kenichi Fukaya, Ryota Hiraide, Akihiro Takayama, Tatsuya Tunoda, Yuuki Saito, Koichiro Ueki Department of Oral & Maxillofacial Surgery (Chief: Prof. Koichiro Ueki, DDS, PhD), Division of Clinical Medicine, Graduate Faculty of Interdisciplinary Research, University of Yamanashi, 1110 Shimokato, Chuo, Yamanashi, 409-3898, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 4 February 2016 Accepted 31 May 2016 Available online xxx
The purpose of this study was to evaluate the effects of Le Fort I osteotomy on nasal septum deviation and differences in left and right airway sizes, and to determine whether the nasal septum was affected by differences in the direction of movement. Forty patients underwent conventional Le Fort I osteotomy, and computed tomography (CT) was performed preoperatively, and 1 week and 1 year postoperatively. The nasal septum angle and airway area were measured at the anterior, middle, and posterior positions on the CT images Patients were divided into 2 groups depending on each difference in movement (impaction 5 mm or other; anterior movement or other; and impaction asymmetry or other). There were no significant differences in the nasal septum angle and the airway of all patients. Among the patient groups, there were no significant differences in the nasal septum angle and airway. We concluded that conventional LI osteotomy did not influence the nasal septum deviation or the left and right airway asymmetry. Differences in the method of moving the maxilla have not been shown to affect changes in the nasal septum. © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Nasal septum Computer tomography Le Fort I osteotomy
1. Introduction The nasal septum is an important part of what constitutes the form of a nose. It divides the nasal airway symmetrically, and defines the position and height of the nose apex. Deflection of the large nasal septum inhibits the nasal ventilation function (Haarmann et al., 2009). Therefore, extensive damage of the nasal septum is likely to impair both aesthetics and function. Perforation or deviation of the nasal septum has been reported as one of the complications of Le Fort I (LI) osteotomy (Erbe et al., 2001). In these cases, the nasal septum deviation was rectified using surgery (Ibrahim et al., 2014). There have been many reports of the nasal ventilation and the nasal form after orthognathic surgery, although few reports examined the effects on the nasal septum. The effects of LI osteotomy on the midface soft and hard tissue have been investigated in previous studies. In particular, changes of the nasal airway in function and form have been evaluated from various measurement points. It has been reported that nasal airflow increased, while nasal airway resistance and total nasal volume * Corresponding author. Tel.: þ81 55 273 9673; fax: þ81 55 273 8210. E-mail address: [email protected] (A. Moroi).
decreased (Pourdanesh et al., 2012). Advancement of the maxilla by LI osteotomy can improve nasal respiratory function; however, maxillary impaction reduces nasal respiratory function (Ghoreishian and Gheisari, 2009). On the other hand, there have been no reports of nasal airway changes after LI osteotomy impaction and advancement (Erbe et al., 2001). The different types of LI osteotomy and the maxillary multidirectional movements of LI osteotomy result in these contradictory nasal outcomes (Pourdanesh et al., 2012). These effects on the nasal septum may also occur after orthognathic surgery; however, there have been no reports on the differences of bone movement in LI osteotomy influencing the nasal septum after surgery. The purpose of this study was to evaluate the effects of LI osteotomy on the nasal septum form and on both sides of the nasal cavity, as well as to investigate the differences in directions in LI osteotomy and their influence on the nasal septum. 2. Materials and methods 2.1. Patients This retrospective study included 40 patients (14 men and 26 women; mean age: 24.6 years; range: 16e49 years). All patients
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Table 1 Patient data. SSRO: sagittal split ramus osteotomy, L1: Le Fort I osteotomy, PLLA: poly-L-lactic acid (absorbable) plate. uHA/PLLA: uncalcined and unsintered hydroxyapatite and poly-L-lactic acid (absorbable) plate. Case number
Diagnosis
Age
Sex
Procedures
#1 #2
Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Open bite Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry Mandibular prognathia, open bite Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Open bite Mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry Bi-maxillary asymmetry, mandibular prognathia Open bite Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Open bite Mandibular prognathia Bi-maxillary asymmetry, mandibular prognathia Mandibular prognathia Mandibular prognathia Open bite
19 19
F F
LI,SSRO LI,SSRO
7 3
23
M
LI,SSRO
24 19 37
F F F
23 18
#3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19 #20 #21 #22 #23 #24 #25 #26 #27 #28 #29 #30 #31 #32 #33 #34 #35 #36 #37 #38 #39 #40
Setback right (mm)
Plate
Maxillary movement
5 8
uHA/PLLA uHA/PLLA
Left 5 mm up Right 5 mm up
5
3
uHA/PLLA
Right 6 mm up, left 2 mm up
LI,SSRO LI,SSRO LI,SSRO
3 11 9
3 2 1
uHA/PLLA uHA/PLLA uHA/PLLA
Whole 4 mm up Left 8 mm up Right 3 mm up and 2 mm advance
M F
LI,SSRO LI,SSRO
0 9
1 4
uHA/PLLA uHA/PLLA
Right 10 mm up Right 7 mm up
44 28
M M
LI,SSRO LI,SSRO
8 2
7 5
uHA/PLLA uHA/PLLA
22 27 19
F F M
LI,SSRO LI,SSRO LI,SSRO
11 1 13
10 2 8
uHA/PLLA uHA/PLLA uHA/PLLA
Whole 1 mm down and 1 mm advance Right 3 mm up, advance 3 mm, and 4 mm side shift to the left Advance 5 mm Right 10 mm up Advance 3 mm
24
M
LI,SSRO
9
9
uHA/PLLA
Left 5 mm up and 2 mm setback
19
M
LI,SSRO
6
4
uHA/PLLA
18
F
LI,SSRO
10
7
uHA/PLLA
23
F
LI,SSRO
5
3
uHA/PLLA
Left 6 mm up, 2 mm advance, and 2 mm side shift to the left Whole 2 mm up, 2 mm advance, and 2 mm side shift to the left Right 7 mm up
25 20 26 34 20
F M F F M
LI,SSRO LI,SSRO LI,SSRO LI,SSRO LI,SSRO
4 5 11 5 11
5 6 9 2 8
uHA/PLLA uHA/PLLA uHA/PLLA uHA/PLLA uHA/PLLA
Whole 5 mm up Whole 4 mm up and 1 mm advance Whole 4 mm up Left 6 mm up and 2 mm side shift to the left Right 4 mm up
17 19
F F
LI,SSRO LI,SSRO
2 5
4 4
uHA/PLLA PLLA
Whole 4 mm up Right 6 mm up
30
M
LI,SSRO
11
11
uHA/PLLA
Right 8 mm up and Left 4 mm up
20
F
LI,SSRO
5
11
PLLA
Left 4 mm up
19
M
LI,SSRO
7
3
uHA/PLLA
2 mm side shift to the left
17 16 20 27
F F M M
LI,SSRO LI,SSRO LI,SSRO LI,SSRO
2 8 13 2
4 8 8 4
uHA/PLLA uHA/PLLA uHA/PLLA PLLA
4 mm setback and anterior 3 mm down Whole 4 mm up 4 mm advance Right 7 mm up, left 3 mm up, and 2 mm advance
28
F
LI,SSRO, Genioplasty
8
7
uHA/PLLA
Right 8 mm up, left 3 mm up, and 4 mm setback
21 23
M F
LI,SSRO LI,SSRO
10 7
10 2
PLLA uHA/PLLA
Whole 4 mm down Right 4 mm up and 3 mm advance
30 28 49
F F F
LI,SSRO LI,SSRO LI,SSRO
11 10 6
2 10 10
uHA/PLLA uHA/PLLA uHA/PLLA
Whole 4 mm up 3 mm advance Right 4 mm up
36 34 19
F F F
LI,SSRO LI,SSRO LI
4 2
2 3
PLLA uHA/PLLA uHA/PLLA
Left 2 mm up and 5 mm setback Whole 4 mm up and 2 mm advance 5 mm advance
underwent LI osteotomy performed between December 2008 and January 2015. Informed consent was obtained from all patients in accordance with the Declaration of Helsinki, and the study was approved by the ethics committees of Yamanashi University Hospital, Yamanashi Prefecture, Japan. 2.2. Surgical procedure All patients underwent a standard LI osteotomy, following a periodontal incision at the anterior teeth and a vestibular incision
Setback left (mm)
at the posterior teeth to prevent postoperative scars at the labial gingival tissue, with inter-maxillary fixation screws (Stryker LEIBINGER, Freiburg, Germany, or Jeli Medical, Seoul, Korea) implanted in the maxillary anterior alveolar bone. The alar base width was measured at the start of surgery. The lateral wall of the maxillary sinus was cut using a reciprocating saw, and the nasal septum and lateral nasal walls were sectioned with a chisel. A bone separator was fixed in a thick bony area of the lateral wall of the maxillary sinus, attached with screws implanted in the maxilla, and wired to fracture and pull down the maxillary segment. The posterior wall of
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Fig. 1. A: Measurement of nasal septum angle and airway area at anterior region. B: Measurement of nasal septum angle and airway area at middle region. C: Measurement of nasal septum angle and airway area at posterior region. Yellow line indicates nasal septum line. Range surrounded by the green line indicates airway area. D: Yellow line indicates zygomatic frontal suture line.
the maxillary sinus, the maxillary tuberosity, and the pterygoid process were exposed. The maxillary segment was pulled down and pushed forward, and the sonopet UST-2001™ ultrasonic bone curette (Miwatec Co., Ltd., Kawasaki, Kanagawa, Japan) was used to remove interference between the pterygoid process and the posterior part of the maxilla without damaging either the descending palatine artery or other vessels and nerves. “Artificial fracture” of the pterygoid plate facilitated movement of the maxilla (Ueki et al., 2004 and Ueki et al., 2009). The maxillary segment was then repositioned with an intermediate occlusal split and fixed with mini-plates and monocortical screws. For 5 patients, we used 2 L-type absorbable plates at the site of the piriform rim, 2 L-type absorbable plates at the site of the zygomatic buttress, and screws (poly-L-lactic acid (PLLA): NEOFIX®, Gunze, Kyoto, Japan); for 35 patients, we used other absorbable plates and screws (uncalcined and unsintered hydroxyapatite (uHA) and PLLA: super FIXSORB®MX, Takiron Co. Ltd, Osaka, Japan) in the same manner (Table 1). A cinch suture was placed at the alar base using a 2/0 nonabsorbable suture and a cutting needle. The suture was placed through the vestibular incision and passed through the perinasal musculature in a lateral to medial direction. This suturing technique made it possible to grasp a lot of soft tissue. It was placed superficial to the alar base, and passed through the perinasal musculature and fibroareolar tissue on the opposite side in a lateral to medial direction. A hole was made the anterior nasal spine through lateral to lateral using a 2.0-mm diameter drill. The free ends of the sutures were then passed through the hole in the nasal
spine. Making a knot of the suture repositioned the alar base medially and adjusted the measured distance to that of just before maxillary osteotomy surgery. 2.3. Computed tomography (CT) measurements A CT was performed preoperatively, 1-week postoperatively, and 1-year postoperatively.
Fig. 2. Deformation of the nasal septum.
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Table 2 Patients divided by the difference of moving direction. More than 5 mm group or Less than 4 mm group More than 5 mm group
Less than 4 mm group
#1.2.3.5.7.8.12.14.15.17.18.21.24.25.31.32
#4.6.9.10.11.13.16.19.20.22.23.26.27.28.29.30.33.34.35.356.37.38.39.40
Anterior group or Not anterior group Anterior group
Not anterior group
#6.9.10.11.13.15.16.19.29.30.31.34.36.39.40
#1.2.3.4.5.7.8.12.14.17.18.20.21.22.23.24.25.26.27.28.32.33.35.37.38
Asymmetry impaction group or Symmetry impaction group Asymmetry movement group
Symmetry movement group
#1.2.3.5.7.8.12.14.15.17.21.22.23.24.25.26.31.32.34.37
#4.6.9.10.11.13.16.18.19.20.27.28.29.30.33.35.36.38.39.40
The patients were placed in the gantry with the tragal-canthal line perpendicular to the ground for CT scanning. They were instructed to breathe normally and to avoid swallowing during the scanning process. The CT scans were obtained in our radiology department by skilled radiology technicians: 19 patients received high-speed, advantage-type CT generator (Light Speed Plus; GE Healthcare, Milwaukee, WI), with each sequence taken 1.25-mm apart (120 kV; average: 150 mA; 0.7 s/rotation; and helical pitch: 0.75), and 21 received a high-speed, advantage-type CT generator (Aquilion One; Toshiba Medical Systems Corp, Tochigi, Japan), with each sequence taken 0.5-mm apart (80e120 kV; 280 mA; 0.5 s/ rotation; and helical pitch: 0.75). 2.4. Measurement using CT The CT images were reconstructed using computer software (SimPlant 2011; Materialise Dental, Leuven, Belgium). Measurements by CT were in the coronal 3 across sections, and a number of landmarks were set on each. The anterior coronal section contained the anterior nasal spine, the middle coronal section contained the natural ostium, and the posterior coronal section contained the posterior nasal spine (Fig. 1AeC). The measurements were calculated on the screen at double enlargement using ImageJ (ImageJ; Research Services Branch, National Institute of Mental Health, Bethesda, MD). All CT images were measured by an author (M.A). All patients were measured again 10 days later using a paired t-test (P > 0.05). The zygomatic frontal suture line was defined as passing through 2 points on the right and left zygomatic frontal sutures (Fig. 1D); the nasal septum line as passing through the upper end of the nasal septum and the narrowest part of the nasal septum; and the nasal septum angle as between the right end of zygomatic frontal suture line and the nasal septum line. An inferior angle of the septum line of less than 150 was considered to indicate deformation of the nasal septum (Fig. 2). If the septum was crooked, the septum line was passed through the upper end of the nasal septum and the point of the crooked septum. The airway area was defined as surrounding the upper end of the inferior nasal concha and nasal surface, with fewer than zero Hounsfield units. Grouping by the difference in movement
1. Impaction more than 5 mm or less than 4 mm All patients were divided into 2 groups based on the amount of impaction in LI. The larger-than-5-mm group consisted of those for whom the amount of impaction was more than 5 mm (n ¼ 24), and the smaller-than-4-mm group consisted of those for whom the amount of impaction was smaller than 4 mm (n ¼ 16) (Table 2). 2. Movement anterior or not anterior All patients were divided into 2 groups based on the direction of movement in LI. The anterior group consisted of those who displayed anterior movement in LI (n ¼ 15), and the not-anterior group consisted of those who did not (n ¼ 25) (Table 2). 3. Impaction asymmetry or symmetry All patients were divided into 2 groups on the asymmetry movement in LI. The asymmetry movement group consisted of those for whom the amount of impaction differences were more than 4 mm between the left and the right side (n ¼ 20), and the symmetry movement group consisted of those for whom the amount of impaction differences were less than 3 mm between the left and right side (n ¼ 20) (Table 2).
2.5. Statistical analysis Septum angle and airway area values were analyzed statistically using StatView version 4.5 software (Abacus Concepts Inc., Berkeley, CA). Differences in the airway area between right and left were analyzed using an unpaired t-test. Time-dependent changes were examined using repeated-measures analysis of variance (ANOVA). Differences of rate of occurrence to deformation of the nasal septum between preoperative and 1 year were analyzed using the Fisher exact test.
Table 4 The nasal septum angle in the >5 mm or <4 mm impaction groups. Preoperatively
Table 3 The nasal septum angle in all patients.
Anterior Middle Posterior
Pre
1w
1y
89.3 ± 3.1 87.9 ± 5.7 89.6 ± 2.7
89.0 ± 7.9 89.0 ± 7.9 89.4 ± 2.9
87.8 ± 8.8 88.3 ± 6.3 89.6 ± 2.8
More than 5 mm impaction Anterior 89.5 ± 3.2 Middle 89.6 ± 5.0 Posterior 89.7 ± 3.6 Less than 4 mm impaction Anterior 89.1 ± 3.1 Middle 86.7 ± 6.0 Posterior 89.5 ± 1.9
1-week
1-year
88.9 ± 9.4 89.4 ± 8.5 89.5 ± 4.1
84.9 ± 11.6 88.5 ± 5.5 89.9 ± 3.3
89.0 ± 6.9 88.8 ± 7.5 89.4 ± 1.8
90.0 ± 5.4 88.3 ± 6.9 89.4 ± 2.4
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Table 5 The nasal septum angle in the movement anterior or not anterior groups. Preoperatively Right More than 5 mm impaction Anterior 770.2 ± Middle 745.8 ± Posterior 504.9 ± Less than 4 mm impaction Anterior 835.3 ± Middle 678.7 ± Posterior 430.8 ±
1-week Right
Left
Right
Left
162.4 203.6 215.0
664.4 ± 283.7 705.5 ± 271.5 409.5 ± 148.3
525.9 ± 232.1 204.1 ± 211.5 224.9 ± 211.2
589.8 ± 360.6 187.1 ± 226.3 171.2 ± 192.5
562.9 ± 227.4 441.7 ± 277.0 311.6 ± 147.8
572.8 ± 322.2 487.8 ± 275.4 418.0 ± 208.1
255.3 205.6 183.7
704.3 ± 337.1 641.3 ± 299.1 462.3 ± 188.6
781.2 ± 307.0 262.9 ± 218.5 278.8 ± 200.0
717.0 ± 421.3 303.2 ± 289.1 242.6 ± 177.7
768.6 ± 207.3 621.5 ± 295.0 406.9 ± 184.0
776.2 ± 522.0 658.2 ± 313.9 443.4 ± 226.3
Table 6 The nasal septum angle in the impaction asymmetry or symmetry groups. Preoperatively Anterior movement Anterior 88.9 Middle 86.1 Posterior 90.2 Non anterior movement Anterior 89.5 Middle 89.0 Posterior 89.2
1-year
Left
1-week
Table 8 The airway area in the movement anterior or not anterior groups.
1-year
Preoperatively
± 3.9 ± 6.9 ± 2.9
89.1 ± 7.5 89.2 ± 8.3 90.3 ± 3.3
90.0 ± 5.9 87.5 ± 6.4 89.5 ± 2.5
± 2.6 ± 4.6 ± 2.6
88.8 ± 8.3 89.0 ± 7.8 88.9 ± 2.6
86.4 ± 10.0 88.9 ± 6.3 89.7 ± 3.0
3. Results Intra-operatively, there were no unfavorable fractures or severe damage to the nasal septum in any cases. Postoperatively, no patient experienced wound infections. In the nasal septum angle of all cases, the time-course change was not found to be significant by repeated-measures ANOVA (between subjects: F ¼ 0.687, df ¼ 2, and P ¼ 0.5052; within subjects: F ¼ 0.437, df ¼ 2, and P ¼ 0.6464) (Table 3). Deformities of the nasal septum were observed in 8 (20%) of 40 patients. 3.1. Impaction larger than 5 mm or less than 4 mm The time-course change was not significant by repeatedmeasures ANOVA (between subjects: F ¼ 0.918, df ¼ 5, and P ¼ 0.4722; within subjects: F ¼ 0.858, df ¼ 2, and P ¼ 0.4252) (Table 4). In both groups, there was no significant difference in the airway area between the right side and the left side at anterior, middle, and posterior positions preoperatively, at 1 week, and at 1 year (Table 5). The rate of occurrence of deformities of the nasal septum also showed no significant difference (P ¼ 0.2290).
Asymmetry impaction Anterior 89.2 Middle 89.4 Posterior 89.5 Symmetry impaction Anterior 89.4 Middle 86.5 Posterior 89.6
1-week
1-year
± 3.2 ± 4.7 ± 3.2
87.7 ± 8.8 89.1 ± 7.6 89.4 ± 3.5
85.6 ± 11.0 88.4 ± 4.9 90.0 ± 2.9
± 3.1 ± 6.3 ± 2.3
90.2 ± 7.0 89.0 ± 8.3 89.5 ± 2.3
90.0 ± 5.4 88.3 ± 7.6 89.2 ± 2.6
P ¼ 0.5521; within subjects: F ¼ 0.859, df ¼ 2, and P ¼ 0.4251) (Table 6). The 2 groups showed no significant difference in the airway area between the right side and the left side at anterior, middle, and posterior positions preoperatively, at 1 week and 1 year postoperatively (Table 7). No significant difference was seen in the rate of occurrence of deformities of the nasal septum (P ¼ 0.6857). 3.3. Impaction asymmetry or symmetry The time-course change was not significant by repeatedmeasures ANOVA (between subjects: F ¼ 0.848, df ¼ 5, and P ¼ 0.5197; within subjects: F ¼ 0.539, df ¼ 2, and P ¼ 0.5842) (Table 8). In the 2 groups, there was no significant difference in the airway area between the right side and the left side at the anterior, the middle, and the posterior positions preoperatively, at 1 week and 1 year postoperatively (Table 9). There was also no significant difference in the rate of occurrence of deformities of the nasal septum (P ¼ 0.7025). 4. Discussion
3.2. Movement anterior or not anterior The time-course change was not significant by repeatedmeasures ANOVA (between subjects: F ¼ 0.800, df ¼ 5, and
The use of CT allowed us to investigate the various sites that could not be seen until after orthognathic surgery. Some studies have reported a relationship between orthognathic surgery and the
Table 7 The airway area in the impaction >5 mm or <4 mm groups. Preoperatively Right Anterior movement Anterior 744.7 Middle 669.9 Posterior 404.3 Not anterior movement Anterior 845.4 Middle 729.6 Posterior 497.1
1-week
1-year
Left
Right
Left
Right
Left
± 216.8 ± 188.9 ± 189.1
565.3 ± 199.5 573.3 ± 311.1 408.0 ± 185.8
640.7 ± 222.1 265.2 ± 215.3 213.9 ± 191.4
694.3 ± 342.6 347 ± 313.4 218.1 ± 188.8
677.9 ± 180.3 614.7 ± 308.0 344.4 ± 180.3
646.1 ± 295.1 644.0 ± 256.2 423.4 ± 197.5
± 218.4 ± 214.6 ± 199.4
760.6 ± 347.0 725.8 ± 259.4 459.0 ± 165.1
691.8 ± 345.0 221.5 ± 217.3 281.1 ± 210.8
644.1 ± 431.9 197.9 ± 224.2 208.7 ± 186.8
683.2 ± 268.6 503.3 ± 289.7 379.6 ± 172.7
716.0 ± 532.1 550.8 ± 333.3 438.1 ± 230.8
Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024
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A. Moroi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7
Table 9 The airway area in the impaction asymmetry or symmetry groups. Preoperatively Deviation side Asymmetry impaction Anterior 740.3 ± 311.0 Middle 679.1 ± 253.5 Posterior 439.9 ± 217.0 Preoperatively Right Symmetry impaction Anterior 836.4 ± 247.6 Middle 681.9 ± 206.2 Posterior 471.7 ± 183.4
1-week
1-year
Non-deviation side
Deviation side
Non-deviation side
Deviation side
Non-deviation side
733.9 ± 210.5 748.6 ± 229.3 446.9 ± 140.2
656.8 ± 391.1 219.9 ± 237.5 263.2 ± 218.1
618.8 ± 342.1 195.6 ± 241.4 161.1 ± 165.9
656.3 ± 497.8 575.5 ± 324.8 370.7 ± 173.9
714.9 ± 314.6 591.6 ± 355.4 443.2 ± 214.6
Left
1-week Right
Left
1-year Right
Left
686.6 ± 326.4 623.7 ± 300.9 451.2 ± 207.7
732.2 ± 296.3 268.4 ± 202.1 282.8 ± 198.8
685.8 ± 373.9 326.5 ± 276.9 244.5 ± 181.9
740.8 ± 260.6 496.6 ± 195.5 361.5 ± 153.3
629.9 ± 294.5 585.2 ± 289.4 417.2 ± 243.5
maxillary sinus using the LundeMackay rhinologic staging scale, which is a method of evaluating the maxillary sinus using CT images (Sharp et al., 1999; Basu et al., 2005). Additionally, some studies have assessed the oropharyngeal airway after LI and investigated the correlation between this change and surgical maxillary movement (Almuzian et al., 2016). These reports revealed complications following orthognathic surgery that have not thus far been recognized. One of these complications was deformation or deflection of the nasal septum. Nocini et al. examined anatomic defects or surgery-induced alternations that could lead to paranasal homeostasis disruption (2016). In addition, it has been reported that postoperative findings indicate the presence of septal perforations in 3 out of 20 cases (Erbe et al., 2001). While similar nasal septum issues have been reported, there are no reports involving statistically analysis of nasal septum issues. A possible reason for a cartilaginous septum deviation or perforations after maxillary osteotomy is dislocation by a partially deflated cuff during extubation (Acebal-Bianco et al., 2000; Kramer et al., 2004). This is the one of the most important factors in deviation of the septum; it is also considered that LI osteotomy itself will affect the nasal area in terms of the moving direction and moving method. A number of reports related to maxillary orthognathic surgery and the nasal area cited the moving direction and moving method as factors that influence the nasal area (Kim and Park, 2007). In this study, we evaluated the nasal septum by using not only the angle of nasal septum but also both of the nasal airways into which the nasal septum is divided. This was more useful than septum angles in assessing its influence on the nasal cavity and nasal function. It has been reported that after maxilla orthognathic surgery, nasal volume decreased in all cases; it showed remarkable decreases in maxillary impaction cases (Pourdanesh et al., 2012). In addition, clinically significant advancement of the maxilla results in a significant increase in the airway dimension at the nasopharynegeal level (Jakobsone et al., 2011). These studies evaluated the overall nasal area both pre- and post-operatively; however, they did not assess left-right differences. Many studies have compared the nasal or nasopharyngeal airways before and after orthognathic surgery using CT analysis (Jakobsone et al., 2010; Kaur et al., 2014). Compared to diverse evaluation methods, such as 3D construction, CT analysis enables internal and external evaluation of the form and physicality of objects both (Zheng et al., 2014). On the other hand, it is very difficult to ensure reproducibility with CT imaging, as it can be affected by reproducibility of the scanning position, body movement during scanning, and the settings of the CT imaging apparatus. Although measurement of the angle or the length can be modified by calibration, the measurement of the area and volume cannot be modified. Therefore, in our study, evaluation of the area
has been carried out only on the same screen; longitudinal evaluation was not carried out in this study. However, the nasal septum angle measurement from the reference line was carried out to evaluate the time course. The internal width and sectional area at the Isthmus nasi increased significantly in impactions of the maxilla up to 5 mm (Erbe et al., 2001); the maxillary impaction reduced total nasal resistance up to 5 mm, and thus improved the total nasal air flow (Pourdanesh et al., 2012). These reports suggest a close relationship between impaction of maxilla in LI and nasal form and function, in addition to using 5 mm as the reference value. In our study, the deviation of the nasal septum and the airway area were investigated using a reference value of 5 mm; there was no difference between the 2 groups in this study. We found that the anterior movement of maxilla increased the volume of the nasopharyngeal and the hypopharyngeal airway spaces (Greco et al., 1990). Although it was expected that preventing the change would increase volume, there was no significant difference between the advance group and the not-advance group in this study. In terms of improvement of asymmetry, it has been reported that asymmetrical soft tissue was corrected using the jawbone for the asymmetric correction (Moroi et al., 2014). In this study, there was no significant difference between the 2 groups for either the nasal septum angle or the airway area. These results suggest that the nasal septum adapts to the new maxilla and nasal form. In our study, the nasal septum angle larger than 5-mm impaction group at 1 year was 84.9 ± 11.6, and the rate of occurrence of deformation of the nasal septum was 8 (20%) of 40 patients. Excursion or deformation in the nasal septum may occur as a complication; therefore, there is a need for patients' informed consent regarding the nasal septum prior to LI osteotomy surgery. 5. Conclusion In this study, we concluded that conventional LI osteotomy did not influence nasal septum deviation and did not cause left and right asymmetry in the airway. Differences in the methods of moving the maxilla have been shown not to cause changes in the nasal septum. Funding None. References Acebal-Bianco F, Vuylsteke PL, Mommaerts MY, De Clercq CA: Perioperative complications in corrective facial orthopedic surgery: a 5-year retrospective study. J Oral Maxillofac Surg 58: 754e760, 2000
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A. Moroi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e7 Almuzian M, Almukhtar A, Ju X, Al-Hiyali A, Benington P, Ayoub A: Effects of Le Fort I osteotomy on the nasopharyngeal airway-6-month follow-up. J Oral Maxillofac Surg 74: 380e391, 2016 Basu S, Georgalas C, Kumar BN, Desai S: Correlation between symptoms and radiological findings in patients with chronic rhinosinusitis: an evaluation study using the Sinonasal Assessment Questionnaire and Lund-Mackay grading system. Eur Arch Otorhinolaryngol 262: 751e754, 2005 €de U, Wigand ME, Neukam FW: Nasal airway changes after Le Erbe M, Lehotay M, Go Fort Ieimpaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg 30: 123e129, 2001 Ghoreishian M, Gheisari R: The effect of maxillary multidirectional movement on nasal respiration. J Oral Maxillofac Surg 67: 2283e2286, 2009 Greco JM, Frohberg U, Van Sickels JE: Cephalometric analysis of long-term airway space changes with maxillary osteotomies. Oral Surg Oral Med Oral Pathol 70: 552e554, 1990 Haarmann S, Budihardja AS, Wolff KD, Wangerin K: Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery: a prospective study. Int J Oral Maxillofac Surg 38: 321e325, 2009 Ibrahim A, Balakrishnan R, Ebenezer V, Padmanabhan A, Muthlingam V: Combating nasal septum deviation in Le Fort 1 orthognathic surgery complications, with submental intubation. J Clin Diagn Res 8: 46e48, 2014 Jakobsone G, Neimane L, Krumina G: Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of Class III malocclusion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110: 234e242, 2010 Jakobsone G, Stenvik A, Espeland L: The effect of maxillary advancement and impaction on the upper airway after bimaxillary surgery to correct Class III malocclusion. Am J Orthod Dentofacial Orthop 139: 369e376, 2011 Kaur S, Rai S, Kaur M: Comparison of reliability of lateral cephalogram and computed tomography for assessment of airway space. Niger J Clin Pract 17: 629e636, 2014
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Please cite this article in press as: Moroi A, et al., Assessment of nasal septum after Le Fort I osteotomy with computer tomography, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.05.024