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Effects of maxillary advancement and impaction on nasal airway function
Int. J. Oral Maxillofac. Surg. 2012; 41: 1350–1352 http://dx.doi.org/10.1016/j.ijom.2012.03.024, available online at http://www.sciencedirect.com
Clinical Paper Orthognathic Surgery
Effects of maxillary advancement and impaction on nasal airway function
F. Pourdanesh1, R. Sharifi2, A. Mohebbi3, A. Jamilian4 1 Department of Oral & Maxillofacial Surgery, School of Dentistry, Shahid Beheshti, Tehran, Iran; 2Department of Oromaxillofacial Surgery, Tehran University of Medical Sciences, Tehran, Iran; 3Department of Head and Neck Surgery, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran; 4Department of Orthodontics, Dental Branch, Islamic Azad University, Tehran, Iran
F. Pourdanesh, R. Sharifi, A. Mohebbi, A. Jamilian: Effects of maxillary advancement and impaction on nasal airway function. Int. J. Oral Maxillofac. Surg. 2012; 41: 1350–1352. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The effects of Le Fort I osteotomy on the nasal airway are controversial. This study aimed to evaluate nasal airway changes after Le Fort I. 25 patients underwent conventional Le Fort I osteotomy and were separated into three groups depending on the type of surgery they underwent. 11 patients needed maxillary impaction, 9 underwent maxillary advancement, and 5 had both maxillary impaction and advancement. Rhinological examinations, anterior rhinomanometry and acoustic rhinometry were carried out 1 week before surgery and 3 months after that. Wilcoxon and x2 tests were used for data analysis. The samples included 19 females and 6 males with a mean age of 22.4 3.32 years. Rhinomanometric assessment showed that total nasal airflow was increased from 406 202 ml/s to 543 268 ml/s in all three groups. Significant decrease in nasal airway resistance was seen in all three groups. Acoustic rhinometry revealed a significant decrease in total nasal volume but an increase in the cross-sectional areas of isthmus nasi (IN) and inferior concha. The rhinomanometric measurements showed improvements in the total nasal airflow after Le Fort I osteotomy with alar base cinch suture in cases where the impaction was not higher than 5.5 mm.
Different movements of the maxilla in Le Fort I osteotomies have distinct effects on the nasal morphology. Kunkel and Hochban were the first to describe the effect of maxillary movement on nasal volume assessed by acoustic rhinometry.1 Turvey et al. found that superior repositioning of the maxilla, with or without involvement of the nasal floor, usually results in decreased nasal resistance.2 Erbe et al. found no nasal airway changes after Le Fort I impaction or advancement.3 Spalding et al. reported that no prediction could be made for any patient regarding the 0901-5027/01101350 + 03 $36.00/0
effect of maxillary surgery on nasal function parameters and there was no consistent association between the amount or direction of maxillary surgical movement or the position of the maxilla and nasal respiration.4 These contradictory results might be due to different types of Le Fort I osteotomy and whether the patient had alar base cinch suture. The contradictory results in the literature encouraged the authors to carry out new research. The purpose of this study is to evaluate nasal airflow and resistance after maxillary impaction, maxillary advancement, or a
Key words: Le Fort I osteotomy; nasal airway; nasal volume; nasal resistance; maxillary impaction; maxillary advancement. Accepted for publication 23 March 2012 Available online 26 April 2012
combination of both. The investigators hypothesized that improvements might be seen after Le Fort I osteotomy with alar base cinch suture. The specific aims of the study are to evaluate nasal airflow, nasal resistance and the patient’s nasal volume before and after Le Fort I osteotomy. Materials and methods
The investigators designed and implemented a clinical prospective study composed of patients who were referred to
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1351
The effects of maxillary advancement and impaction the Oromaxillofacial Department for Le Fort I surgery. All participants signed an informed consent agreement. To be included in the study sample, the patients had to have dentofacial deformity which required Le Fort I osteotomy for correction. Patients were excluded as study subjects if they had sinusitis, allergic rhinitis, adenoid hyperplasia, craniofacial syndromes, segmental Le Fort I, previous trauma and surgery, especially rhinoplasty. The patients were separated into 3 surgical groups depending on the type of orthognathic surgery they had received, including maxillary impaction (Group 1), maxillary advancement (Group 2) or a combination of both (Group 3). All the patients underwent conventional Le Fort I osteotomy with alar base cinch suture. The research began 1 week before surgery when the patients filled out a questionnaire and underwent rhinological examination, anterior rhinomanometry and acoustic rhinometry. The examinations were repeated by the same otorhinolaryngologist 3 months after surgery. Examinations carried out included documentation of luxations, presence of septal deviations, perforations, spurs, mucosal changes and enlarged turbinates (Table 1). Uninasal anterior active mask rhinomanometry was performed using a NR6 rhinomanometer (GM Instruments Ashgrove, Kilwinning, UK) to assess the nasal airflow and airway resistance of each patient.1 In rhinomanometry, total nasal flow and total nasal resistance were measured. Acoustic rhinometry, described by Jackson et al.,5 was used to evaluate total nasal volume, cross-sectional areas of nostrils at the isthmus nasi (IN) and head of the inferior concha in cm.2 An A1 acoustic rhinometer (GM Instruments Ashgrove, Kilwinning, UK) was used for evaluations before and after surgery. 5 randomly selected patients were reevaluated to determine the level of error in the measurements. There was no significant difference between the measurements. Wilcoxon matched-pairs signed rank test was used for pre- and postoperative findings. The x2 test was used for intergroup evaluations. The data were analyzed using the Statistical Package for the Social Sciences (version 18, SPSS, Chicago, IL, USA).
Table 1. Pre- and postoperative findings of anterior rhinoscopy. Anterior rhinoscopy
Preoperative
Postoperative
0 18 0 19 1 21
Luxations Septal deviations Perforations Spurs Mucosal changes Enlarged turbinate
2 16 0 3 3 12
Table 2. The mean of maxillary impaction and advancement in all three groups. Group 1 2 3
Maxillary impaction (mm)
Maxillary advancement (mm)
5.14 1.78 — 3.6 0.89
orthognathic surgery they had received. Group 1 comprised 11 patients who needed maxillary impaction. Group 2 included 9 patients who underwent maxillary advancement. Group 3 was composed of 5 patients undergoing both maxillary impaction and advancement. The amount of maxillary movement in each of the groups is shown in Table 2 All the patients underwent conventional Le Fort I osteotomy with alar base cinch suture. Table 1 shows the pre- and postoperative findings of anterior rhinoscopy. Table 3 shows the rhinomanometric measurements of nasal airflow and nasal resistance. Total nasal airflow increased from 406 202 to 543 268 ml/s (P < 0.0005) and total nasal resistance decreased from 0.62 0.78 to 0.41 0.4 ml/s (P < 0.0005). Tables 4 and 5 show the acoustic rhinometry measurements for the total nasal volume and cross-sectional areas at the IN and concha inferior before and after surgery. Total nasal volume decreased from 7.8 1.3 to
— 5.22 1.72 2.8 1.3
7.3 1.5 cm3 (P < 0.001). The total cross-section of the IN increased significantly from 0.49 0.1 to 0.52 0.1 cm2; while, the total cross-section of the concha inferior showed no significant changes. Discussion
Nasal airflow and resistance changes were evaluated after Le Fort I osteotomy. It was hypothesized that they might improvement after Le Fort I osteotomy with alar base cinch suture. The rhinoscopic, rhinomanometric, and acoustic rhinometric measurements show that the total nasal function of all patients in the three groups improved significantly after Le Fort I surgery regardless of the direction of surgery. Nasal airflow showed a significant increase in all groups; while nasal resistance showed a significant reduction (Table 3). These results contradict the results found by Erbe et al. who found no significant changes in total nasal airflow or nasal resistance in any patients.3
Table 3. Results of nasal airflow (NA) and nasal resistance (NR) measurements (rhinomanometry) in ml/s. Groups
Preoperative
Postoperative
P value
Total nasal airflow Group 1 (NA) Group 2 (NA) Group 3 (NA) Total nasal resistance Group 1 (NR) Group 2 (NR) Group 3 (NR)
406 202 473 197 296 205 456 147 0.62 0.78 0.37 0.15 1.07 1.19 0.36 0.13
543 268 618 262 460 308 530 195 0.41 0.4 0.27 0.09 0.62 0.62 0.32 0.13
0.0005 0.008 0.008 0.08 0.0005 0.01 0.008 0.08
Table 4. Total nasal volume pre- and postoperatively in the three groups (acoustic rhinometry) in cm3.
Results
Groups
25 patients (6 males, 19 females) with a mean age of 22.4 3.32 years were evaluated. The patients were separated into 3 surgical groups based on the type of
Total Group 1 Group 2 Group 3
Preoperative 7.8 1.3 7.3 1.1 8.7 0.9 7.2 1.5
Postoperative
P value
7.3 1.5 6.5 1.2 8.7 0.8 6.7 1.5
0.001 0.001 0.8 0.03
1352
Pourdanesh et al.
Table 5. Cross-sectional area at the isthmus nasi (IN) and concha inferior (CI) in cm2 pre- and postoperatively in the three groups (acoustic rhinometry). Groups Total cross-section of isthmus nasi Group 1 (IN) Group 2 (IN) Group 3 (IN) Total cross-section of concha inferior Group 1 (CI) Group 2 (CI) Group 3 (CI)
Acoustic rhinometry revealed that total nasal volume decreased in all patients. This decrease was significant in Groups 1 and 3, but was non-significant in Group 2 patients. The cross-sectional area at the IN showed a significant increase in Groups 1 and 2 and totally, but no significant changes in Group 3. The cross-sectional area at the concha inferior showed no significant changes in any of the groups or totally. Rhinomanometry and acoustic rhinometry are reliable and objective methods of determining functional and geometric changes in the nasal cavity after Le Fort I osteotomy.6,7 The findings of this study corroborate previous studies suggesting that maxillary repositioning opens internal nose dimensions, thus improving nasal airflow and reducing nasal resistance.2,4,8–11 Maxillary advancement tends to increase the nasolabial angle and thus to increase the vertical axis of the valve area. This results in a more favourable inflow of air into the nasal cavity and respiratory resistance. Enlarged turbinates and bony spurs can cause a decrease in airflow through the nose, so their reduction will result in an increase in nasal volume. The resulting increase in nasal volume plays a favourable role in decreasing airway resistance and increasing airway flow. An increase in the width of the alar base is commonly observed especially after maxillary impaction surgery. Supplementary surgical procedures, such as an alar cinch, may also improve nasal breathing by changing the external nares from narrow slits to more ovoid forms postoperatively.12 The authors presume that their findings regarding improvement of airflow differ from those of Erbe et al. because of
Preoperative
Postoperative
P value
0.49 0.1 0.43 0.1 0.6 0.1 0.41 0.1 0.5 0.1 0.47 0.1 0.55 0.2 0.4 0.2
0.52 0.1 0.47 0.1 0.64 0.1 0.43 0.1 0.51 0.1 0.49 0.1 0.54 0.1 0.5 0.1
0.003 0.002 0.05 0.1 0.4 0.1 0.8 0.6
the cinch procedure in the alar base. The results give the authors an opportunity for correlative clinical studies. This study has some limitations such as the small sample size. The effects of maxillary setback on nasal airflow can be studied in future research. In conclusion, up to 5.5 mm of maxillary impaction, advancement or a combination of both as a result of Le Fort I surgery combined with cinched procedure in the alar base will reduce total nasal resistance and thus improve total nasal airflow. Patients undergoing Le Fort I osteotomy should be advised about possible improvements in their nasal airflow especially if the impaction is less than 5.5 mm. Funding
This research was supported by Head and Neck Research Center of Rasoul Akram Medical Complex, TUMS. Competing interests
None declared. Ethical approval
All the patients signed informed consent form before their surgery. It was done as the normal procedure of the hospital where the surgeries were done. References 1. Kunkel M, Hochban W. The influence of maxillary osteotomy on nasal airway patency and geometry. Mund Kiefer Gesichtschir 1997;1:194–8.
2. Turvey TA, Hall DJ, Warren DW. Alterations in nasal airway resistance following superior repositioning of the maxilla. Am J Orthod 1984;85:109–14. 3. Erbe M, Lehotay M, Gode U, Wigand ME, Neukam FW. Nasal airway changes after Le Fort I—impaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg 2001;30:123–9. 4. Spalding PM, Vig PS, Lints RR, Vig KD, Fonseca RJ. The effects of maxillary surgery on nasal respiration. Int J Adult Orthodon Orthognath Surg 1991;6:191–9. 5. Jackson AC, Butler JP, Millet EJ, Hoppin Jr FG, Dawson SV. Airway geometry by analysis of acoustic pulse response measurements. J Appl Physiol 1977;43:523–36. 6. Cakmak O, Coskun M, Celik H, Buyuklu F, Ozluoglu LN. Value of acoustic rhinometry for measuring nasal valve area. Laryngoscope 2003;113:295–302. 7. Numminen J, Dastidar P, Heinonen T, Karhuketo T, Rautiainen M. Reliability of acoustic rhinometry. Respir Med 2003;97: 421–7. 8. Gotzfried HF, Masing H. On the improvement of nasal breathing following mid-face osteotomies, and possible reasons for the phenomenon. J Maxillofac Surg 1984;12: 29–32. 9. Guenthner TA, Sather AH, Kern EB. The effect of Le Fort I maxillary impaction on nasal airway resistance. Am J Orthod 1984;85:308–15. 10. Stoker NG, Epker BN. The posterior maxillary ostectomy: a retrospective study of treatment results. Int J Oral Surg 1974;3: 153–7. 11. Timms DJ. Re: The effect of Le Fort I maxillary impaction on nasal airway resistance. Am J Orthod 1984;86:439. 12. 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 2009;38:321–5.
Address: Abdolreza Jamilian No. 2713 Vali Asr St. Tehran 1966843133 Iran Tel.: +98 21 22011892; Fax: +98 21 22022215 E-mail: [email protected]
Clinical Paper Orthognathic Surgery
Effects of maxillary advancement and impaction on nasal airway function
F. Pourdanesh1, R. Sharifi2, A. Mohebbi3, A. Jamilian4 1 Department of Oral & Maxillofacial Surgery, School of Dentistry, Shahid Beheshti, Tehran, Iran; 2Department of Oromaxillofacial Surgery, Tehran University of Medical Sciences, Tehran, Iran; 3Department of Head and Neck Surgery, Rasool Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran; 4Department of Orthodontics, Dental Branch, Islamic Azad University, Tehran, Iran
F. Pourdanesh, R. Sharifi, A. Mohebbi, A. Jamilian: Effects of maxillary advancement and impaction on nasal airway function. Int. J. Oral Maxillofac. Surg. 2012; 41: 1350–1352. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. The effects of Le Fort I osteotomy on the nasal airway are controversial. This study aimed to evaluate nasal airway changes after Le Fort I. 25 patients underwent conventional Le Fort I osteotomy and were separated into three groups depending on the type of surgery they underwent. 11 patients needed maxillary impaction, 9 underwent maxillary advancement, and 5 had both maxillary impaction and advancement. Rhinological examinations, anterior rhinomanometry and acoustic rhinometry were carried out 1 week before surgery and 3 months after that. Wilcoxon and x2 tests were used for data analysis. The samples included 19 females and 6 males with a mean age of 22.4 3.32 years. Rhinomanometric assessment showed that total nasal airflow was increased from 406 202 ml/s to 543 268 ml/s in all three groups. Significant decrease in nasal airway resistance was seen in all three groups. Acoustic rhinometry revealed a significant decrease in total nasal volume but an increase in the cross-sectional areas of isthmus nasi (IN) and inferior concha. The rhinomanometric measurements showed improvements in the total nasal airflow after Le Fort I osteotomy with alar base cinch suture in cases where the impaction was not higher than 5.5 mm.
Different movements of the maxilla in Le Fort I osteotomies have distinct effects on the nasal morphology. Kunkel and Hochban were the first to describe the effect of maxillary movement on nasal volume assessed by acoustic rhinometry.1 Turvey et al. found that superior repositioning of the maxilla, with or without involvement of the nasal floor, usually results in decreased nasal resistance.2 Erbe et al. found no nasal airway changes after Le Fort I impaction or advancement.3 Spalding et al. reported that no prediction could be made for any patient regarding the 0901-5027/01101350 + 03 $36.00/0
effect of maxillary surgery on nasal function parameters and there was no consistent association between the amount or direction of maxillary surgical movement or the position of the maxilla and nasal respiration.4 These contradictory results might be due to different types of Le Fort I osteotomy and whether the patient had alar base cinch suture. The contradictory results in the literature encouraged the authors to carry out new research. The purpose of this study is to evaluate nasal airflow and resistance after maxillary impaction, maxillary advancement, or a
Key words: Le Fort I osteotomy; nasal airway; nasal volume; nasal resistance; maxillary impaction; maxillary advancement. Accepted for publication 23 March 2012 Available online 26 April 2012
combination of both. The investigators hypothesized that improvements might be seen after Le Fort I osteotomy with alar base cinch suture. The specific aims of the study are to evaluate nasal airflow, nasal resistance and the patient’s nasal volume before and after Le Fort I osteotomy. Materials and methods
The investigators designed and implemented a clinical prospective study composed of patients who were referred to
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1351
The effects of maxillary advancement and impaction the Oromaxillofacial Department for Le Fort I surgery. All participants signed an informed consent agreement. To be included in the study sample, the patients had to have dentofacial deformity which required Le Fort I osteotomy for correction. Patients were excluded as study subjects if they had sinusitis, allergic rhinitis, adenoid hyperplasia, craniofacial syndromes, segmental Le Fort I, previous trauma and surgery, especially rhinoplasty. The patients were separated into 3 surgical groups depending on the type of orthognathic surgery they had received, including maxillary impaction (Group 1), maxillary advancement (Group 2) or a combination of both (Group 3). All the patients underwent conventional Le Fort I osteotomy with alar base cinch suture. The research began 1 week before surgery when the patients filled out a questionnaire and underwent rhinological examination, anterior rhinomanometry and acoustic rhinometry. The examinations were repeated by the same otorhinolaryngologist 3 months after surgery. Examinations carried out included documentation of luxations, presence of septal deviations, perforations, spurs, mucosal changes and enlarged turbinates (Table 1). Uninasal anterior active mask rhinomanometry was performed using a NR6 rhinomanometer (GM Instruments Ashgrove, Kilwinning, UK) to assess the nasal airflow and airway resistance of each patient.1 In rhinomanometry, total nasal flow and total nasal resistance were measured. Acoustic rhinometry, described by Jackson et al.,5 was used to evaluate total nasal volume, cross-sectional areas of nostrils at the isthmus nasi (IN) and head of the inferior concha in cm.2 An A1 acoustic rhinometer (GM Instruments Ashgrove, Kilwinning, UK) was used for evaluations before and after surgery. 5 randomly selected patients were reevaluated to determine the level of error in the measurements. There was no significant difference between the measurements. Wilcoxon matched-pairs signed rank test was used for pre- and postoperative findings. The x2 test was used for intergroup evaluations. The data were analyzed using the Statistical Package for the Social Sciences (version 18, SPSS, Chicago, IL, USA).
Table 1. Pre- and postoperative findings of anterior rhinoscopy. Anterior rhinoscopy
Preoperative
Postoperative
0 18 0 19 1 21
Luxations Septal deviations Perforations Spurs Mucosal changes Enlarged turbinate
2 16 0 3 3 12
Table 2. The mean of maxillary impaction and advancement in all three groups. Group 1 2 3
Maxillary impaction (mm)
Maxillary advancement (mm)
5.14 1.78 — 3.6 0.89
orthognathic surgery they had received. Group 1 comprised 11 patients who needed maxillary impaction. Group 2 included 9 patients who underwent maxillary advancement. Group 3 was composed of 5 patients undergoing both maxillary impaction and advancement. The amount of maxillary movement in each of the groups is shown in Table 2 All the patients underwent conventional Le Fort I osteotomy with alar base cinch suture. Table 1 shows the pre- and postoperative findings of anterior rhinoscopy. Table 3 shows the rhinomanometric measurements of nasal airflow and nasal resistance. Total nasal airflow increased from 406 202 to 543 268 ml/s (P < 0.0005) and total nasal resistance decreased from 0.62 0.78 to 0.41 0.4 ml/s (P < 0.0005). Tables 4 and 5 show the acoustic rhinometry measurements for the total nasal volume and cross-sectional areas at the IN and concha inferior before and after surgery. Total nasal volume decreased from 7.8 1.3 to
— 5.22 1.72 2.8 1.3
7.3 1.5 cm3 (P < 0.001). The total cross-section of the IN increased significantly from 0.49 0.1 to 0.52 0.1 cm2; while, the total cross-section of the concha inferior showed no significant changes. Discussion
Nasal airflow and resistance changes were evaluated after Le Fort I osteotomy. It was hypothesized that they might improvement after Le Fort I osteotomy with alar base cinch suture. The rhinoscopic, rhinomanometric, and acoustic rhinometric measurements show that the total nasal function of all patients in the three groups improved significantly after Le Fort I surgery regardless of the direction of surgery. Nasal airflow showed a significant increase in all groups; while nasal resistance showed a significant reduction (Table 3). These results contradict the results found by Erbe et al. who found no significant changes in total nasal airflow or nasal resistance in any patients.3
Table 3. Results of nasal airflow (NA) and nasal resistance (NR) measurements (rhinomanometry) in ml/s. Groups
Preoperative
Postoperative
P value
Total nasal airflow Group 1 (NA) Group 2 (NA) Group 3 (NA) Total nasal resistance Group 1 (NR) Group 2 (NR) Group 3 (NR)
406 202 473 197 296 205 456 147 0.62 0.78 0.37 0.15 1.07 1.19 0.36 0.13
543 268 618 262 460 308 530 195 0.41 0.4 0.27 0.09 0.62 0.62 0.32 0.13
0.0005 0.008 0.008 0.08 0.0005 0.01 0.008 0.08
Table 4. Total nasal volume pre- and postoperatively in the three groups (acoustic rhinometry) in cm3.
Results
Groups
25 patients (6 males, 19 females) with a mean age of 22.4 3.32 years were evaluated. The patients were separated into 3 surgical groups based on the type of
Total Group 1 Group 2 Group 3
Preoperative 7.8 1.3 7.3 1.1 8.7 0.9 7.2 1.5
Postoperative
P value
7.3 1.5 6.5 1.2 8.7 0.8 6.7 1.5
0.001 0.001 0.8 0.03
1352
Pourdanesh et al.
Table 5. Cross-sectional area at the isthmus nasi (IN) and concha inferior (CI) in cm2 pre- and postoperatively in the three groups (acoustic rhinometry). Groups Total cross-section of isthmus nasi Group 1 (IN) Group 2 (IN) Group 3 (IN) Total cross-section of concha inferior Group 1 (CI) Group 2 (CI) Group 3 (CI)
Acoustic rhinometry revealed that total nasal volume decreased in all patients. This decrease was significant in Groups 1 and 3, but was non-significant in Group 2 patients. The cross-sectional area at the IN showed a significant increase in Groups 1 and 2 and totally, but no significant changes in Group 3. The cross-sectional area at the concha inferior showed no significant changes in any of the groups or totally. Rhinomanometry and acoustic rhinometry are reliable and objective methods of determining functional and geometric changes in the nasal cavity after Le Fort I osteotomy.6,7 The findings of this study corroborate previous studies suggesting that maxillary repositioning opens internal nose dimensions, thus improving nasal airflow and reducing nasal resistance.2,4,8–11 Maxillary advancement tends to increase the nasolabial angle and thus to increase the vertical axis of the valve area. This results in a more favourable inflow of air into the nasal cavity and respiratory resistance. Enlarged turbinates and bony spurs can cause a decrease in airflow through the nose, so their reduction will result in an increase in nasal volume. The resulting increase in nasal volume plays a favourable role in decreasing airway resistance and increasing airway flow. An increase in the width of the alar base is commonly observed especially after maxillary impaction surgery. Supplementary surgical procedures, such as an alar cinch, may also improve nasal breathing by changing the external nares from narrow slits to more ovoid forms postoperatively.12 The authors presume that their findings regarding improvement of airflow differ from those of Erbe et al. because of
Preoperative
Postoperative
P value
0.49 0.1 0.43 0.1 0.6 0.1 0.41 0.1 0.5 0.1 0.47 0.1 0.55 0.2 0.4 0.2
0.52 0.1 0.47 0.1 0.64 0.1 0.43 0.1 0.51 0.1 0.49 0.1 0.54 0.1 0.5 0.1
0.003 0.002 0.05 0.1 0.4 0.1 0.8 0.6
the cinch procedure in the alar base. The results give the authors an opportunity for correlative clinical studies. This study has some limitations such as the small sample size. The effects of maxillary setback on nasal airflow can be studied in future research. In conclusion, up to 5.5 mm of maxillary impaction, advancement or a combination of both as a result of Le Fort I surgery combined with cinched procedure in the alar base will reduce total nasal resistance and thus improve total nasal airflow. Patients undergoing Le Fort I osteotomy should be advised about possible improvements in their nasal airflow especially if the impaction is less than 5.5 mm. Funding
This research was supported by Head and Neck Research Center of Rasoul Akram Medical Complex, TUMS. Competing interests
None declared. Ethical approval
All the patients signed informed consent form before their surgery. It was done as the normal procedure of the hospital where the surgeries were done. References 1. Kunkel M, Hochban W. The influence of maxillary osteotomy on nasal airway patency and geometry. Mund Kiefer Gesichtschir 1997;1:194–8.
2. Turvey TA, Hall DJ, Warren DW. Alterations in nasal airway resistance following superior repositioning of the maxilla. Am J Orthod 1984;85:109–14. 3. Erbe M, Lehotay M, Gode U, Wigand ME, Neukam FW. Nasal airway changes after Le Fort I—impaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg 2001;30:123–9. 4. Spalding PM, Vig PS, Lints RR, Vig KD, Fonseca RJ. The effects of maxillary surgery on nasal respiration. Int J Adult Orthodon Orthognath Surg 1991;6:191–9. 5. Jackson AC, Butler JP, Millet EJ, Hoppin Jr FG, Dawson SV. Airway geometry by analysis of acoustic pulse response measurements. J Appl Physiol 1977;43:523–36. 6. Cakmak O, Coskun M, Celik H, Buyuklu F, Ozluoglu LN. Value of acoustic rhinometry for measuring nasal valve area. Laryngoscope 2003;113:295–302. 7. Numminen J, Dastidar P, Heinonen T, Karhuketo T, Rautiainen M. Reliability of acoustic rhinometry. Respir Med 2003;97: 421–7. 8. Gotzfried HF, Masing H. On the improvement of nasal breathing following mid-face osteotomies, and possible reasons for the phenomenon. J Maxillofac Surg 1984;12: 29–32. 9. Guenthner TA, Sather AH, Kern EB. The effect of Le Fort I maxillary impaction on nasal airway resistance. Am J Orthod 1984;85:308–15. 10. Stoker NG, Epker BN. The posterior maxillary ostectomy: a retrospective study of treatment results. Int J Oral Surg 1974;3: 153–7. 11. Timms DJ. Re: The effect of Le Fort I maxillary impaction on nasal airway resistance. Am J Orthod 1984;86:439. 12. 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 2009;38:321–5.
Address: Abdolreza Jamilian No. 2713 Vali Asr St. Tehran 1966843133 Iran Tel.: +98 21 22011892; Fax: +98 21 22022215 E-mail: [email protected]