The Study of Orthognathic Surgery on Nasal Function and Morphology

 

Abstract

"Orthognathic surgery" changes the maxilla and mandible position, and as a result, it alters the nasal form. The purpose of analysis was order to check the publications on modifications by "maxillary orthognathic surgery". Comprehending these modifications is necessary to plan surgery also acquiring consent letter, With has forensic implications. It is possible to anticipate the results of distinct surgical movements during "orthognathic surgery planning", and this is an essential aspect of the planning process. In this way, the predicted alterations should be determined and the degree of their desirability for each patient should be specified. Several procedures for managing adverse nasal alterations are discussed, such as aids to minimize these potential impacts, and other surgical methods to betterment adverse modifications after that.

 

Keywords: Maxillary osteotomy; orthognathic surgery; nasal changes; orthodontics; suture.

 

Introduction

A complete examination of the deformation and tissues under management is required for a prosperous result in facial aesthetics and "reconstructive surgery". Any surgery that is performed to correct or change facial features will lead to nasal aesthetics (1). we prepare for orthognathic surgery must be the nose (2).

To restore inborn and acquired "dentofacial abnormalities", orthognathic surgery is often performed. The consequent modifications in the "maxillomandibular skeleton" have outcomes for the overlying soft tissue wrapping of the face. Surgeons who conduct these operations should be familiar with possible changes that may appear in the structure of the nose, therefore they can properly plan assisted approaches and advise their patients on the anticipated aesthetic results and the potential urge for further surgery (1). Orthognathic surgery results in changes in the “maxilla and maxillary position” and will alter the nasal morphology and function (3).

This report will discuss the anticipated differences in the nasal appearance of orthognathic surgery. Also, it will focus on “Le Fort I type surgeries”, as it is the most typical sort of surgery essayed in isolation or as part of "bimaxillary orthognathic surgery" and directly influences nasal look.

 

Impacts of “orthognathic surgery” on nasal function

The movement of the mandibular has little influence on nose parameters, but it changes association among chin and nose (Figure 1). This must be taken into consideration when assessing predictions and advising the patient. Prior investigations indicated that after disorder in maxilla, a reduction of respiratory resistance was seen (4). Excessive reduction of the maxilla may cause the narrow nares to dilate, which is frequently observed in these cases, and improve the “external nasal valve” (5). For "airway resistance", high primary values are most beneficial for patients. (6).

 

Effects of a Vertical Skeletal Pattern on Nasal Respiratory Function and Upper Airway

Lots of research has been conducted on the effect of the vertical structuring of the skeleton on the morphology of the airways. Ucar et al reported significant differences in nasopharyngeal airway space and postero-upper airway space between low, moderate, and high angle patients, measuring nasopharyngeal airway space and posterior upper airway space. posterosuperior airway in low-angle subjects more than in high-angle subjects. Celikoglu et al found that a high-angle population decreased upper airway volume (7).

 

Effects of a Sagittal Skeletal Pattern on Nasal Respiratory Function and Upper Airway

In valid previous studies, Rezaei Taleb et al. It was found that airway resistance significantly increased after correction of Class III malocclusion by maxillofacial surgery with respect to respiratory function. By studying airway morphology, El et al reported that the posterior airway area, the area of the most narrowed area at the base of the tongue, and the oropharyngeal airway volume are the largest in the mandibular class III group, And the smallest group of mandibular retraction of the second category. A significant difference in nostril size was found only in group I and group II mandibular retraction (Figure 2) . Alves et al examined the difference between skeletal class I and class II patients and reported that skeletal class II patients had significantly lower airway volume and lower axial area than skeletal class I patients. They had larger pharyngeal airways than Class I skeletal adolescents. The upper airway profile was similar to previous studies. With regard to the effect of the craniofacial skeleton pattern on nasal respiratory function, the craniofacial skeleton pattern can influence the morphology of the upper airways and thus the nasal respiratory function. The results of this work showed that the NPR of skeletal group III is higher than others, indicating nasal asymmetry in the respiratory system of skeletal group III. Although there was no significant difference between the three groups in the bilateral nasal cavity volume ratio (Naso-Vr), previous studies had shown that the proportion of facial asymmetry was slightly higher in patients with structural class III.(7).

 

Impact of Le-Fort I osteotomy on anatomical and functional aspects of the nasal airway and on quality of life
Movements of the upper jaw cause changes in the external dimensions of the nose, which often leads to an increase in the width of the base of the nose (Figure 1). This stretching at the base of the nasal valve can reduce the resistance of the nasal airway when the nasal valve is opened. Rhinoacoustic data paradoxically show an increase in the diameter of the valvular region during maxillary movement. The advance of the maxilla tends to increase the nasolabial angle (Figure 3) and increase the vertical axis of the valve region. This leads to better airflow in the nasal cavity and resistance to breathing. An increase in the width of the base of the wing is often observed, especially after maxillary retraction surgery. Additional surgical procedures, such as tying the wings, can improve nasal breathing by changing the external nostrils from narrower incisions to more oval incisions after surgery (8).

The influence of orthognathic surgery on ventilation during sleep

The possible effect of corrective surgery on respiratory function during sleep was first noted by GUILLEMINAULT et al. They describe two cases of lower inferior recession in which obstructive sleep apnea (OSA) developed long after surgery. Two years later, Riley et al. They reported the same case. The first systematic study of sleep apnea index in orthodontic patients was conducted by TURNBULL & BATTAGEL. Although no polygraphs or polysomnography were performed, nocturnal oximetry data and respiratory noise descriptions obtained from the patients showed no significant changes in the incidence of snoring or wheezing postoperatively. In the lower inferior manifestation group, changes in sleep quality were observed, but only in cases with early signs of sleep disturbance (9).

 

The impacts “orthognathic surgery” on nasal morphology

There is a known correlation between jaw growth and nasal function (10). Nasal airway obstruction can lead to excessive mouth breathing in infancy. This can affect the growth and morphology of the face. In particular, maxillary entrapment and mandibular displacement (eg, “Maxillary Vertical Enlargement [VME]”) (3).

Most osteotomies are "LeFort I", whether ablation or advancement. When the periosteum is raised above the face of the upper jaw, the muscles in this region diverge in their degrees. and there was a recession that led to the expansion of the islets. Attached muscles include "the zygomaticus major, levator lip superior, levator lip superior, alar superior, and nasalis." Contractions of these muscles also shorten the upper lip.

The nasal tip supports come from different parts of the anatomy of the nose and their fibrous connections. Medial crural footplates fixed to the septum, the quality of the lower lateral cartilage ,the nasal septum and lower and upper lateral cartilage junction, all of them are related to tip support (12). These structures are in direct contact with the maxillary bone by the crest of the nosal bone and the nasal spine. Thats why the movement of the upper jaw should affect the projection and tip of the nose. Although a consistent relationship between these changes has not been adequately demonstrated by researchers (12).

Maxillary progression, usually accompanied by upper or lower displacement, affects the important alteration in the base and tip of the nose. Anterior displacement of the alar base and upper lip after maxillary advancement was revealed in corpse studies (13, 14). There was a dilation of the “alar bases” and a diminish in columella as well as an exacerbation of supratip failure (11). Investigations were accomplished only with the development of the maxilla and in the corpse, so perinasal muscle influences cannot be considered (1).

Short upper lip and retracted columella are usually seen in patients that need repositioning of the mandibular (15). After surgery, these features may worsen. Notably, moving the inferior part of the maxilla may result in the tip of the nose dropping. Polly-beak anomaly can be formed by these procedures: loss of the supratip break and filling of supratip region with the dorsum convexity (16).

Superior maxillary motion in long-faced patients likewise causes the alar base to dilate (17). In addition, it can reduce the angle of the nasolabial, but it will allow the tip of the nose to move better (18).

For Class II malocclusion, eventually, the setback of maxillary can lead to modifications. These modifications are slighter than those seen with other maxilla motions. These contain an upsurge in nasolabial angles, nasal tip downcast movement, and a supratip depression reduction.

Numerous researchers have tried to minimize the alters observed with different maxillary movements. However, there are specific trends throughout the publications, and slight data has been confirmed in investigations. Most studies that have analyzed quantifying or linking soft tissue alterations to bone displacement have achieved separate values and connections (1, 19).

A previous study declared 25 maxillary advancement patients with a mean of 8.8 months of pursuit. All cases progressed, nevertheless, no statement was made on whether there was any maxilla inferior or superior positioning. Based on lateral cephalograms, they informed no considerable difference in the position of the tip of the nose, but they found a tend to be superior and anterior displacement to the tip of the nose (20). Subnasale moved to a standard of 0.668 to the distance the incisors repositioned. In this investigation, all cases experienced nasal muscle re-approximation and advanced VY intraoral incision closure (20).

One study declared altering in morphology of nose after LeFort I osteotomy. The study assessed 41 cases who experienced superior or anterior maxillary movement (21). The width of the alar was raised by a norm of 3.4 mm, whereas there wasn't any connection between the displacement of the maxilla and the portion of dilation of the alar. Moreover, an upsurge projection at the tip of the nose was observed with all maxillary advances despite never being observed with distinct superior maxillary displacement. These results differ from other published results that characterize alters in tip projection related to the movement of the maxillary (21).

Gassmann et al (22) operated “cephalometric analysis” to assess the morphology of the nose and declared the outcomes of fifty “LeFort I osteotomies”. They notified differences in the “projection angle, the columellar angle, and the supratip break angle of the nose”. A positive relation was observed among point A movement and movement of the nasal tip. Nevertheless, there was no considerable association with the "projection angles" of the" nasal tip". Progression of point A was correlated with an upsurge in "columellar angle", but no association was observed between maxillary rotation or point A movement and the "supratip break angle". In addition, the researchers divided patients into two groups: 1- those who were neared linearly and 2- those who were neared with VY progression. No remarkable impact was observed on any of the measured "soft tissue angles" (22).

An investigation in 2006 employed a "three-dimensional imaging system" to assess nasal modifications quantitatively following "orthognathic surgery" (23). Regardless of the direction of rotation, they show an upsurge in intra-alar width and intranasal with nearly all the maxillary advancement procedures. Interestingly, two cases who progressed with an upward rotation due to class III malformations displayed a reduction in intra-allar but not intranasal width. There was not any association between alters in the width of intraalar and alters in the width of the intranostril. The protrusion of the tip of the nasal indicated no association with the movement of the maxilla. Cases who experience progress and rotate upwards show a decline in projection, while most patients who undergo progress without rotation indicate an upsurge in projection. An upsurge in the nasolabial angle after surgery was seen in all of the cases with class II anomalies, while the maxilla downward tendency displayed a decline in angle. Class III abnormality cases that underwent mandibular rotation upward indicated an important reduction in their nasolabial angles (23).

In short, it is challenging, if not inconceivable, to predict differences in the morphology of the nose after "orthognathic surgery." After the advancement of the maxilla, the upsurge in the protrusion of the tip and the “alar base” dilation is the most constant change seen in the articles. However, we cannot predict if these modifications quantitatively and continuously show no association with the grade of displacement of maxillary.

After LeFort I osteotomy, anticipating nasal modifications is difficult and complex due to the numerous preoperative dissimilarities among patients and the distorting features that impact the morphology of the nasal. The elasticity and thickness of the skin, the supporting structures of the tip of the nose, and the slight differences in the structure of the facial muscles all help to reduce or increase the forecasted influences (24, 25).

Moreover, all the mentioned approaches for the analysis of soft tissue have an error of about 1 mm. Modifications in this volume can be ignored via quantitative analysis, which adds to the hardship of forecasting postoperative changes. Finally, it has been found that shifts in the morphology of the nose ensue up to 12 months after "rhinoplasty", and we should expect the same after "orthognathic surgery", which also contains the structure of the nose (1).

 

Intraoperative methods for managing nasal changes with "orthognathic surgery"

a. Alar base cinch suture: It may be operated on to diminish the upsurge in the width of the nose caused via osteotomy. In spite of the fact that several researchers informed its effectiveness, little is comprehended about the long-term stability of the maneuver. Guymon et al.(26) have declared a significant limiting influence on increasing the alar base width in the postoperative year, but some authors discovered that cinch suturing is useless or has dilated the alar base (19, 27). "Orthognathic surgery" is a method to decline dilatation of the "alar base with maxillary surgery"(28, 29). The upsurge in nasal width following the "Le Fort I type osteotomy" was an upsurge without re-approximating the muscles around the mouth and perinasal (30). Also, the clearance of adhesions from the periosteum and nasal adjacent muscles, edema, and the spatial alteration of the supporting bone to the base of the nose are suggested (2). The traditional "cinch suture" operates a 3/0 nonabsorbent stitch that is passed across an "intra-oral incision" and traps the "fibro-areolar tissue" and the "transverse nasalis muscle." These organized orientation of the perinasal muscles is considering to produce better anticipated with steady outcome from them spontaneous repositioning (21). This has been criticized because it is unpredictable, inaccurate, and can result in other potential consequences, including "lengthening" the upper lip. The "naso-endotracheal tube" can distort the nostrils, causing it difficult to measure the alar base width accurately, and undertaking of the suture challenging and inaccurate (31). The issue of utilizing "subcutaneous intubation" has been discoursed by several surgeons (32, 33). Also, several surgeons have proposed replacing "naso-endotracheal tube by "oral endotracheal tube" ensuing consolidation mandible (34, 35). Minimizing alar dilatation in different studies is controversial, and some of these studies indicated no important results, while others were supportive of the efficacy of "alar base cinch sutures" (36-38). A study showed a small, clinically unimportant reduction in alar breadth dilation (0.5 mm) and supposed that it had a small advantage (29). Another investigation showed that the dilatation of the alar was remarkably decreased by 1.6 and 2.3 mm with "cinch sutures" in comparison to the controls (39).

A further critique is an unintentional rotation of the tip of the nose (upwards), which occurs as a consequence of the "maxillary bone" ventral pressure on the "lateral crurae" (40). Also, Increased "nasolabial angle" has been recognized in previous investigations (2, 41). Suturing through a 10 mm "posterior nasal septum" in order that limit correction to this impact is nasal spine (42). Nevertheless, a considerable upsurge was observed in the projection of the tip of the nose horizontally and the ratio of soft tissue to hard upper lip movement in the modified alar cinch suture and V-Y closure (mACVY) group (43).

Stability should be tested at least a year after surgery because postoperative edema removal takes up to six months (44). Investigations, in which samples were observed for a year, show that there is reasonable "medium-term stability" (35, 36, 45). However, the type of suture used, i.e., the absorbable type (46) or the non-absorbable type (47), may influence the stability of this method. "Extra-oral insertion with partial retraction, extra-oral suture insertion", and transseptal approach are some of the modifications utilized to increase stability, for which prospective and mainly randomized trials have been performed (29, 48, 49). One study found that the modified versions were more efficient than the classic "cinch suture" in preserving the width of the alar base (50), however, a prospective double-blind investigation was not found a significant difference from their proposed correction (51).

b. “Anterior nasal spine (ANS) recontouring/subspinal osteotomy”: To Control the rotation of the tip of nose, ANS decline become performed while moving the upper jaw forward, as the progression of the maxilla usually results in the tip of the nose being turned (52, 53). It is also challenging to quantify the extent and location of bone removal and measurements in "lateral cephalometric radiographs" because of modifications in site anatomy, so this may have led to slight evidence, although it is usually done clinically. A different method to limit the rotation of the tip of the nose for patients experiencing maxillary progression or occlusion is a "subspinal osteotomy" (54, 55). It is recommended that protection of natural muscular insertions of "transverse nasalis" and "depressor septi muscles" can be performed if the anterior part of the regular “circumvestibular incision” is essayed in a V-shaped complete thickness way and the “anterior osteo-musculo-mucosal flap” from the nasal septum is maintained (55). Some of these decrease the dilation of the alar base and the rotation of the tip, although others found no distinction in the elevation and protrusion of the tip of the nose (56). A retrospective investigation of two matching groups receiving a typical "Le Fort I osteotomy" for maxillary progression and occlusion with "ANS recontouring, alar base cinch suture, and VY closure or subspinal osteotomy." Adaptation established on the amount and orientation of skeletal motion authorizes a better accurate comparison of the impact of the procedures, whereas it is crucial to mention that the comparison of Le Fort I with numerous auxiliary methods which have their own impacts on nasal shape.

c. VY closure: This includes medial improvement of superior part of the "vestibular incision" to make the ‘Y’ shape, to aid in re-approximate the "nasolabial musculature", decreasing the preference for shortening and thinning of the upper lip with "Le Fort I osteotomies" (56). Examinations frequently affect cases who receive "cinch sutures" along with "VY closures," and it is challenging to determine which of these methods makes what impact (43). The tendency to close the VY, which helps to minimize the shortening of the upper lip, has been reported in the publications (43), although some investigations have not seen a statistically considerable difference (57). A study showed a statistically notable increment in the height of the upper lip with "alar cinch suture and VY ligation (1.10 mm ± 0.34)”, indicating a 23% upsurge in comparison to the shortening of the superficial closure group with a "cinch suture (–0.79 mm ± 0.45) ". Furthermore, with VY ligation, the thinning of the upper lip was extremely low (58).

 

Secondary surgical methods for managing nasal modifications with “orthognathic surgery”

Basic correction surgery may be considered to correct undesired modifications in the "allar base" following "orthognathic surgery". Preferably, the most lateral aspect of the alar should fall within a perpendicular line descended from the medial aspect of the medial canthus, and "infratip lobule" width must be about 75% of the nasal width. When planning this procedure, the following areas should be evaluated: the amount of the "nasal sill", "inter-alar" width, the absence or presence of "alar flaring", the thickness of the "alar rim", and the shape of the "nostril". Decreasing the base of alar is better to accomplish at the "nasal sill". If the issue is originally a flare-up, the incisions may be limited to "alar facial groove". The deployment of incisions to the surface of the "internal vestibular" relies on the tendency for the naris to deform. If the edge of the alar is thick, it can be necessary to cut more wedges from the edge to narrow it (60). Septoplasty should be used to correct the buckling septum following maxillary occlusion to make the nasal airway better and counteract any asymmetry caused by it. Columellar contraction due to over-removal of the "caudal septum" and ANS may be repaired employing filling grafts and septum extension grafts. Prolonged consistency is more suitable with septal extension grafts, whereas patients probably complain of nasal firmness. Eventually, ensuing the refinement of the maxilla, in patients where there is a deformity of the saddle, it is possible to improve the dorsal profile by using cut cartilage in the “temporalis fascia”. This provides a steady outcome and authorizes the dorsum to combine well with adjacent spaces.

 

Conclusion

Aesthetic and operational analysis of the nose should be part of the diagnostic and treatment planning process for "orthognathic surgery". Patients must be advised regarding nasal modifications that can happen with "orthognathic surgery" and related procedures for their management. It is a skill to let certain changes happen when these are considered good, but to minimize undesirable results. However, several lateral maneuvers are feasible, and these modifications even result in changes in the nose that need to be evaluated, and in some patients, secondary action may be needed. The ability to perform a complete septorhinoplasty, either initially planned or later presented based on “post-orthognathic” surgical evaluation, supplies a strong mechanism for the facial surgeon. While it can be tempting to perform rhinoplasty at the same time as maxillary osteotomy, this temptation should be avoided by the authors, both in terms of inaccurate planning and the incapability to reach a high-quality technical result. Nose alterations throughout maxillary osteotomy and preoperative examinations will not be identical, making a precise rhinoplasty program a challenge. Furthermore, any method can take some hours, causing the procedure long and anesthetic concerns, like a shift of nasal tubes to oral, or "submental intubation" to be taken out at the beginning, can become a requirement. Taking out "rhinoplasty" and "maxillary osteotomy" at the same time is controversial and supported by several researchers (61), and the present researchers would suggest instead their sequential performance in most cases.

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