Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 347e350

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Subnasal modified Le Fort I osteotomy: Indications and results Jacinto Fernández Sanromán*, Alberto Costas López, Martín Fernández Ferro, Jorge Arenaz Bua, Annahys López de Sánchez Department of Oral and Maxillofacial Surgery (Head: Dr. J. Fernández Sanromán), Povisa Hospital, Vigo, PO, Spain

a r t i c l e i n f o

a b s t r a c t

Article history: Paper received 15 January 2013 Accepted 28 May 2013

Purpose: To study the possible morphologic changes in the nose after subnasal modified Le Fort I maxillary osteotomy to correct class III dentofacial deformities in patients with considered normal nasal morphology. Material and methods: Fifteen patients (7 males, 8 females) requiring maxillary advancement to treat class III dentofacial deformities were studied prospectively between January 2004 and January 2011. All the patients had an adequate projection of the nasal tip preoperatively preventing a conventional Le Fort I osteotomy. Patients received preoperatively (T1), 6 months after surgery (T2), and 12 months after the initial surgical procedure (T3) lateral cephalograms, CT-3D studies and clinical nose analysis to measure different morphologic variables including: the alar/nose base width, nasal tip protrusion and nasal bridge length using a digital sliding calliper directly on the soft-tissue surface of the face. Results: Mean age was 26.2 years, range 20e36 years. A significant advancement of the maxilla was noted postoperatively (mean 7.5 mm). After surgery the different anthropometric variables of the nasal region analysed had not suffered any significant variation. No significant differences were found when comparing T2 with T3 measures. No significant complications were found. Conclusion: The results indicated that maxillary advancement using a subnasal modified Le Fort I osteotomy can prevent undesirable soft tissue changes of the nose when anterior repositioning of the maxilla is indicated in patients with preoperatively normal nasal morphology. Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Keywords: Orthognathic surgery Maxillary osteotomies Dentofacial deformity Nasal morphology

1. Introduction Le Fort I osteotomy for anterior or superior repositioning alters to some extent nasal and labial aesthetics (Bell, 1975; Altman and Oeltjen, 2007). Some possible undesirable changes include an increase in alar base width, upturning of the nasal tip, flattening and thinning of the upper lip, loss of normal lip pout and downturning of the corners of the mouth. The amount of these postsurgical changes depends both on the previous profile of the patient and on the magnitude of the anterior repositioning of the maxilla (Rosen, 1988; Chung et al., 2008). Certain nasal changes may be desirable depending on the patient’s preoperative profile. However, in patients with a normal nasal morphology prior to surgery who require maxillary advancements of more than 5 mms these changes can significantly worsen their nasal and lip aesthetics: increasing * Corresponding author. Servicio de Cirugía Oral y Maxilofacial, Hospital Povisa, Rua Salamanca 5, 36211 Vigo, PO, Spain. Tel.: þ34 986413144. E-mail addresses: [email protected], [email protected] (J. Fernández Sanromán).

supratip break and tip elevation, symmetric or asymmetric nasal base widening and alteration of the projection of the nasal dorsum. Many surgical techniques have been described to control or minimize these unfavourable changes. The preferred method for controlling alar base width is the alar cinch technique (Collins and Epker, 1982; Schendel and Williamson, 1983; Westermark et al., 1991) with or without a V-Y mucosal suturing. In some cases some other adjunctive procedures (Schendel and Williamson, 1983; Waite and Matukas, 1991; Ghali and Sinn, 1996) have been advocated: anterior nasal spine reduction, nasal floor reduction, excision of the alar base, adjusting the caudal septum or different nasal tip corrections. Although these surgical procedures have improved the predictability of the soft tissue changes after Le Fort I osteotomy, the outcome is still often unpredictable. (Becelli et al., 1996 and Mommaerts et al., 1997) reported some modifications of the standard Le Fort I osteotomy that preserve the perinasal musculature insertions and the pre-existing position of the anterior nasal spine and nasal septum with excellent clinical outcomes.

1010-5182/$ e see front matter Ó 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2013.05.024

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Morphologic changes in soft tissue in the nasal and labial areas after orthognathic surgery have been assessed in studies using lateral cephalometric radiographs, clinical photographs, 3-D laser scanning, 3-D computed tomography and cone-beam computed tomography. However, all these methods showed different limitations in providing accurate and reproducible measurements (Donatsky et al., 2009; Aboul-Hosn Centenero and HernándezAlfaro, 2012; Park et al., 2012; 2013). Using a digital sliding calliper directly on the soft-tissue surface of the face can be a more accurate way to assign the possible morphologic changes in the nasal morphology that happen after maxillary osteotomies (Farkas, 1994; Chung et al., 2008). 15 patients with class III dentofacial deformity and normal nasal morphology prior to surgery who required maxillary advancement were treated with this subnasal modified Le Fort I osteotomy. The clinical results and possible indications are presented. 2. Material and methods Fifteen adult patients (7 males, 8 females) requiring maxillary advancement to treat class III dentofacial malocclusion were studied prospectively between January 2004 and January 2011, after approval by our hospital review board. Patients with a previous history of congenital defects or trauma to the osseous structures of the face were not included in the study. All the patients had the Le Fort I variation technique already described by Becelli (Becelli et al., 1996). In this technique preservation of the insertion of the perirhinal muscles to the piriform region with a subnasal spine osteotomy is performed. A lateral and posterior standard Le Fort I osteotomy leaving intact the piriform aperture was done. After repositioning the maxilla in the planned position, only 1 titanium prebend ‘L’ shape miniplate was placed lateral to the piriform rim on each side. Standard alar cinch suture technique with V-Y vestibular closure was accomplished in all the cases using absorbable sutures, in contrast with (Mommaerts et al., 1997) technique (Farkas, 1994) in which these technical procedures were not performed. All the patients received pre and postoperative conventional orthodontic treatment. Standarized lateral cephalographs and CT-3Ds were taken preoperatively (T1) and at 6 (T2) and 12 months (T3) postoperatively. The horizontal reference plane was taken at 7 from a line connecting the S (sella) and N (nasion) points (SN line), while a line perpendicular to this horizontal plane passing the nasion was used as the vertical reference plane. The shortest distances of the A point (the deepest point in the concavity of the anterior maxilla in the midlane) in relation to the horizontal and vertical reference planes were measured: AV (vertical) and AH (horizontal), to represent the position of the maxilla. All cephalometric tracings and superimpositions were carried out twice by the same examiner following a 2-week interval. The presurgical (T1) and postsurgical (T2, T3) nasal morphology were measured using a digital sliding calliper (CeosaÒ) as described by (Farkas, 1994; Chung et al., 2008) The anthropometric landmarks and measurements used are shown in Fig. 1. Analysis of the variables was studied using the SPSS program (SPSS version 13.0, Chicago, IL, USA). All significance tests were performed using a probability of type I error 0.05 or less. The extent of random error was determined by Dahlberg’s formula. Manne Whitney U-test was used to examine the possible changes in the nasal variables analysed. 3. Results The mean age was 26.2 years (range, 20e36 years). Vertical and horizontal changes in the maxilla indicated a mean anterior

Fig. 1. Anthropometric landmarks and measurements (in mms) of the nose (using a digital sliding calliper directly on the soft-tissue surface of the face): AC (alare), the most lateral point on each alar contour; ACeAC: alar base width. AL (alar curvature), the most lateral point in the curved base line of each alar; ALeAL: nose base width. N (soft-tissue nasion), PRN (pronasale: the most prominent point of the nasal tip), SN (subnasale: the midpoint of the angle at the columella base): PRN-N: nasal bridge length; PRN-SN: nasal tip protrusion; N-PRN/PRN-SN: nasal tip angle in grades.

advancement of the maxilla of 7.5 mms (range, 4.5e14 mms) along with a mean inferior displacement of 0.8 mm (range, 3.5 to 2.6 mms). No significant differences were found when comparing T3 with T2 measures demonstrating a stable position of the maxilla overtime. The nose/alar base width, nasal bridge length, nasal tip protrusion, and the nasal tip angle did not suffer any statistical significant change after surgery (T2 versus T1 nasal measurements) (Table 1) (Figs. 2 and 3). 4. Discussion Maxillary movement after Le Fort I osteotomy have an effect on the form of both the nose and the upper lip. Increase in alar base width and upturning of the nasal tip after maxillary advancement are often seen (Bell, 1975; Becelli et al., 2002; Honrado et al., 2006; Altman and Oeltjen, 2007; Park et al., 2012). These changes can be considered unfavourable in some cases in which normal aesthetics of the nasolabial region were present before surgery (O’Ryan and Schendel, 1989; Arnett and Bergman, 1999). Some authors (Schendel and Williamson, 1983; Chung et al., 2008) have suggested that transection without reapproximation of the perioral and perinasal musculature is the major reason for the unaesthetic postoperative changes of the nasolabial region. To avoid these unfavourable changes (O’Ryan and Schendel, 1989) in the soft tissues, different surgical techniques have been described (Collins and Epker, 1982; Schendel and Williamson, 1983; Westermark et al., 1991; Betts et al., 1993): anterior nasal spine reduction, nasal floor reduction, alar-base cinch suturing technique and the V-Y vestibular closure. Even using these surgical procedures the outcome is often unpredictable (Park et al., 2012). Betts Table 1 Changes in nasal morphology, before (T1) and after surgery: T2 (6 months) and T3 (12 months). Measures in mms using a digital sliding calliper directly on the softtissue surface of the face. T1

Alar width: ACeAC Nose width: ALeAL Nasal bridge length Nasal tip protrusion Nasal tip angle

T2

T3

Mean

SD

Mean

SD

Mean

SD

38.8 29.3 48.4 21.3 87.8

2.5 3.4 3.4 1.9 3.8

38.9 30.2 48.5 21.6 87.9

2.4 3.5 3.3 1.8 3.6

38.9 29.5 48.5 21.5 87.7

2.4 3.3 3.4 1.8 3.7

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Fig. 2. (A) A 25 years-old man with class 3 dentofacial deformity. A severe retrusion of the maxilla is demonstrated. A considered normal nasal morphology was observed; (B) 1 year after surgery (subnasal Le fort I osteotomy advancing 10 mms the maxilla and a reduction genioplasty). No significant changes in nasal morphology were noted.

Fig. 3. (A) A 29 years-old man with class 3 dentofacial deformity. Retrusion of the maxilla was diagnosed. A considered normal nasal morphology was observed both in clinical and 3D-CT images obtained; (B) 1 year after surgery (subnasal Le fort I osteotomy advancing 8 mms the maxilla). No significant changes in nasal morphology were noted.

et al. (1993) reported that the alar base widened most in the group of patients who received an alar cinch suture compared with subjects who did not received this technique. Asymmetry in nostril position after this surgical technique has been described frequently. Different modifications in the alar cinch technique have been proposed to minimize these complications (Schendel and Williamson, 1983; Mommaerts et al., 1997; Shams and Motamedi, 2002).

Becelli (Becelli et al., 1996) described a subnasal modified Le fort I osteotomy, based on the previous works of Mommaerts (Mommaerts et al., 1997), to avoid undesirable soft tissue changes secondary to anterior repositioning of the maxilla with excellent clinical outcomes. Mommaerts (Mommaerts et al., 2000) suggested that the advancing the piriform aperture pushing on the alae was the main cause for the increase in nasal tip projection after both

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conventional and subnasal Le Fort I osteotomies. Becelli’s technique modifications preserving the position of the piriform aperture could prevent this unfavourable outcome. 5. Conclusion Our clinical findings suggest that maxillary advancement using a subnasal modified Le Fort I osteotomy can prevent undesirable soft tissue changes of the nose when anterior repositioning of the maxilla is indicated in patients with normal preoperative nasal morphology. References Aboul-Hosn Centenero S, Hernández-Alfaro F: 3D planning in orthognathic surgery: CAD/CAM surgical splints and prediction of the soft and hard tissues results e our experience in 16 cases. J Craniomaxillofac Surg 40: 162e168, 2012 Altman JI, Oeltjen JC: Nasal deformities associated with orthognathic surgery: analysis, prevention, and correction. J Craniofac Surg 18: 734e739, 2007 Arnett WA, Bergman RT: Facial keys to orthodontic diagnosis and treatment planning. Part II. Am J Orthod Dentofac Orthop 116: 239e253, 1999 Becelli R, De Ponte RS, Fadda MT, et al: Subnasal modified Le Fort I for nasolabial aesthetics improvement. J Craniofac Surg 7: 399e402, 1996 Becelli R, Renzi G, Carboni A, et al: Evaluation of the esthetic results of a 40-patient group treated surgically for dentoskeletal class III malocclusion. Int J Adult Orthod Orthognath Surg 17: 171e179, 2002 Bell WH: Le Fort I osteotomy for correction of maxillary deformities. J Oral Surg 33: 412e426, 1975 Betts NJ, Vig KWL, Vig P, et al: Changes in the nasal and labial soft tissues after surgical repositioning of the maxilla. Int J Adult Orthod Orthognath Surg 8: 7e 23, 1993 Chung C, Lee Y, Park K-H, et al: Nasal changes after surgical correction of skeletal class III malocclusion in Koreans. Angle Orthod 78: 427e432, 2008 Collins CC, Epker BN: The alar cinch: a technique for prevention of alar base flaring secondary to maxillary surgery. Oral Surg 53: 549e553, 1982

Donatsky O, Bjørn-Jørgensen J, Hermund NU, et al: Accuracy of combined maxillary and mandibular repositioning and of soft tissue prediction in relation to maxillary antero-superior repositioning combined with mandibular set back. A computerized cephalometric evaluation of the immediate postsurgical outcome using the TIOPS planning system. J Craniomaxillofac Surg 37: 279e284, 2009 Farkas LG: Anthropometry of the head and neck. New York, NY: Raven Press, 1994 Ghali GE, Sinn DP: Nasal surgery an adjunct to orthognathic surgery. Oral Maxillofac Surg Clin North Am 8: 33e43, 1996 Honrado CP, Lee S, Bloomquist DS, et al: Quantitative assessment of nasal changes after maxillomandibular surgery using a 3-dimensional digital imaging system. Arch Facial Plast Surg 8: 26e35, 2006 Mommaerts MY, Abeloos JVS, De Clercq CAS, Neyt LF: The effect of the subspinal Le Fort I-type osteotomy on interalar rim width. Int J Adult Orthod Orthognath Surg 12: 95e100, 1997 Mommaerts MY, Lippens F, Abeloos JVS, Neyt LF: Nasal profile changes after maxillary impaction and advancement surgery. J Oral Maxillofac Surg 58: 467e 470, 2000 O’Ryan F, Schendel S: Nasal anatomy and maxillary surgery. II. Unfavorable esthetics following the Lefort I osteotomy. Int J Adult Orthod Orthognath Surg 4: 27e34, 1989 Park S-B, Yoon J-K, Kim Y-I, et al: The evaluation of the nasal morphologic changes after bimaxillary surgery in skeletal class III malocclusion by using the superimposition of cone-beam computed tomography (CBCT) volumes. J Craniomaxillofac Surg 40: 87e92, 2012 Park S-B, Kim Y-I, Hwang D-S, Lee J-Y: Midfacial soft-tissue changes after mandibular setback surgery with or without paranasal augmentation: conebeam computed tomography (CBCT) volume superimposition. J Craniomaxillofac Surg 41: 119e123, 2013 Rosen HM: Lip-nasal aesthetics following Le Fort I osteotomy. Plast Reconstr Surg 81: 171e182, 1988 Schendel SA, Williamson LW: Muscle reorientation following superior repositioning of the maxilla. J Oral Maxillofac Surg 41: 235e240, 1983 Shams MG, Motamedi MHK: A more effective alar cinch technique. J Oral Maxillofac Surg 60: 712e715, 2002 Waite PD, Matukas VJ: Indications for simultaneous orthognathic and septorhinoplastic surgery. J Oral Maxillofac Surg 49: 133e140, 1991 Westermark AH, Bystedt H, Von Konow L, et al: Nasolabial morphology after Le Fort I osteotomies. Effect of alar base suture. Int J Oral Maxillofac Surg 20: 25e30, 1991