This study evaluated changes in nasal airway function following Le Fort I osteotomy in 25 patients. Patients underwent either maxillary impaction, advancement, or both, with alar base cinch suture. Pre- and post-operative nasal examinations, rhinomanometry, and acoustic rhinometry were performed. The results showed that total nasal airflow increased and resistance decreased significantly following surgery in all groups. Nasal volume decreased but cross-sectional areas at the isthmus nasi increased. The study concluded that maxillary impaction or advancement of up to 5.5 mm combined with alar base cinch suture can improve nasal airflow by reducing resistance.

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Effect of maxillary advancement on the change
in the soft tissues after treatment of patients
with class III malocclusion
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2. Clinical Paper
Orthognathic Surgery
Effects of maxillary
advancement and impaction on
nasal airway function
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.
F. Pourdanesh1
, R. Sharifi2
,
A. Mohebbi3
, A. Jamilian4
1
Department of Oral & Maxillofacial Surgery,
School of Dentistry, Shahid Beheshti, Tehran,
Iran; 2
Department of Oromaxillofacial
Surgery, Tehran University of Medical
Sciences, Tehran, Iran; 3
Department of Head
and Neck Surgery, Rasool Akram Hospital,
Tehran University of Medical Sciences,
Tehran, Iran; 4
Department of Orthodontics,
Dental Branch, Islamic Azad University,
Tehran, Iran
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 Æ 3.32 years. Rhinomanometric
assessment showed that total nasal airflow was increased from 406 Æ 202 ml/s to
543 Æ 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.
Key words: Le Fort I osteotomy; nasal airway;
nasal volume; nasal resistance; maxillary im-
paction; maxillary advancement.
Accepted for publication 23 March 2012
Available online 26 April 2012
Different movements of the maxilla in Le
Fort I osteotomies have distinct effects on
the nasal morphology. Kunkel and Hoch-
ban 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
Spald-
ing et al. reported that no prediction could
be made for any patient regarding the
effect of maxillary surgery on nasal func-
tion parameters and there was no consis-
tent 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
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 imple-
mented a clinical prospective study com-
posed of patients who were referred to
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
0901-5027/01101350 + 03 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

3. 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 correc-
tion. Patients were excluded as study sub-
jects if they had sinusitis, allergic rhinitis,
adenoid hyperplasia, craniofacial syn-
dromes, segmental Le Fort I, previous
trauma and surgery, especially rhino-
plasty.
The patients were separated into 3 sur-
gical 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 sur-
gery when the patients filled out a ques-
tionnaire and underwent rhinological
examination, anterior rhinomanometry
and acoustic rhinometry. The examina-
tions were repeated by the same otorhino-
laryngologist 3 months after surgery.
Examinations carried out included doc-
umentation of luxations, presence of sep-
tal 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 mea-
sured. Acoustic rhinometry, described by
Jackson et al.,5
was used to evaluate total
nasal volume, cross-sectional areas of nos-
trils 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 re-
evaluated to determine the level of error in
the measurements. There was no signifi-
cant difference between the measure-
ments. Wilcoxon matched-pairs signed
rank test was used for pre- and postopera-
tive findings. The x2
test was used for
intergroup evaluations. The data were ana-
lyzed using the Statistical Package for the
Social Sciences (version 18, SPSS, Chi-
cago, IL, USA).
Results
25 patients (6 males, 19 females) with a
mean age of 22.4 Æ 3.32 years were eval-
uated. The patients were separated into 3
surgical groups based on the type of
orthognathic surgery they had received.
Group 1 comprised 11 patients who
needed maxillary impaction. Group 2
included 9 patients who underwent max-
illary advancement. Group 3 was com-
posed 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 Æ 202 to
543 Æ 268 ml/s(P < 0.0005)andtotalnasal
resistance decreased from 0.62 Æ 0.78 to
0.41 Æ 0.4 ml/s (P < 0.0005). Tables 4
and 5 show the acoustic rhinometry mea-
surements 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 Æ 1.3 to
7.3 Æ 1.5 cm3
(P < 0.001). The total
cross-section of the IN increased signifi-
cantly from 0.49 Æ 0.1 to 0.52 Æ 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 improve-
ment after Le Fort I osteotomy with alar
base cinch suture. The rhinoscopic, rhino-
manometric, and acoustic rhinometric
measurements show that the total nasal
function of all patients in the three groups
improved significantly after Le Fort I sur-
gery regardless of the direction of surgery.
Nasal airflow showed a significant
increase in all groups; while nasal resis-
tance showed a significant reduction
(Table 3). These results contradict the
results found by Erbe et al. who found
no significant changes in total nasal air-
flow or nasal resistance in any patients.3
The effects of maxillary advancement and impaction 1351
Table 1. Pre- and postoperative findings of anterior rhinoscopy.
Anterior rhinoscopy Preoperative Postoperative
Luxations 0 2
Septal deviations 18 16
Perforations 0 0
Spurs 19 3
Mucosal changes 1 3
Enlarged turbinate 21 12
Table 2. The mean of maxillary impaction and advancement in all three groups.
Group Maxillary impaction (mm) Maxillary advancement (mm)
1 5.14 Æ 1.78 —
2 — 5.22 Æ 1.72
3 3.6 Æ 0.89 2.8 Æ 1.3
Table 4. Total nasal volume pre- and postoperatively in the three groups (acoustic rhinometry)
in cm3
.
Groups Preoperative Postoperative P value
Total 7.8 Æ 1.3 7.3 Æ 1.5 0.001
Group 1 7.3 Æ 1.1 6.5 Æ 1.2 0.001
Group 2 8.7 Æ 0.9 8.7 Æ 0.8 0.8
Group 3 7.2 Æ 1.5 6.7 Æ 1.5 0.03
Table 3. Results of nasal airflow (NA) and nasal resistance (NR) measurements (rhinomano-
metry) in ml/s.
Groups Preoperative Postoperative P value
Total nasal airflow 406 Æ 202 543 Æ 268 0.0005
Group 1 (NA) 473 Æ 197 618 Æ 262 0.008
Group 2 (NA) 296 Æ 205 460 Æ 308 0.008
Group 3 (NA) 456 Æ 147 530 Æ 195 0.08
Total nasal resistance 0.62 Æ 0.78 0.41 Æ 0.4 0.0005
Group 1 (NR) 0.37 Æ 0.15 0.27 Æ 0.09 0.01
Group 2 (NR) 1.07 Æ 1.19 0.62 Æ 0.62 0.008
Group 3 (NR) 0.36 Æ 0.13 0.32 Æ 0.13 0.08

4. 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 rhinome-
try 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 air-
flow 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 resis-
tance and increasing airway flow. An
increase in the width of the alar base is
commonly observed especially after max-
illary 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 postopera-
tively.12
The authors presume that their
findings regarding improvement of airflow
differ from those of Erbe et al. because of
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 maxil-
lary impaction, advancement or a combi-
nation 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 possi-
ble 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: anato-
mical 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 measure-
ments. 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. Laryngo-
scope 2003;113:295–302.
7. Numminen J, Dastidar P, Heinonen T, Kar-
huketo T, Rautiainen M. Reliability of
acoustic rhinometry. Respir Med 2003;97:
421–7.
8. Gotzfried HF, Masing H. On the improve-
ment 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 max-
illary 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 resis-
tance. 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 rhino-
surgery: a prospective study. Int J Oral Max-
illofac 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: info@jamilian.net
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 Preoperative Postoperative P value
Total cross-section of isthmus nasi 0.49 Æ 0.1 0.52 Æ 0.1 0.003
Group 1 (IN) 0.43 Æ 0.1 0.47 Æ 0.1 0.002
Group 2 (IN) 0.6 Æ 0.1 0.64 Æ 0.1 0.05
Group 3 (IN) 0.41 Æ 0.1 0.43 Æ 0.1 0.1
Total cross-section of concha inferior 0.5 Æ 0.1 0.51 Æ 0.1 0.4
Group 1 (CI) 0.47 Æ 0.1 0.49 Æ 0.1 0.1
Group 2 (CI) 0.55 Æ 0.2 0.54 Æ 0.1 0.8
Group 3 (CI) 0.4 Æ 0.2 0.5 Æ 0.1 0.6