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Oropharyngeal airway changes following bimaxillary
surgery in Class III female adults
Gu¨lnaz MARSxAN
1
, Samet VASFI KUVAT
2
, Evren O
¨ZTASx
1
, Nil CURA
1
, Zeynep SU
¨SAL
1
, Ufuk EMEKLI
2
1
Department of Orthodontics (Head: Prof. Dr. Nil Cura), Faculty of Dentistry, Istanbul University, Istanbul, Turkey;
2
Department of Plastic and Reconstructive Surgery (Head: Prof. Dr. Metin Erer), Medical Faculty of Istanbul
University, Istanbul, Turkey
SUMMARY. Aim: The aim of this study was to evaluate oropharyngeal airway changes following Le Fort I max-
illary advancement and impaction with mandibular setback in Class III deformity. Subjects and methods: 53
female Class III patients (mean age: 24.9 ^0.8 years) had Le Fort I maxillary advancement with impaction, and
mandibular setback osteotomies. Lateral cephalograms were taken before (T0), one week postoperatively (T1)
and 1.3 ^0.2 years after (T2) bimaxillary surgery. Paired tand Pearson tests were used to evaluate the changes.
Results: The mandibular plane-hyoid, upper retropalatal airway space (URP) and hyoid to horizontal reference
plane (HY-HOR) distances significantly increased and the third vertebra to menton, hyoid to vertical reference
plane (HY-VER) distances decreased in the T0eT1 period. Relapses were found in mandibular plane to hyoid
(MP-HY), URP, HY-HOR, third cervical vertebra to menton (C3-Me) and HY-VER distances in T1eT2 period.
Correlations were found between the mandibular retraction and increases of the narrowest retropalatal (r: 0.29,
p\0.05) and lowest retropalatal airway spaces (r:0.30, p\0.05) and posterior movement of hyoid (r: 0.60,
p\0.001). Conclusions: Bimaxillary surgery caused an increase in the URP, together with posterior and
inferior movement of hyoid bone one week postoperatively. Some relapse was found in these changes over one
year later. Ó2008 European Association for Cranio-Maxillofacial Surgery
Keywords: oropharyngeal airway, bimaxillary surgery
INTRODUCTION
Class III skeletal deformity may be the result of mandibular
prognathism and/or maxillary deficiency (Obwegeser,
1969; Legan et al., 1981). The surgical correction of severe
Class III deformities is achieved by combined mandibular
setback and maxillary advancement procedures as sug-
gested by cephalometric analysis and examination of facial
profiles (Obwegeser, 1969; Legan et al., 1981; Rosen,
1991).
Many studies have attempted to investigate the effect
of orthognathic surgery on the upper airway space in
patients with Class III deformity (Wenzel et al., 1989;
Greco et al., 1990; Katakura et al., 1993; Lowe et al.,
1995; Hochban et al., 1996; Nakagawa et al., 1998;
Kawamata et al., 2000; Gu¨ ven and Sarac¸o˘
glu, 2005;
Chen et al., 2007; Meisami et al., 2007; Posnick et al.,
2007; De˘
gerliyurt et al., 2008; Muto et al., 2008).
However, most of these investigated only the effects of
mandibular setback surgery for correcting mandibular
prognathism (Wenzel et al., 1989; Katakura et al., 1993;
Enacar et al., 1994; Lowe et al., 1995; Hochban et al.,
1996; Kawamata et al., 2000; Patel et al., 2004; Chen
et al., 2005; Eggensperger et al., 2005; Kawakami
et al., 2005; Muto et al., 2008). The effect of orthognathic
surgery on the upper airway is still not fully described
in the literature (Riley et al., 1987; Lowe et al., 1995;
Goncalves et al., 2006; Posnick et al., 2007).
The purpose of this study was to determine the changes
in pharyngeal airway dimensions after bimaxillary sur-
gery in adult Turkish females with Class III deformity.
SUBJECTS AND METHODS
53 female Class III patients (mean age: 24.9 ^0.8 years)
had Le Fort I maxillary advancement with impaction and
mandibular setback with bilateral sagittal split osteotomy.
The orthodontic treatment procedures were completed
at the Department of Orthodontics, Faculty of Dentistry
and the bimaxillary surgical procedures were performed
at the Department of Plastic and Reconstructive Surgery,
Medical Faculty of Istanbul University, Istanbul, Turkey.
All patients were diagnosed as having Class III skeletal
deformities and underwent surgical-orthodontic treat-
ment. Exclusion criteria included previous orthognathic
surgery, marked mandibular bone asymmetry, habitual
snoring, obstructive sleep apnoea, chronic upper airway
diseases, previous tonsillectomy or adenoidectomy, and
excessive obesity. Patients who had received genioplas-
ties were not included in the study, to exclude any resul-
tant effect on vertical face height.
The objective of this study was to compare the changes
in pharyngeal airway dimensions at one week and
1.3 ^0.2 years postoperatively with Le Fort I maxillary
advancement and impaction combined with mandibular
69
Journal of Cranio-Maxillofacial Surgery (2009) 37,69e73
Ó2008 European Association for Cranio-Maxillofacial Surgery
doi:10.1016/j.jcms.2008.11.001, available online at http://www.sciencedirect.com
setback in Class III deformity. The amount of maxillary
impaction was 3.2 ^0.7 mm.
In this study, the dentofacial and pharyngeal growth of
subjects were complete, therefore, and they were appropri-
ate subjects for morphologic evaluations. Only women
subjects were selected because gender differences in pha-
ryngeal airway changes are known (Samman et al., 2003).
Lateral cephalograms were taken by a standard tech-
nique with the jaws in centric relationship. The film was
exposed during relaxed tidal breathing after swallowing.
All radiographs were obtained utilizing a standardized
method on the same machine (Proline 2002 CC, Plan-
meca, Helsinki, Finland). Lateral cephalograms were
taken at T0 (before surgery), T1 (one week after surgery)
and T2 (1.3 ^0.2 years after surgery) periods.
Cephalometric analysis
The cephalograms were traced and the landmarks identi-
fied manually by one operator (Dr. Marsxan) onto acetate
paper. SeN7was used as the horizontal reference
plane (HOR), and the perpendicular line drawn from
Fig. 1 eCephalometric landmarks and planes: N: Nasion, S: sella, Ba: Basion, Co: Condylion, Me: menton, Go: Gonion, A: Point A, B: Point B, Ar:
Articulare, ANS: Anterior nasal spine, PNS: Posterior nasal spine, Ptm: Pterygomaxillary fissure, U: Tip of soft palate, V: Valeculla, UPW: Upper
pharyngeal wall (intersection of the PNS-Ba line and the posterior pharyngeal wall), NPW: Narrowest pharyngeal wall (intersection of the posterior
pharyngeal wall to the narrowest space of the retropalatal region), MPW: Middle pharyngeal airway wall (intersection of a perpendicular line from U
with the posterior pharyngeal wall, RV: Retro-velar (intersection of the posterior surface of the soft palate to the narrowest space of the retropalatal
region), NPW: Narrowest pharyngeal wall (intersection of the posterior wall to the narrowest space of the retropalatal region), C3: Third cervical
vertebra, HY: hyoid (most antero-superior point of hyoid bone), MP: mandibular plane. Linear measurements: URP: upper retropalatal airway space
(Ptm-UPW distance), R-pnar: narrowest retropalatal airway space (the narrowest distance between the soft palate and the posterior pharyngeal wall,
measured by a perpendicular line from the posterior pharyngeal wall, representing the minimal airway dimension at the retropalatal region), U-MPW:
lowest retropalatal airway space (uvula to middle pharyngeal wall distance), PASnar: narrowest retroglossal airway space (the narrowest distance
between the base of the tongue and the posterior pharyngeal wall, measured by a perpendicular line from the posterior pharyngeal wall), C3-Me:
distance from third cervical vertebra to menton, MP-HY: distance from hyoid to mandibular plane measured by a perpendicular line from MP to HY,
C3-HY: Distance from third cervical vertebra to hyoid.
70 Journal of Cranio-Maxillofacial Surgery
sella (S) to the HOR was used as the vertical reference
plane (VER). This coordinate system was transferred
from initial to second and third lateral cephalograms
for the evaluation of horizontal and vertical changes in
T0eT1, T0eT2 and T1eT2 periods (Fig. 1).
STATISTICAL METHODS
The paired ttest was performed for comparisons of the
differences between pre- and post-operative variables
Statistical tests were performed using NCSS 2007 soft-
ware package (NCSS, Kaysville, Utah, USA).
Method error
The methodological error within the cephalometric anal-
ysis was determined by selecting 20 cephalograms at ran-
dom and repeating the tracing by the same investigator
(Dr. Marsxan) one month after the initial tracing. The error
was determined by means of the Dahlberg (1940) For-
mula and the error of the method for parameters corre-
lated with each other may be seen in Table 3.
RESULTS
Table 1 shows the pharyngeal airway measurements at
T0, T1, T2, and the results of the paired ttests of changes
from T0 to T1, T0 to T2, and T1 to T2.
The mandibular plane to hyoid (MP-HY), upper retro-
palatal airway space (URP) and HY-HOR (hyoid to hori-
zontal reference plane) distances significantly increased
(1.7 ^3.8 mm, p\0.001, 2.4 ^2.1 mm, p\0.001,
and 2.1 ^2.4 mm, p\0.001), the third cervical vertebra
to menton (C3-Me) and hyoid to vertical reference plane
Table 1 eDentofacial and oropharyngeal measurements before, one week, and 1.3 ^0.2 years after bimaxillary surgery
Before surgery (T0) One week
after surgery (T1)
1.3 ^0.2 years
after (T2)
Mean SD Mean SD Mean SD
Dentofacial measurements
SNA () 75.2 3.9 80.5 4.1 79.8 3.9
SNB () 87.1 3.5 83.2 3.8 84.3 2.9
ANB ()12.1 4.1 2.7 3.5 4.5 3.7
SNGoGn () 42.5 3.8 39.6 3.2 40.1 2.9
SN-ANS-PNS () 4.5 4.0 5.2 3.3 5.0 3.4
Co-Gn (mm) 132.5 7.5 126.5 6.6 127.1 5.9
N-Me (mm) 138.4 5.1 132.1 4.9 133.2 4.2
Me-VER (mm) 60.1 10.4 54.9 11.1 55.1 10.2
Oropharyngeal measurements
MP-HY (mm) 11.7 4.9 13.6 6.0 12.9 5.2
HY-HOR (mm) 109.7 10.0 110.6 10.2 110.2 10.0
C3-Me (mm) 81.9 7.7 79.4 7.7 80.0 7.3
HY-VER (mm) 17.0 9.4 14.7 8.5 15.4 8.5
URP (mm) 19.2 4.5 21.6 4.3 20.6 4.3
R-Pnar (mm) 10.3 3.3 10.5 2.4 10.4 3.1
U-MPW (mm) 10.2 2.7 10.4 3.4 10.3 2.9
PASnar (mm) 10.3 4.0 10.6 4.1 10.4 3.8
Table 2 eChanges in dentofacial and oropharyngeal measurements in T0eT1, T0eT2 and T1eT2 periods
T0eT1 pT0eT2 pT1eT2 p
Mean SD Mean SD Mean SD
Dentofacial measurements
SNA () 5.3 3.8 *** 4.6 3.7 *** 0.7 3.9 ns
SNB ()3.9 3.4 *** 2.8 3.6 *** 1.1 2.9 ns
ANB () 9.4 2.8 *** 7.6 3.5 *** 1.8 2.7 ns
SNGoGn ()2.9 3.1 *** 2.4 3.3 *** 0.5 3.5 ns
SN-ANS-PNS () 0.7 2.2 ns 0.5 2.7 ns 0.2 2.1 ns
Co-Gn (mm) 6.1 1.9 *** 5.4 2.1 *** 0.7 3.2 ns
N-Me (mm) 6.3 2.6 *** 5.2 2.5 *** 1.1 3.5 ns
Me-VER (mm) 5.2 9.6 *** 5.0 9.9 *** 0.2 7.6 ns
Oropharyngeal measurements
MP-HY (mm) 1.7 3.8 *** 0.9 2.9 ** 0.8 1.6 **
HY-HOR (mm) 2.1 2.4 *** 1.2 2.5 * 0.9 1.6 *
C3-Me (mm) 2.5 3.1 *** 1.9 2.4 ** 0.6 1.1 **
HY-VER (mm) 2.4 3.5 *** 1.5 1.6 ** 0.9 1.4 **
URP (mm) 2.4 2.1 *** 1.6 2.1 *** 0.8 0.9 **
R-Pnar (mm) 0.2 2.7 ns 0.1 3.2 ns 0.1 2.9 ns
U-MPW (mm) 0.2 3.1 ns 0.1 2.8 ns 0.1 3.4 ns
PASnar (mm) 0.3 4.3 ns 0.1 3.7 ns 0.2 4.0 ns
*: p\0.05; **: p\0.01; ***: p\0.001; ns: not significant.
Oropharyngeal airway changes following bimaxillary surgery 71
(HY-VER) distances significantly decreased (2.5 ^
3.1 mm, p\0.001, 2.4 ^3.5 mm, p\0.01) in T0e
T1 period (Table 2).
Relapses were found in the increases of MP-HY, URP
and HY-HOR distances (0.8 ^1.6 mm, p\0.01,
0.8 ^0.9 mm, p\0.01, 0.9 ^1.6 mm, p\0.05)
and in the decreases of C3-Me and HY-VER distances
(0.6 ^1.1 mm, p\0.01, 0.8 ^1.0 mm, p\0.01 and
0.9 ^1.4 mm, p\0.01) in T1eT2 period.
Significant correlations were found between the retrac-
tion of the mandible (Me-VER distance, 5.2 ^9.6 mm,
p\0.001) and the insignificant increase of the lowest ret-
ropalatal airway space (U-MPW distance, 0.2 ^3.1 mm,
r:0.30, p\0.05) and narrowest retropalatal airway
space (R-Pnar distance, 0.2 ^2.7 mm, r: 0.29,
p\0.05) and the backward movement of hyoid bone
(HY-VER distance, 2.4 ^3.5 mm, p\0.001, r: 0.60,
p\0.001).
Discussion
Pharyngeal airway space narrowing after orthognathic
surgery has attracted attention in recent years (Mehra
et al., 2001; Cakarne et al., 2003; Eggensperger et al.,
2005; Kawakami et al., 2005; Chen et al., 2005, 2007;
Barrera et al., 2007; De˘
gerliyurt et al., 2008; Muto
et al., 2008). The mandible, base of tongue, hyoid
bone, and pharyngeal walls are intimately related by their
muscular and ligamentous attachments. The mandible is
related to the base of the tongue by the genioglossus
muscle. The tongue, through multiple muscular and con-
nective tissue attachments, is related to the hyoid bone
and to the mandible in such a way that retraction of the
mandible results in a narrowing of the airway by poste-
rior movement of the tongue.
Based on lateral cephalometric analysis, many studies
indicated that the anatomical alterations associated with
obstructive sleep apnoea were inferior displacement of
the hyoid bone and posterior displacement of the base
of the tongue, with consequent pharyngeal narrowing
(Chen et al., 2007).
Maxillo-mandibular advancement surgery has been
shown to be efficacious in he elimination of obstructive
sleep apnoea because it enlarges the pharyngeal airway
space and tightens the upper airway muscles and tendons,
mainly the velopharyngeal and suprahyoid muscles, by
advancement of their bony origin (Hochban et al.,
1996; Waite and Vilos, 2002; Fairburn et al., 2007).
In contrast, mandibular setback surgery is known to
cause narrowing of the pharyngeal airway (Athanasiou
et al., 1991; Enacar et al., 1994; Hochban et al., 1996;
Kawamata et al., 2000; Gu¨ ven and Sarac¸o˘
glu, 2005;
Kawakami et al., 2005; Chen et al., 2007).
The objective of this study was to compare the
changes in pharyngeal airway space at one week and
1.3 ^0.2 years after bimaxillary surgery with Le Fort I
maxillary advancement and impaction combined with
mandibular setback in Class III deformity. In this study,
the dentofacial and pharyngeal growth of subjects were
already complete. Only women were selected because
gender differences in pharyngeal airway changes are de-
scribed (Samman et al., 2003).
We evaluated airway changes by analyzing cephalo-
grams. Although the cephalogram only provides a two-
dimensional image of the pharyngeal airway, it has
been used extensively in the assessment of sleep apnoea
and craniofacial form (O
¨zbek et al., 1998; Chen et al.,
2007). Furthermore, correlation has been reported be-
tween airway dimensions measured on lateral cephalo-
grams and on three-dimensional computed tomograms
(Kawamata et al., 2000). Similar to previous studies,
Pterygomaxillary fissure-upper pharyngeal wall (Ptm-
UPW), R-Pnar, U-MPW, narrowest retroglossal airway
space (PASnar) dimensions were selected to represent
the upper airway dimensions at the levels of nasophar-
ynx, oropharynx and hypopharynx, respectively (Gon-
calves et al., 2006; Chen et al., 2007).
Hochban et al. (1996) evaluated the effect of mandib-
ular setback on the pharyngeal airway of 16 patients with
mandibular prognathism and reported that the pharyngeal
airway decreased considerably at the oropharyngeal and
hypopharyngeal levels.
In this study, the URP showed an increase of
2.4 ^2.1 mm (p\0.001) at one week, and a relapse
of 0.8 mm (p\0.01) was observed 1.3 ^0.2 years af-
ter bimaxillary surgery. Cakarne et al. (2003) found a sig-
nificant increase in nasopharyngeal airway space 8
months after bimaxillary surgery. Chen et al. (2005)
found no significant upper airway changes 2 years after
bimaxillary surgery and the reason might be that the ad-
vancement of the velum and velopharyngeal muscle
caused by maxillary advancement decreased the con-
stricting effect of mandibular setback surgery. They con-
cluded that, bimaxillary surgery might have less effect on
reduction of the pharyngeal airway than mandibular set-
back surgery alone as mentioned in previous studies
(Samman and Tang, 2002).
In our study, a significant correlation was found be-
tween mandibular retraction and increases of U-MPW
and R-Pnar The error of the method was between 1.6
and 1.2 mm for Me-VER, between 1.2 and 0.9 mm for
HY-VER, between 0.8 and 0.7 mm for U-MPW and be-
tween 1.0 and 0.7 mm for R-Pnar distances (Table 3).
These insignificant differences might be within this error
range. The adaptational changes against the constricting
effect of mandibular setback surgery as mentioned in pre-
vious studies (Eggensperger et al., 2005; Gu¨ ven and Sar-
ac¸o˘
glu, 2005; Kawakami et al., 2005).
In this study, significant upward and backward move-
ment of hyoid bone was observed at one week and a sig-
nificant relapse was found in its position 1.3 ^0.2 years
after bimaxillary surgery. No study was found which in-
vestigated hyoid bone position after bimaxillary opera-
tion. However, postero-inferior displacement of the
Table 3 eError of the method for correlated parameters in preoperative,
postoperative one week and 1.3 years after bimaxillary surgery
Preoperative Postoperative
one week
Postoperative
1.3 years
Me-VER (mm) 1.6 1.1 1.2
HY-VER (mm) 0.9 0.9 1.2
U-MPW (mm) 0.8 0.8 0.7
R-Pnar (mm) 1.0 0.7 0.8
72 Journal of Cranio-Maxillofacial Surgery
hyoid bone has generally been noted immediately after
mandibular setback surgery, carrying the tongue back-
ward and downward, but followed with a tendency to re-
turn to its original position (Eggensperger et al., 2005;
Gu¨ven and Sarac¸o˘
glu, 2005; Kawakami et al., 2005).
CONCLUSIONS
Bimaxillary surgery caused an increase in the URP, and
a posterior and inferior movement of hyoid bone at one
week. Moderate relapse was found in these changes
1.3 ^0.2 years after surgery.
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Dr. Gu
¨lnaz MARSxAN
Istanbul University
Faculty of Dentistry
C¸ apa 34093, Istanbul, Turkey
Tel.: +90 21 2414 2020
Fax: +90 21 2531 2230
E-mail: gulnaz.marsan@yahoo.com
Paper received 24 April 2008
Accepted 5 November 2008
Oropharyngeal airway changes following bimaxillary surgery 73
