BASIC AND PATIENT-ORIENTED RESEARCH

Postsurgical Stability of Oropharyngeal Airway Changes Following CounterClockwise Maxillo-Mandibular Advancement Surgery
Joao Roberto Goncalves, DDS, PhD,* Peter H. Buschang, PhD, Daniela Godoi Goncalves, DDS, MsC, and Larry M. Wolford, DMD

J Oral Maxillofac Surg 64:755-762, 2006

Purpose: This study evaluated oropharyngeal airway changes and stability following surgical counter-

clockwise rotation and advancement of the maxillo-mandibular complex. Methods and Patients: Fifty-six adults (48 females, 8 males), between 15 and 51 years of age, were treated with Le Fort I osteotomies and bilateral mandibular ramus sagittal split osteotomies to advance the maxillo-mandibular complex with a counter-clockwise rotation. The average postsurgical follow-up was 34 months. Each patients lateral cephalograms were traced, digitized twice, and averaged to estimate surgical changes (T2-T1) and postsurgical changes (T3-T2). Results: During surgery, the occlusal plane angle decreased signicantly (8.6 5.8) and the maxillomandibular complex advanced and rotated counter-clockwise. The maxilla moved forward (2.4 2.7 mm) at ANS and the mandible was advanced 13.1 5.1 mm at menton, 10 4.4 mm at point B, and 6.9 3.7 mm at lower incisor edge. Postsurgical hard tissue changes were not statistically signicant. While the upper oropharyngeal airway decreased signicantly (4.2 3.4 mm) immediately after surgery, the narrowest retropalatal, lowest retropalatal airway, and the narrowest retroglossal airway measurements increased 2.9 2.7, 3.7 3.2, and 4.4 4.4 mm, respectively. Over the average 34 months postsurgical period, upper retropalatal airway increased 3.9 3.7 mm, while narrowest retropalatal, lowest retropalatal airway, and narrowest retroglossal airway remained stable. Head posture showed exure immediately after surgery (4.8 5.9) and extension postsurgically (1.6 5.6). Conclusion: Maxillo-mandibular advancement with counter-clockwise rotation produces immediate increases in middle and lower oropharyngeal airway dimensions, which were constrained by changes in head posture but remain stable over the postsurgical period. The upper oropharyngeal airway space increased only on the longest follow-up. 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:755-762, 2006 One of the most common types of dentofacial deformities requiring orthognathic surgery are those with high occlusal plane angle facial morphology.1,2 These patients commonly exhibit a retruded mandible and
*Assistant Professor, Orthodontics, UNESPPaulista State University, Sao Paulo, Brazil; Formerly, Fellow, Oral and Maxillofacial Surgery, Baylor College of Dentistry, Texas A&M University System, Baylor University Medical Center, Dallas, TX. Professor and Director of Orthodontic Research, Department of Orthodontics and Center for Craniofacial Research and Diagnosis, Baylor College of Dentistry, Texas A&M University Health Science Center, Dallas, TX. Graduate Student, Prosthodontics, UNESPPaulista State University, Sao Paulo, Brazil.

maxilla, Class II malocclusion (with or without anterior open bite), and a decreased oropharyngeal airway. While surgical correction of these deformities is performed in all 3 planes of space, surgeons traditionClinical Professor, Department of Oral and Maxillofacial Surgery, Baylor College of Dentistry, Texas A&M University Health Science Center; and Private Practice, Baylor University Medical Center, Dallas, TX. Address correspondence and reprint requests to Dr Wolford: 3409 Worth St, Suite 400, Dallas, TX 75246; e-mail: lwolford@ swbell.net
2006 American Association of Oral and Maxillofacial Surgeons

0278-2391/06/6405-0002$32.00/0 doi:10.1016/j.joms.2005.11.046

755

756 ally avoid counter-clockwise rotation of the maxillomandibular complex and occlusal plane (decrease occlusal plane angle) by ensuring little (perhaps slight) autorotation of the mandible, no occlusal plane change, or clockwise rotation of the maxillo-mandibular complex (increase occlusal plane angle).3,4 However, to produce optimal functional and esthetic results for high occlusal plane patients, substantial counter-clockwise rotation of the maxillo-mandibular complex and occlusal plane is frequently indicated.2 Although concerns about long-term stability have been expressed,5-7 good postsurgical stability following counter-clockwise rotation of the maxillo-mandibular complex in high occlusal plane patients has been documented.8 Mandibular advancement surgery has been previously shown to increase oropharyngeal airway space and is recognized as 1 of the most successful approaches to treat oropharyngeal airway deciencies.9-13 With the exception of Mehra et al,12 who showed a 76% increase in the retroglossal oropharyngeal airway dimension relative to the amount of mandibular advancement, other studies have reported airway increases ranging from 42% to 51%.9,13-15 Counter-clockwise rotation of the maxillo-mandibular complex may further increase the oropharyngeal airway space. Mehra et al12 showed that maxillo-mandibular advancement surgery (mandibular advancement of 7.5 mm) with counter-clockwise rotation (4.2 decrease in occlusal plane angulation) increased the oropharyngeal airway spaces 3.5 mm in the retropalatal region and 5.7 mm in the retroglossal region. Given the potential for postsurgical skeletal relapse and soft-tissue adaptation, it is important to know whether the oropharyngeal airway changes produced by surgery remain stable. Most studies evaluating oropharyngeal airway changes associated with advancement surgery have been short term, without alteration of the occlusal plane.9,11,13,14,16 Farole et al15 showed that approximately 16% of the oropharyngeal airway increase associated with surgery was lost 6 to 42 months after surgery. Yu et al17 concluded that increases in the anteroposterior dimensions of the oropharynx were unpredictable and tended to decrease with time. In contrast, Achilleos et al18 reported no signicant oropharyngeal airway changes for patients evaluated at 6 to 36 months postsurgery. To help resolve the controversy concerning postsurgical stability and to better understand how counter-clockwise rotation of the occlusal plane affects the oropharyngeal airway, the present study tests the following null hypotheses: 1. There is no increase in the oropharyngeal airway space with maxillo-mandibular advancement

OROPHARYNGEAL AIRWAY CHANGES

surgery and counter-clockwise rotation of the occlusal plane. 2. The oropharyngeal airway space does not remain stable over the postsurgical period.

Patients and Methods

This retrospective study evaluated records of 58 patients (50 females, 8 males) who had maxillo-mandibular surgical advancement with counter-clockwise rotation of the occlusal plane. The occlusal plane angle was decreased by posterior downgrafting and/or anterior impaction of the maxilla and mandibular counterclockwise rotation with bilateral ramus sagittal split osteotomy. All osteotomies were stabilized with rigid internal xation. Mean patient age at the time of surgery was 31 years 1 month (range, 15 years 3 months to 56 years 7 months). Presurgical (T1) records were taken 1 day (range, 1 to 6 days) before surgery; postsurgical (T2) records were taken 5 days (range, 2 to 16 days) after surgery; and longterm follow-up (T3) records were taken 2 years 10 months (range, 6 months to 9 years 3 months) after surgery. Patients were selected according to the following criteria: 1. Presurgical occlusal plane angle greater than 14. 2. Treated with bilateral mandibular ramus sagittal split and Le Fort I osteotomies with counterclockwise rotation of the maxillo-mandibular complex and occlusal plane. 3. All surgical procedures performed by 1 surgeon (L.M.W.) 4. Use of maxillary and mandibular rigid xation. 5. Females and males at least 15 and 17 years of age, respectively. Patients were rejected based on the following criteria: 1. Previous surgical intervention in the craniofacial area. 2. Less than 6 months of follow-up. 3. Craniofacial syndromes. 4. Records (radiographs) inadequate or poor quality. The sample included 25 patients with healthy temporomandibular joints (TMJ) and 33 patients diagnosed clinically and by magnetic resonance imaging as having bilateral TMJ articular disc displacements. At the time of surgery, the TMJ displacement group received articular disc repositioning using the Mitek (Mitek Surgical Products Inc, Westwood, MA) anchor-

GONCALVES ET AL

757 There were 28 landmarks identied (Fig 1) and digitized using DFPlus software (Dentofacial Software Inc, Toronto, Canada). The landmarks were used to compute 11 traditional measurements (Fig 2) describing airway dimensions, head position, cervical curvature, hyoid position, and maxillo-mandibular relationships. S-N minus 7 was used as the horizontal reference plane (HRP), and the horizontal and vertical changes for each of the landmarks were evaluated. For example, Figure 1 shows the horizontal and vertical position of menton measured parallel and perpendicular to HRP. Surgical changes in the position of menton were computed as the differences between the T1 and T2 distances. Postsurgical changes were computed as the differences between T2 and T3 distances.
STATISTICAL METHODS

All data were transferred to SPSS (release 9.0; SPSS, Chicago, IL) for statistical analysis. The skewness and

FIGURE 1. Landmarks used for cephalometric assessment (Table 1). HRP is constructed at 7 to the SN plane. The vertical reference plane (VRP) is constructed perpendicular to HRP, through Sella (S). The dotted lines demonstrate the method of measurement of menton (Me) relative to reference planes HRP and VRP. N, nasion; S, sella turcica; ANS, anterior nasal spine (a point posterior to the tip of the median, sharp bony process of the maxilla, on its superior surface, where the maxilla process rst enlarges to a 5 mm width); PNS, posterior nasal spine; UMT, upper molar mesial cusp tip; LDT, lower molar distal cusp tip; LPT2, lower premolar cusp tip; UIE, upper incisor edge; UIA, upper incisor apex; LIE, lower incisor edge; LIA, lower incisor apex; B, B point; Me, menton; Go, gonion; UPW, upper pharyngeal wall (intersection of the PNS-BA line and the posterior pharyngeal wall); UPWA, anterior upper pharyngeal wall (intersection of the PNS-Ba line and the posterior surface of the soft palate); NPW, narrowest pharyngeal wall (intersection of the posterior pharyngeal wall to the narrowest space of the retropalatal region); RV, retro-velar (intersection of the posterior surface of the soft palate to the narrowest space of the retropalatal region); MPW, middle pharyngeal wall (intersection of a perpendicular line from U with the posterior pharyngeal wall); U, tip of the uvula (the most postero-inferior point of the uvula); LPW, lower pharyngeal wall (intersection of the posterior pharyngeal wall to the narrowest space of the retroglossal region); BT, base of tongue; Cv2ig, odontoid process; Cv2ip, second vertebra; Cv4ip, fourth vertebra; C3, third vertebra; HY, hyoid (most antero-superior point of hyoid). Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006. FIGURE 2. Distances and planes used to dene linear and angular measurements. Linear measurements: URP, upper retropalatal airway space (the distance from UPWA to UPW); RPnar, 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 (the distance from U to MPW); 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 C3 to Me; MPHY, distance from hyoid to mandibular plane measured by a perpendicular line from MP to HY; HyC3, distance from hyoid to C3. Angular measurements: OPT/NS, angle of odontoid process/head posture; OPT/CVT, cervical curvature; OPA, angle of occlusion plane to N-S line. Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006.

age technique19,20 concomitantly with the appropriate orthognathic surgical procedures.

CEPHALOMETRIC MEASUREMENTS

Standardized lateral cephalometric radiographics (Quint Sectograph; American Dental Co, Hawthorne, CA) were randomly traced and digitized twice by 1 of the investigators (D.G.G.) approximately 1 week apart. Average values between the 2 replicates were used to decrease landmark technical errors.

758

OROPHARYNGEAL AIRWAY CHANGES

Table 1. PRESURGICAL, SURGICAL, AND POSTSURGICAL CHANGES

T1 Variable MPA (deg) OPA (deg) MP-HY (mm) HY-C3 (mm) URP (mm) RPnar (mm) U-MPW (mm) PASnar (mm) C3-Me (mm) OPT/NS (deg) OPT/CVT (deg)
Mean SD Mean

T2-T1
SD P Mean

T3-T2
SD P

45.9 23.8 23.0 33.8 23.0 8.5 9.5 8.9 72.4 108.6 4.4

5.5 4.6 5.9 5.2 5.0 2.9 2.8 3.5 8.5 7.4 2.8

4.9 8.6 1.1 2.3 4.2 2.9 3.7 4.4 8.3 4.8 0.2

2.9 5.8 5.5 4.2 3.4 2.7 3.2 4.4 7.1 5.9 1.8

** ** ** ** ** ** ** ** **

0.9 0.7 4.4 0.4 3.9 0.5 0.1 0.5 0.9 1.6 0.3

2.4 4.3 4.7 4.3 3.8 2.3 2.8 4.5 6.6 5.6 1.6

** ** **

Abbreviations: MPA, mandibular plane angle; OPA, occlusal plane angle; MP-HY, distance from hyoid to mandibular plane; HY-C3, distance from hyoid to C3; URP, upper retropalatal airway; RPnar, narrowest retropalatal airway; U-MPW, lower retropalatal airway; PASnar, narrowest retroglossal airway space; C3-Me, distance from C3 to menton; OPT/NS, angle of odontoid process to head position; OPT/CVT, cervical curvature. *P .05. **P .01. Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006.

kurtosis statistics showed normal distributions for all variables. Differences were initially compared between 1 group of patients that required TMJ surgery for articular disc repositioning and orthognathic surgery and the other group of patients with healthy TMJs that had orthognathic surgery only. Because there were no statistically signicant differences between these 2 groups in surgical or postsurgical changes, all the patients were analyzed as a single group. Paired t tests were performed to evaluate the surgical (T2-T1) and postsurgical changes (T3-T2). A signicance level of P .05 was applied. Pearson product-moment correlations were used to determine the relationships between changes of specic anatomical measurements and oropharyngeal airway space changes. Correlations were also used to assess the association between surgical and postsurgical changes in the oropharyngeal airway spaces.

Table 2. SURGICAL AND POSTSURGICAL CHANGES (HORIZONTAL AND VERTICAL) OF INCLUDED LANDMARKS

T2-T1 Variable Horizontal ANS PNS B ME GO UIE LIE LDT C3 HY Vertical ANS PNS B ME GO UIE LIE LDT C3 HY
Mean (mm) SD P

T3-T2
Mean (mm) SD P

2.4 1.4 10.0 13.1 2.4 4.3 6.9 6.3 5.1 7.0 1.1 2.4 .32 1.3 1.2 1.8 2.2 2.1 0.7 1.9

2.4 4.1 4.4 5.1 3.3 3.5 3.8 4.2 6.7 5.2 1.1 2.7 2.7 2.6 3.3 2.3 3.2 2.6 1.4 6.2

** * ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** **

0.5 1.0 0.1 0.7 0.3 1.3 0.7 0.2 1.7 0.7 0.2 0.3 0.0 0.2 1.0 0.5 0.1 0.5 0.5 6.1

2.0 3.2 2.5 2.9 2.9 1.9 1.9 2.6 6.4 4.6 1.5 1.5 1.9 1.8 3.2 1.5 1.8 1.3 1.5 5.0

** **

Results
SURGICAL CHANGES (T2-T1)

All oropharyngeal airway space measurements changed signicantly (P .05) as a result of the surgery (T2-T1). Upper retropalatal airway space (URP) decreased 4.2 3.4 mm. The other 3 airway measurements increased as follows: narrowest retropalatal airway space (RPnar), 2.9 2.7 mm; lower retropalatal airway space (U-MPW), 3.7 3.2 mm; and narrowest retroglossal airway space (PASnar), 4.4 4.4 mm. Surgical change associated with the maxillo-mandibular counter-clockwise advancements are seen in Tables 1 and 2 and Figure 3. Both the man-

* * * * **

Abbreviations: ANS, anterior nasal spine; PNS, posterior nasal spine; B, B point; Me, menton; Go, gonion; UIE, upper incisor edge; LIE, lower incisor edge; LDT, lower molar distal cusp tip; C3, third vertebra; HY, hyoid. *P .05. **P .01. Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006.

GONCALVES ET AL

759 hyoid maintained its horizontal position, it did move 6.1 5 mm superiorly, thereby decreasing its distance from the mandibular plane (4.4 4.7 mm). However, there was no signicant change in the distance between the hyoid and the third cervical vertebrae (HY-C3).
CORRELATIONS

FIGURE 3. Schematic drawing showing immediate postsurgical skeletal and oropharyngeal airway space changes: Red, presurgery; blue, immediate postsurgery. Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006.

dibular occlusal plane (8.6 5.8) and the mandibular plane (4.9 2.9) angles decreased signicantly (P .01). The mandible advanced 6.9 3.8 mm at lower incisor tip, 10.0 4.4 mm at B-point, and 13.1 5.1 mm at menton. The maxilla advanced 2.4 2.9 mm at anterior nasal spine and 4.3 3.5 mm at upper incisor edge. Vertically, the anterior nasal spine was moved upward 1.1 2.2 mm and the posterior nasal spine moved downward 2.4 2.7 mm, demonstrating counter-clockwise rotation of the maxilla. During surgery, the hyoid bone showed signicant (P .01) anterior (7.0 5.2 mm) and inferior (1.9 6.2 mm) spatial change. The distance between the hyoid and the third cervical vertebrae increased 2.3 4.2 mm, while the distance from the hyoid to the mandibular plane was maintained. The distance between the third cervical vertebrae and menton increased 8.3 7.0 mm. Head posture (OPT/NS) showed a signicant (P .01) exure (4.8 5.9), while cervical curvature (OPT/CVT) remained stable during the immediate postsurgical interval.
POSTSURGICAL CHANGES (T3-T2)

URP airway space increased 3.9 3.7 mm (P .01), but the other 3 airway measurements remained stable. The upper (UIE) and lower (LIE) incisors moved posteriorly 1.3 1.8 mm and 0.7 1.9 mm, respectively, and the mandibular plane angle increased 0.9 2.4. The anterior aspects of the maxilla and mandible showed postsurgical stability without signicant A-P relapse. The occlusal plane angle showed no signicant postsurgical change. While the

The correlations showed that surgical increases in oropharyngeal airway space were associated with a variety of other changes (Table 3). The further the posterior maxilla (PNS) was advanced, the greater the increase of all 4 oropharyngeal airway measurements immediately postsurgery. Similarly, patients with greater increases in the distance between C3 and menton also showed greater increases in all oropharyngeal airway measurements, except URP airway space. URP airway space and PASnar showed positive correlations with the distance between hyoid and the C3. The more the head was extended (OPT/NS) immediately after surgery, the greater the increases for 3 of the 4 oropharyngeal airway measurements. Patients showing greater straightening of the cervical vertebrae (OPT/CVT) immediately after surgery also showed greater oropharyngeal airway space increases. Postsurgically (Table 3), the strongest correlations were found between changes in oropharyngeal airway dimensions and changes in head position, changes in mandibular position, and changes in hyoid position. Patients who extended their heads more over the postsurgical period showed greater increases in oropharyngeal airway dimensions. Greater anterior movement of menton in relation to C3 also resulted in greater oropharyngeal airway increases. All 4 oropharyngeal airway measures showed greater increases for patients who increased the distance between hyoid and C3. Two of the oropharyngeal airway measures (RPnar and U-MPW) showed negative correlations with horizontal changes in hyoid position. Table 4 shows that surgical changes in oropharyngeal airway dimensions were negatively related with long-term postsurgical changes in oropharyngeal airway spaces. T2-T1 changes in the PASnar and URP airway spaces explained 28% and 20% of the variation in their respective T3-T2 changes. Despite the fact the correlations were low, the negative nature of the correlations indicate that individuals who demonstrated the greatest increase in oropharyngeal airway at T2-T1 showed the greatest decreases at T3-T2. There was also a negative association between the T2-T1 and T3-T2 changes in head posture (OPT/NS) (r 0.59; P .01) and cervical curvature (OPT/CVT) (r 0.55; P .01).

760

OROPHARYNGEAL AIRWAY CHANGES

Table 3. PEARSON CORRELATION COEFFICIENTS BETWEEN SURGICAL AND POSTSURGICAL CHANGES

Variable (T2-T1)/(T3-T2) ANS_VT ANS_HT PNS_VT PNS_HT B_VT B_HT Me_VT Me_HT MPA OPA OPT/NS OPT/CVT C3_VT C3_HT C3_Me MP_HY HY_C3 HY_VT HY_HT

Surgical Changes
URP RPnar U-MPW PASnar URP

Postsurgical Changes
RPnar U-MPW PASnar

0.10 0.28* 0.26 0.34** 0.33* 0.02 0.35** 0.05 0.20 0.14 0.20 0.03 0.18 0.22 0.23 0.07 0.27* 0.06 0.04

0.12 0.18 0.84 0.45** 0.21 0.20 0.13 0.14 0.00 0.02 0.30* 0.32* 0.11 0.23 0.33* 0.03 0.23 0.06 0.10

0.12 0.11 .13 0.41** 0.16 0.25 0.13 0.24 0.04 0.12 0.28* 0.26* 0.09 0.21 0.37** 0.08 0.19 0.05 0.09

0.16 0.25 0.11 0.39** 0.20 0.28* 0.17 0.24 0.04 0.01 0.49** 0.06 0.21 0.48** 0.63** 0.04 0.54** 0.12 0.14

0.015 0.119 0.33* 0.08 0.01 0.07 0.01 0.00 0.04 0.02 0.21 0.03 0.31* 0.07 0.29* .052 0.38** 0.02 .051

0.32* 0.12 0.04 0.09 0.17 0.01 0.21 0.05 0.06 0.00 0.49** 0.05 0.57** 0.19 0.57** 0.13 0.47** 0.04 0.33*

0.24 0.20 0.03 0.13 0.10 0.03 0.10 0.00 0.09 0.06 0.56** 0.11 0.59** 0.28* 0.56** 0.20 0.43** 0.01 0.39**

0.10 0.09 0.01 0.12 0.09 0.14 0.08 0.14 0.02 0.13 0.63** 0.20 0.58** 0.25 0.60** 0.31* 0.61** 0.09 0.21

Abbreviations: ANS_VT, vertical position of the anterior nasal spine; ANS_HT, horizontal position of the anterior nasal spine; PNS_VT, vertical position of posterior nasal spine; PNS_HT, horizontal position of posterior nasal spine; B_VT, vertical position of B point; B_HT, horizontal position of B point; Me_VT, vertical position of menton; Me_HT, horizontal position of menton; MPA, mandibular plane angle; OPA, occlusal plane angle; OPT/NS, head position; OPT/CVT, cervical curvature; C3_HY, distance from C3 to hyoid; C3_Me, distance from C3 to menton; MP_HY, distance from mandibular plane to hyoid; HY_C3, distance from hyoid to C3; HY_VT, vertical position of hyoid; HY_HT, horizontal position of hyoid; URP, upper retropalatal airway space; RPnar, narrowest retropalatal airway space; U-MPW, lowest retropalatal airway space; PASnar, narrowest retroglossal airway space. *P .05. **P .01. Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006.

Discussion
In our study, the amount of maxillary advancement fell within the range reported in previous studies of maxillo-mandibular advancement.11-17 Mandibular advancement measured at menton was substantially greater as a result of the counter-clockwise rotation of the maxillo-mandibular complex. Counter-clockwise
Table 4. PEARSON CORRELATION COEFFICIENTS BETWEEN SURGICAL AND POSTSURGICAL OROPHARYNGEAL AIRWAY CHANGES

(T3-T2) (T2-T1) UPW_UPWA RV_PAS U_MPW BT_PAS

UPW RV_PAS U_MPW23 BT_PAS23

0.45** 0.04 0.13 0.05

0.18 0.35** 0.29* 0.33*

0.11 0.35** 0.36** 0.35**

0.39** 0.28* 0.39** 0.53**

Abbreviations: UPW_UPWA, upper retropalatal airway space; RV_PAS, narrowest retropalatal airway space; U_MPW, lowest retropalatal airway space; BT_PAS, narrowest retroglossal airway space. *P .05. **P .01. Goncalves et al. Oropharyngeal Airway Changes. J Oral Maxillofac Surg 2006.

rotation resulted in menton advancing 3.1 mm more than point B and 6.2 mm more than the lower incisor tips, which demonstrates the advantage of counterclockwise rotation in advancing the mandible and chin in the high occlusal plane facial type patients. All oropharyngeal airway measurements showed changes due to the surgery. The decrease of the URP airway dimension immediately postsurgery was probably related to surgically induced soft palate and pharyngeal wall edema. Edema is supported by the fact that only the URP airway space showed a signicant change (an increase) during the postsurgical period (T3-T2). Moreover, Li et al,11 who evaluated the upper airway changes during the early postoperative period on 70 maxillo-mandibular advancement patients using nasopharyngolaryngoscopy, found mild to moderate lateral pharyngeal edema in all the patients in their study. In our study, 3 of the oropharyngeal airway space measurements (RPnar, U-MPW, and PASnar) showed signicant dimensional increases immediately postsurgery. Mehra et al12 showed slightly greater absolute and substantially greater relative increases in retropalatal and retroglossal airway dimensions, possibly because their mandibular advancements were

GONCALVES ET AL

761 rotation of the occlusal plane may provide the best way to increase the distance between C3 and Me. Except for the URP airway space, which increased post surgery due to resolution of edema, the other 3 oropharyngeal airway spaces remained stable over the postsurgical period. There was slight extension of the head postsurgically (T3-T2), probably as a result of the supra- and infra-hyoid musculature adapting to the surgical changes. The individuals who extended their heads the most showed the greatest postsurgical increases in the oropharyngeal airway dimensions. Gale et al16 showed head exure 1 year after mandibular advancement in 71.7% of their sample; 26.7% experienced head extension in the same evaluation period. Our overall changes (T1-T3) also indicated approximately the same proportions of individuals showing head exure. Phillips et al24 also reported head exure and after mandibular advancement only (1.55 5.6) and maxillary intrusion with mandibular advancement (3.4 5.33). The literature has also shown a signicant upward and forward hyoid movement 6 weeks to 3 years after mandibular advancement.16,18 Our study showed that the hyoid bone moved forward immediately after surgery and superiorly during the postsurgical period. The later superior movement may be related to immediate postsurgical edema of the tongue and the use of palatal splints that displaced the tongue downward at the immediate postsurgical (T2) evaluation. The superior and anterior movements of the hyoid bone that we observed between T1-T3 were larger than amounts previously reported,16,18 probably related to the greater amount of mandibular advancement created by the counter-clockwise, maxillo-mandibular rotation, edema resolution, and removal of the palatal splint at approximately 4 weeks postsurgery. A limitation of this study was the lack of control over the patients head and neck positions. The most accurate way to verify the actual oropharyngeal airway dimension changes from surgery is by means of a xed reproducible head and neck position. Our subjects clearly changed head and neck posture immediately and long-term postsurgery. The long-term retrospective nature of the study made it impossible to ensure xed reproducible head and neck positions. Greater control over head and neck position might be expected to decrease the variability observed between subjects and increase the oropharyngeal airway dimensions observed. We concluded that maxillo-mandibular advancement surgery with counter-clockwise occlusal plane rotation improves the oropharyngeal airway dimensions. Decreases of the occlusal plane angle were correlated with the anterior chin movements and changes of the C3-Me distance were correlated with oropharyngeal airway changes. Head and neck posi-

smaller. Reiche-Fischel and Wolford21 showed that there was a greater percentage of change (increase) of the oropharyngeal airway dimensions for the rst 10 mm of advancement. Beyond 10 mm, the airway continues to increase in dimension, but proportionally less relative to the amount of mandibular advancement. The oropharyngeal airway improvement observed in the present study falls at the lower end of the range previously reported by studies evaluating the minimal widths of the retropalatal and retroglossal regions.9,17,20,22 The reduced response of the oropharyngeal airway dimensions in the present study is mainly related to changes in OPT/NS immediately after surgery. Our results showed that patients exed their heads after surgery (average, 4.76) and that the oropharyngeal airway changes were positively correlated with changes in head position. Previous studies have reported 0.65 to 3.4 of head exure following advancement surgery.16,23-25 The greater amount of head exion in our study may be due to the counterclockwise rotation of the maxillo-mandibular complex, resulting in a greater amount of mandibular advancement at menton and subsequent increased tension of the supra- and infra-hyoid musculature. There was no correlation between the oropharyngeal airway changes during the T2-T1 interval and the amount of mandibular or maxillary advancement that occurred except at point B and PASnar. However, the moderate correlation observed with oropharyngeal airway changes and changes in the distance between C3-Me indicates that oropharyngeal airway improvement due to the counter-clockwise rotation of the maxillomandibular complex would be signicantly greater if the patients had maintained the same OPT/NS postsurgery as they had before surgery. In other words, changes in head and neck posture immediately postsurgery constrained the immediate oropharyngeal airway improvement. The inuence of head and neck posture on the oropharyngeal airway dimensions has been demonstrated in clinical and experimental studies.26-30 Muto et al30 showed that changes in OPT/NS is 1 of the most important variables explaining oropharyngeal airway improvements; they showed that 10 of head extension can improve the oropharyngeal airway dimensions by about 4 mm. They also showed that the distance between C3 to Me was related to the oropharyngeal airway improvement, which is supported by our correlations. Decreases in the occlusal plane and mandibular plane angles were directly correlated with the anterior movement of Me. Anterior movement of Me was positively correlated to increases in C3-Me, which was directly correlated to the 3 lower oropharyngeal airway measurements. Geometrically, surgical maxillo-mandibular advancement with counter-clockwise

762 tion also inuenced the changes in airway dimensions that occurred after maxillo-mandibular advancement surgery. With the exception of URP, which increased, oropharyngeal airway spaces remained stable over the postsurgical follow-up period.

OROPHARYNGEAL AIRWAY CHANGES

14. Turnbull NR, Battagel JM: The effects of orthognathic surgery on pharyngeal airway dimensions and quality of sleep. J Orthodont 27:235, 2000 15. Farole A, Mundenar MJ, Braitman LE: Posterior airway changes associated with mandibular advancement surgery: implications for patients with obstructive sleep apnea. Int J Adult Orthodont Orthognath Surg 5:255, 1990 16. Gale A, Kilpelinen PVJ, Laine-Alava MT: Hyoid bone position after surgical mandibular advancement. Eur J Orthodont 23: 695, 2001 17. Yu LF, Pogrel MA, Ajayi, M: Pharyngeal airway changes associated with mandibular advancement. J Oral Maxillofac Surg 52:40, 1994 18. Achilleos S, Krogstad O, Lyberg T: Surgical mandibular advancement and changes in uvuloglossopharyngeal morphology and head posture: A short- and long-term cephalometric study in males. Eur J Orthodont 22:367, 2000 19. Wolford LM, Cottrell DA, Karras SC: Mitek mini anchor in maxillofacial surgery. Proceedings of SMST-94 of the First International Conference on Shape Memory and Superelastic Technologies. Monterey, CA, 1995, pp 477 20. Mehra P, Wolford LM: The mitek mini anchor for TMJ disc repositioning: Surgical technique and results. Int J Oral Maxillofac Surg 30:497, 2001 21. Reiche-Fischel O, Wolford LM: Posterior airway space changes after double jaw surgery with counter-clockwise rotation. AAOMS 78th Annual Meeting and Scientic Sessions. J Oral Maxillofac Surg 54:96, 1996 22. Prinsell JR: Maxillomandibular advancement surgery in a sitespecic treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest 116:1519, 1999 23. Schendel SA, Epker BN: Results after mandibular advancement surgery: An analysis of 87 cases. J Oral Surg 38:265, 1980 24. Phillips C, Snow MD, Turvey TA, et al: The effect of orthognathic surgery on head posture. Eur J Orthodont 13:397, 1991 25. Pim Valk JW, Zonnenberg AJJ, Van Maanen CJ, et al: The biomechanical effects of a sagittal split ramus osteotomy on the relationship of the mandible, the hyoid bone, and the cervical spine. Am J Orthod Dentofac Orthop 120:154, 2001 26. Harris RS: The effect of extension of the head and neck upon the infrahyoid respiratory passage and the supraclavicular portion of the human trachea. Thorax 14:176, 1959 27. Solon B, Tallgren A: Head posture and craniofacial morphology. Am J Phys Anthropol 44:417, 1976 28. Hellsing E: Changes in the pharyngeal airway in relation to extension of the head. Eur J Orthod 11:359, 1989 29. Ozbek MM, Miyamoto K, Lowe AA, et al: Natural head posture, upper airway morphology and obstructive sleep apnea severity in adults. Eur J Orthod 20:133, 1998 30. Muto T, Takeda S, Kamazawa M, et al: The effect of head posture on the pharyngeal airway space (PAS). Int J Oral Maxillofac Surg 31:579, 2002

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