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92 Orthodontics July 2019

Enhanced CPD DO C

Timothy McSwiney Sadaf Khan and Daljit Dhariwal

Nasal Considerations with


the Le Fort I Osteotomy
Abstract: Orthognathic surgery involves the correction of severe dentofacial deformities through a combination of orthodontics, surgery
and, occasionally, restorative dentistry. This procedure, when involving surgical movement of the maxilla, can lead to changes in the
overlying nasal morphology. In this paper, the standard nasal assessment that is undertaken prior to a Le Fort I osteotomy is outlined
along with the reported nasal changes seen following this procedure. In addition, the various risk factors associated with adverse nasal
changes are considered, as are the management techniques adopted by clinicians to minimize these changes
CPD/Clinical Relevance: Clinicians should be aware of the adverse nasal changes associated with the Le Fort I osteotomy.
Ortho Update 2019; 12: 92–97

Detailed examination of the


A Le Fort I osteotomy is performed Clinical nasal evaluation nose can take place in four dimensions:
to correct an underlying midface It is imperative that clinicians
skeletal deformity and to improve facial 1. Frontal;
develop the clinical acumen to evaluate 2. Lateral;
aesthetics.1 It can be used to correct nasal morphology as part of a wider
discrepancies in both the antero- 3. Basal; and
assessment of facial aesthetics. 4. 45˚ views.3
posterior and vertical dimensions and Initially, the overall proportion
is widely adopted by maxillofacial and symmetry of the face should be
surgeons owing to its relative simplicity Frontal nasal analysis
analysed. This examination is carried In the frontal view, the alar
and efficiency. Although complications out with the patient in the natural head
associated with this procedure are base width, outlines of the alar rims
position (NHP). This is a standardized and and the columella are assessed (Figure
uncommon, careful evaluation of the reproducible position with the subject
nose should take place prior to this 1). The width of the alar base should
focusing on a distant point at eye level. approximate the intercanthal distance.
procedure. Typically, undesirable changes In order to achieve ideal aesthetics, the
in the nasal region, such as widening of In Caucasians, this measures 32 ± 3 mm.
nose should be symmetrical in shape In Africo-Americans, however, the width
the alar base or upturning of the nose, and be positioned in the midline of the
can accompany this procedure.1,2,3 Careful of the alar base is greater (35 ± 3 mm).
face. The projection and size of the nose In individuals where the intercanthal
pre-surgical planning, as well as intra- should be considered in relation to lip
operative preventive techniques, have distance is narrower than an eye width,
and chin projection.3 In addition, as the alar base width should be slightly
the potential to limit these undesirable with any assessment of facial aesthetics,
changes. This article aims to cover the wider.3 For ideal aesthetics, the nares
the ethnicity of the patient should be should be scarcely visible and the
clinical evaluation of the nose prior considered. There is wide variation in the
to a Le Fort I osteotomy, the reported columella should appear marginally
nasal prominence, shape and alar width below and parallel to the alar rims.
nasal changes seen following this amongst differing ethnic groups.3 It is
procedure, the risk factors associated imperative that the clinician is sensitive Lateral nasal analysis
with these adverse nasal changes and to the ethnicity of the patient as this will In the lateral view, the nasal
the techniques employed to minimize have an important influence on nasal length, nasal dorsum, tip projection
possible adverse outcomes. aesthetics. and nasolabial angle are assessed

Timothy McSwiney, BDS(Hons), MFDS RCS, DClinDent(Orth), MOrth RCS, FDS(Orth) RCS, Locum Consultant Orthodontist, Dublin Dental
University Hospital, 2 Lincoln Place, Dublin, Ireland (email: Timothy.McSwiney@dental.tcd.ie), Sadaf Khan, BSc(Hons), BDS(Hons), MFDS
RCS, MSc, MOrth RCS, FDS(Orth) RCS, Consultant Orthodontist, Eastman Dental Hospital, 256 Gray’s Inn Road, London and Daljit Dhariwal,
BDS, FDS RCS, MBBCh, FRCS, FRCS(OMFJ), Consultant Oral and Maxillofacial Surgeon, John Radcliffe Hospital, Oxford, UK.

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July 2019 Orthodontics 93

of tip projection (alar tip to cheek-alar of the medial crural footplates to the
junction) should equal two-thirds of the septum during maxillary surgery. This
nasal length, whilst the degree of tip will lead to undesirable deepening of a
rotation is assessed via the nasolabial supratip depression, however, in some
angle. This is the angle between the line cases may have the desirable effect of
drawn through the midpoint of the nostril camouflaging a small dorsal hump.1,10
aperture and a line drawn perpendicular Nasal soft tissue changes seen
to the Frankfort plane while intersecting following inferior maxillary movement
subnasale.4 It is influenced by the shape differ from those seen in maxillary
of the columella. In males, the average advancement and superior impaction.
nasolabial angle is between 90°−95°, whilst Here, there is downward movement of
in females it is more obtuse, measuring the alae, columella and nasal tip.7 Nasal
between 95°−105°.5 The pre-treatment features should be carefully evaluated
nasolabial angle is of crucial importance pre-surgery as downward movement of
when planning maxillary surgery.4 an already inadequate nasal tip rotation
Figure 1. Frontal view analysis of the nose.
may lead to the loss of any supratip
Basal nasal analysis break.10
In the basal view, the nares and In summary, despite these
position of the columella are assessed. In reported changes, it is important to
Caucasians, the nares are ovoid in shape appreciate that, owing to the great
whilst, in African-Americans, a more circular variation in nasal morphology, accurate
appearance prevails. The nostrils should prediction of nasal changes following a
be symmetrical in shape and their width Le Fort I osteotomy is difficult. Careful
approximately three-quarters of the alar pre-surgical planning on an individual
base distance. Lastly, the columella should basis is paramount to achieving the best
lie in the midline on basal view analysis. post-operative results.

45˚ nasal analysis Risk factors


The 45˚ view provides an It is crucial that cases at high
excellent view of nasal anatomy. It is risk of undesirable nasal changes are
considered by some individuals as the best identified prior to the commencement
view of facial aesthetics. The shape of the of orthognathic surgery. Various factors
dorsum, supratip appearance and contour have been reported in the literature to
of the nasal cartilage are well illustrated be associated with undesirable nasal
in this view (Figure 3).3 The supratip is the changes. These include:
Figure 2. Lateral nasal analysis. nasal region where the inferior aspect  The Deflection Resistance Index (DRI);11
of the nasal dorsum meets the tip of the  Magnitude of maxillary
nose.3 advancement;2,12
 Degree of subperiosteal dissection;1
Nasal changes following Le  Pre-operative columellar angle.11
Fort I osteotomy The DRI, as described by
A Le Fort I osteotomy inevitably McFarlane,11 reflects the tissue bulk of
leads to changes in nasal morphology.2 An the nasal tip in relation to the horizontal
increase in alar base width is seen following size of the nose. A low DRI index score
both maxillary advancement and superior signifies increased tissue bulk. With
maxillary impaction.1,6,7 This results from greater tissue bulk, the nose becomes
elevation of the periosteum from the more susceptible to undesirable tip
maxilla and subsequent retraction of the deflections following surgery. The
zygomaticus major, levator labii superiorus, larger nasal tip, which has an increased
levator labii superiorus alaeque nasi and development of the lateral crus of the
nasalis from their points of insertion. It is alar cartilages, transmits a greater force
crucial that the alar base width is carefully to the upper lateral cartilage, which in
evaluated prior to maxillary surgery so as turn leads to an upward tip rotation. The
to prevent any adverse effects to facial magnitude of maxillary advancement
Figure 3. 45˚ nasal analysis. aesthetics post-surgery. has been shown to be the greatest
A rise in the nasal tip is seen contributor to nasal tip deflection.2,12
following both maxillary advancement However, accurate prediction of the
and impaction.8,9 This is associated extent of nasal tip deflection has not
(Figure 2). The nasal length should equal been determined. Factors such as soft
with increased nostril show and the
the distance from stomion to menton. The characteristic ‘Miss Piggy’ appearance. Nasal tissue lip variations, extent of oedema,
nasal dorsum should be free of depressions tip elevation results from disruption to the radiographic and surgical technique
and humps and should project from the nasal septum and the upper and lower variations, and methodical differences in
face at an angle of 30°−35°. The length lateral cartilages, as well as the attachment study designs have accounted for this.13

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94 Orthodontics July 2019

as described later, can be employed


to limit this adverse change. The
pre-operative columella angle (angle
formed by the intersection of nasion
vertical to the columellar tangent)
can also contribute to undesirable
nasal changes post-surgery. As the
columella angle becomes more obtuse,
the likelihood of tip deflection at the
anterior nasal tip increases.11 This in
turn leads to an increase in nostril show
which further worsens nasal aesthetics.

Management strategies
Strategies in mitigating
against adverse soft tissue nasal
changes are as follows:
1. Avoiding maxillary surgery;
2. Pyriform aperture recontouring;
3. The alar base cinch suture;
4. The V-Y closure;
5. The subnasal modified Le Fort I
osteotomy;
6. Anterior Nasal Spine (ANS) resection.

Avoiding maxillary surgery


Anticlockwise rotation
of the mandible alone to close an
Figure 4. Cinch suture. anterior open bite can be considered
in circumstances where a bimaxillary
procedure is likely to cause adverse
aesthetic nasal effects. This clinical
practice is gaining increased interest,
especially in situations where the
anteroposterior and vertical position
of the maxilla is within normal limits,
the mandibular ramus is short and
the condyles show no evidence of
resorption.14 However, mandibular
surgery alone is not possible where
vertical maxillary excess or maxillary
hypoplasia are the presenting features.

Pyriform aperture recontouring


The pyriform aperture
represents the anterior end of the bony
nasal opening. During maxillary surgery,
the pyriform aperture is frequently
recontoured to accommodate the soft
tissues at the base of the nose. This
technique is of particular importance
in superior and anterior repositioning
of the maxilla. Studies in the literature
have suggested that alteration to the
lateral aspects of the pyriform aperture
during surgery is likely to have the most
Figure 5. V-Y suture. profound impact on nasal changes.15,16
Mommarts et al concluded that it is
the pyriform aperture pushing on the
alae and not the nasal spine that is
Alar base widening, in contrast, is affected movement. This is due to freeing the facial responsible for the nasal tip changes.
more by the extent of sub-periosteal muscles from the nasolabial region and Failure to recontour the pyriform rim
dissection than the magnitude of skeletal anterior nasal spine. Muscle resuturing, sufficiently may lead to alar base flaring,

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96 Orthodontics July 2019

on both sides, with approximately


0.5−1 mm of excess tissue persisting
in the midline. The excess tissue is
subsequently approximated. The V-Y
closure technique thereby restricts
lateral retraction of the perioral muscles
by suturing them to the superior aspect
of the vestibular incision. Advancement
of muscle, mucosa and periosteum
occurs in union. This technique can
be performed in conjunction with the
cinch suture or alone. Whilst Rosen
concluded that the results from V-Y
closure are unpredictable,2 others have
found the V-Y closure to be effective at
minimizing alar base widening.15 The
V-Y closure, however, has been reported
to have little effect on vertical changes
of the nasal tip.23

The subnasal modified Le Fort I osteotomy


The subspinal osteotomy
is performed to reduce nasal tip
change and produce a more acute
NLA than seen in conventional Le Fort
I osteotomies. With this technique,
the cartilaginous septum, median
nasal support, attachments of the
footplates to the caudal aspect of
Figure 6. Subspinal osteotomy. the nasal septum and nasal spine are
all left intact (Figure 6). It has been
postulated that the Le Fort I subspinal
osteotomy is more conservative to the
perinasal muscular attachments than
nasal tip elevation and even asymmetry results.22 In addition to minimizing alar the traditional Le Fort I osteotomy. Both
of the nose.16 Recontouring of the base widening, the alar base suture Becelli et al24 and Mommaerts et al 25 in
pyriform rims is necessary to allow the has the secondary effect of increasing a preliminary study, observed superior
alar bases to sit within the pyriform rims the NLA, which results from the suture results with this technique, protecting
and so resist nasal widening.16 crossing the midline and compressing against both alar base widening and
the tissues in this region. This effect nasal tip upturning. In a subsequent
The alar base cinch suture could be reduced by suturing the alar study, however, Mommaerts et al
The alar base cinch suture base to the bony rim of the pyriform demonstrated no difference in nasal
(Figure 4) was initially described by aperture.20 Nasal tip projection is tip elevation or nasal tip projection in
Millard in cleft lip patients.17 It was reported to be unaffected by the cinch matched groups undergoing maxillary
later described by Collins and Epker suture.20 The alar base suture is not advancement/impaction with and
in non-cleft patients18 and modified indicated in all cases. The alar base width without subspinal osteotomy.16 It
by others.19,20 It is a surgical technique is often narrow in vertical maxillary was concluded that recontouring of
employed to minimize widening of the excess cases, and the subsequent the pyriform aperture during surgery
alar base. This is achieved by placing widening that results following surgery played a more important role in
a non-resorbable suture bilaterally helps produce a more harmonious facial resisting nasal tip changes than the
through the periosteum in the alar balance. type of surgery performed.
region, thereby anchoring the fibro-
areolar tissues and the transverse nasalis The V-Y closure Anterior Nasal Spine (ANS) resection
muscle. The cinch suture is indicated The V-Y closure (Figure The precise contribution
in osteotomies involving anterior or 5) is performed to minimize alar of the ANS to nasal tip projection is
superior repositioning of the maxilla, base widening. Using an absorbable unknown. The ANS is often resected,
where the alar base width is normal suture, the superior aspect of the either partially or completely, in
pre-surgery. The effectiveness of the vestibular incision is pulled anteriorly, individuals undergoing maxillary
alar base suture has been reported in in a horizontal mattress fashion, by advancement or impaction surgery,
many studies.18,19,21 Collins and Epker18 engaging smaller fragments of the with a prominent nasal spine or
as well as others19,21 observed continued superior margin and larger fragments obtuse subnasale contour. The soft
flaring despite interalar base sutures. The of the inferior margin. The lip is then tissues attached to the base of the
classic cinch technique was subsequently retracted and the superior tissue is nose should not be disrupted during
modified, demonstrating improved advanced the desired amount and closed this procedure. It has been suggested

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24. Mommaerts MY, Abeloos JV, De
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Acknowledgement deflection with Le Fort I osteotomy.
subspinal Le Fort I-type osteotomy
The authors would like to Am J Orthod Dentofacial Orthop
on interalar rim width. Int J Adult
thank the medical illustration team at 1995; 107: 259−267.
Orthodon Orthognath Surg 1997; 12:
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Conflict of Interest: The authors declare 13. Engel GA, Quan RE, Chaconas SJ.
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