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Enhanced CPD DO C
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.
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.
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.
that ANS resection has the favourable 2nd edn. New York: Thieme, 2002. base cinching following maxillary
effect of reducing nasal tip rise and 6. Soncul M, Bamber MA. Evaluation osteotomy. Int J Adult Orthodon
excess nostril show.1 However, ANS of facial soft tissue changes with Orthognath Surg 1993; 8: 33−36.
resection is not indicated in all cases. optical surface scan after surgical 19. Westermark AH, Bystedt H,
Nasal tip elevation is beneficial in correction of class III deformities. von Konow L et al. Nasolabial
patients undergoing inferior maxillary J Oral Maxillofac Surg 2004; 62: morphology after Le Fort I
repositioning, or in those with pre- 1331−1340. osteotomies. Int J Maxillofac Surg
existing nasal tip droop undergoing 7. Honrado CP, Lee S, Bloomquist 1991; 20: 25−30.
maxillary advancement or impaction DS et al. Quantitative assessment 20. Guymon M, Crosby D, Wolford
osteotomies. In addition, an ANS of nasal changes after LM. The alar base cinch suture to
resection is contra-indicated in those maxillomandibular surgery using control nasal width in maxillary
with a retracted columella, irrespective a 3-dimensional digital imaging osteotomies. Int J Adult Orthodon
of the maxillary surgical move.1 Careful system. Arch Facial Plast Surg 2006; Orthognath Surg 1988; 3: 89−95.
case selection is therefore imperative 8: 26−35. 21. Rauso R, Gherardini G, Santillo V et
prior to performing this procedure. 8. Chew MT. Soft and hard tissue al. Comparison of two techniques of
changes after bimaxillary surgery cinch suturing to avoid widening of
Conclusion in Chinese class III patients. Angle the base of the nose after Le Fort I
Orthod 2005; 75: 959−963. osteotomy. Br J Oral Maxillofac Surg
Nasal soft tissue
9. Jensen AC, Sinclair PM, Wolford LM. 2010; 48: 356−359.
morphology should be carefully
Soft tissue changes associated with 22. Muradin MS, Seubring K, Stoelinga
considered at diagnosis and
double jaw surgery. Am J Orthod PJ et al. A prospective study on the
incorporated into treatment planning
Dentofacial Orthop 1992; 101: effect of modified alar cinch sutures
for patients undergoing a Le Fort I
266−275. on nasolabial changes after Le
osteotomy. Patients should be informed
10. Schendel SA, Carlotti AE. Nasal Fort I intrusion and advancement
of, and understand the aesthetic
considerations in orthognathic osteotomies. J Oral Maxillofac Surg
significance of, possible adverse nasal
surgery. Am J Orthod Dentofacial 2011; 69: 870−876.
changes associated with this procedure.
Orthop 1991; 100: 197−208. 23. Becelli R, De Ponte FS, Fadda MT et
It is key that clinicians are aware of the
11. McFarlane RB, Frydman WL, al. Subnasal modified Le Fort I for
risk factors to these adverse changes
nasolabial aesthetics improvement.
and the various techniques available to McCabe SB. Identification of
J Craniofac Surg 1996; 7: 399−402.
minimize deleterious outcomes. nasal morphologic features that
24. Mommaerts MY, Abeloos JV, De
indicate susceptibility to nasal tip
Clercq CA, Neyt LF. The effect of the
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:
the John Radcliffe Hospital, Oxford, for 12. O’Ryan F, Schendel S. Nasal
95−100.
their production of the line diagrams in anatomy and maxillary surgery. 1.
this article. Esthetic and anatomic principles.
Int J Adult Orthodon Orthognath
Compliance with Ethical Standards Surg 1989; 4: 27−37.
Conflict of Interest: The authors declare 13. Engel GA, Quan RE, Chaconas SJ.
that they have no conflict of interest. Soft tissue change as a result of
Informed Consent: Informed consent maxillary surgery. A preliminary
was obtained from all individual study. Am J Orthod Dentofacial
participants included in the article. Orthop 1979; 75: 291−300. CPD Answers for
14. Bisase B, Johnson P, Stacey M.
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