Jeffrey C. Posnick, DMD, MD

“Irregularities of the teeth being so frequently associated with some pathologic obstruction of the nasal passages or nasopharynx, this fact should ever be present in the operator’s mind and suitable examination being made; and in case [as is often found] the oral deformity be complicated by the presence of hypertrophied faucal tonsils, adenoid hypertrophies in the vault of the pharynx, or obstruction of the nasal passages, the orthodontist’s work can only be made complete by the assistance of a rhinologist and laryngologist.”²

—EDWARD H. ANGLE, MD, DDS (1907)

“The nasal fossae are bounded by the maxillary bones and by bones attached to the maxillae; therefore deformities of maxillary bones are bound to influence the size, shape and patency of the nasal fossae. Nasal obstruction may be due directly to deformity or to lack of development of the maxillae. Any [intranasal] bony [obstructions] are removed [surgically] until ample breathing space is established. If nasal obstruction is due simply to lack of size of the nasal fossae and there are erupted [permanent] molar teeth [on each side], then the treatment consists of placing a jackscrew across the mouth from one upper molar to the other. As the screw is spread, the intermaxillary suture opens, the maxillae separate, and the nasal obstruction is relieved.”¹⁰

—VILRAY PAPIN BLAIR, AM, MD, FACS (1914)

Frequent Causes of Chronic Obstructive Nasal Breathing

Nasal septoplasty is a generic descriptor of the surgical correction of septal thickenings and deflections frequently carried out to improve nasal airflow and sinus drainage (Figs. 10-1 and 10-2).^{3,7,20,30,52,53,57,75,80,88,89,91,93,94} Enlarged inferior turbinates also commonly obstruct nasal breathing and interfere with sinus drainage (Fig. 10-3). Hypertrophic inferior turbinates that are only minimally responsive to medical treatment are best managed by partial (surgical) reduction.^8,23,77 A tight nasal inlet or constricted pyriform apertures occur in conjunction with a narrow maxillary arch (Fig. 10-4).^58,86,90,95 An elevated floor of the nose is a frequent finding in the presence of anterior vertical maxillary excess (i.e., long face growth pattern) (Fig. 10-5).^63,81,112 A scarred nasal vestibule seen with a repaired cleft nasal malformation may be another cause of persistent nasal obstruction (Fig. 10-6). Nasal septal deformities, inferior turbinate enlargement, a tight nasal inlet, and an elevated nasal floor all commonly coexist with maxillary deformities (Figs. 10-7 and 10-8).^1,12–14 Favorable access to the nasal septum, the inferior turbinates, the pyriform apertures, and the nasal floor to correct these airway obstructions and deformities is possible through the Le Fort I down-fracture osteotomy that is commonly used in orthognathic surgery (Figs. 10-9, 10-10, and 10-11).^82–85

Maxillofacial literature has traditionally addressed aspects of nasal obstruction, nasal anatomy, and sinus drainage in the patient who is undergoing orthognathic surgery, but often only in subjective and limited ways.8,18,24,27,32,33,36,38,55,56,71,73,74,76,103,104,107 Authors traditionally discuss the effects of Le Fort I osteotomies on nasal morphology (i.e., aesthetics) and occasionally recommend adjunctive soft-tissue techniques in the hopes of limiting suboptimal aesthetics (e.g., the alar cinch stitch).³⁷ Little consideration is given to either baseline upper airway findings or how the maxillary surgery may affect long-term nasal breathing. Warren and colleagues discusses issues of nasal airway changes after Le Fort I osteotomy with maxillary impaction, advancement, and transverse widening.¹⁰⁸ They used a pressure flow meter to assess nasal airway breathing before and after maxillary osteotomies.^21,29 Turvey and colleagues recognized preexisting nasal obstruction in many of their orthognathic patients.¹⁰³ They suggested methods of avoiding adverse effects on nasal airway resistance that may result from Le Fort I maxillary osteotomy procedures.¹⁰⁴ Moses and coworkers reported about a series of patients who were treated for nasal obstruction and sinus drainage difficulties after Le Fort I maxillary procedures were carried out for long face growth patterns (e.g., vertical maxillary excess with anterior open bite).⁷¹ They concluded that Le Fort I impaction frequently aggravates preexisting nasal airway obstruction and sinus disease. Williams and colleagues examined the nasal airway function (breathing) in a consecutive series of subjects (n = 50) before and 5 months after undergoing (1) Le Fort I osteotomy with advancement and vertical lengthening (2) maxillary segmentation with transverse expansion (14 of 50 subjects, 28%); and (3) recontouring of the nasal floor and pyriform rims with a rotary drill. Despite these favorable nasal airway surgical maneuvers, when ignoring potential pathology of the septum (e.g., buckling and deviation) and the inferior turbinates (e.g., hypertrophy/enlargement), a full 20% of their study subjects experienced a worsening of their nasal airway function after surgery.^113a

Unfortunately, in the individual with a dentofacial deformity, a methodic approach to the evaluation and management of chronic nasal airway obstruction at the time of orthognathic surgery is often not undertaken. We suggest that any upper airway obstructions be assessed by the orthognathic surgeon with the same vigor as the effects of the presenting jaw deformities on malocclusion are evaluated (Figs. 10-12 and 10-13).^{51,83–85,87}

The Effects of Respiratory Pattern and Jaw Posture on Maxillofacial Growth

The link between an open mouth or oral breathing pattern and maxillofacial growth has been documented in the literature.4,5,11,17,24,25,28,31,41,43,45–48,59–66,96,97,105,106,109,110 There has been both animal experimental and human clinical research to support a link between oral respiration, open mouth posture, and the development of maxillomandibular disharmonies. With the use of rhesus monkeys as an experimental model, Harvold and colleagues completely blocked the nares of newborn monkeys.^45–48 The researchers observed consistent facial morphologic changes that gradually occurred with growth in the presence of a constant open mouth and tongue protrusive mandibular posture. The research of this group documented that a constantly open mouth (i.e., clockwise rotation of the mandible) in a growing rhesus monkey was followed by the vertical lengthening of the maxilla. The mandibular inferior border then gradually steepens, with a resulting obtuse gonial angle. Through years of primate laboratory research, Harvold and coworkers confirmed that there are significant correlations between alterations in respiratory patterns (i.e., forced mouth breathing), mandibular (open mouth) posture, tongue protrusion, and characteristic maxillomandibular dysmorphic growth (i.e., long face growth pattern).^45–48

In human children who have significant nasal obstruction and a resulting open mouth posture, clinical observational studies document a similar downward and backward rotation of the mandible with hypereruption of the maxillary dentition.59–65 Over several years, the affected children develop what we now recognize as a long face growth pattern. This is documented as a vertically long and horizontally retrusive maxillomandibular complex. The term adenoid facies was coined to describe the child who presents with a long, narrow, flat face; protruding teeth; and lips that are widely separated at rest. These features are often accompanied by an anterior open-bite malocclusion and lip strain when attempting mouth closure. To better understand the concept, Linder-Aronson and Woodside completed a study in which they analyzed the faces of children with chronic nasal obstruction who were scheduled to undergo tonsillectomies and adenoidectomies at a pediatric hospital in Stockholm, Sweden.⁶³ They documented a tendency toward a long lower anterior facial height in this group of children. Interestingly, they found that, after the adenoids were removed and with enough time, there was at least some improvement in the children’s facial morphology. Unfortunately, the structure of these long faces did not return to normal. With or without adenoidectomy being carried out during childhood, many of these children reach adolescence with persistent nasal airway obstruction in combination with significant jaw dysmorphology and malocclusion (i.e., the long face growth pattern). It is our recommendation that, by adolescence, all aspects (i.e., airway obstruction, skeletal dysmorphology, and malocclusion) be simultaneously addressed to improve function in the head and neck (e.g., breathing, swallowing, speech, chewing, lip closure) and to enhance facial aesthetics.^83–85

Simultaneous Management of Chronic Obstructed Nasal Breathing and the Presenting Dentofacial Deformity

Posnick and colleagues conducted a clinical study with the use of the Nasal Obstruction Symptom Evaluation (NOSE) survey questionnaire to prospectively assess a consecutive series of patients (N = 43) who reported both chronic nasal obstruction and the presence of a significant dentofacial deformity with malocclusion that involved at least the maxilla.⁸³ The NOSE questionnaire is considered to be a useful marker of symptomatic nasal airway obstruction.^42,98–101 Each study subject was documented to have septal deviation and inferior turbinate enlargement that were consistent with airway symptoms. Any presenting physical findings of a tight nasal inlet or an elevated nasal floor were not specifically studied but were clinically addressed in each patient, when indicated. Each study patient simultaneously underwent septoplasty, the reduction of the inferior turbinates, and the surgical correction of the presenting jaw deformity that included, at minimum, a Le Fort I osteotomy. Septoplasty and inferior turbinate reduction were performed at the time of Le Fort I osteotomy through exposure provided by the down-fracture. The consecutive series of patients (N = 43) who met the inclusion criteria were given the NOSE survey questionnaire before they underwent surgery. The NOSE questionnaire was completed in each patient 3 months after surgery and again at least 6 months after surgery.

The study group included 16 males and 27 females with a mean age of 25 years (range, 15 to 55 years). All patients were treated with a comprehensive orthodontic and orthognathic surgical approach that included a Le Fort I osteotomy as part of the surgical correction. The most frequent pattern of jaw deformity identified in the study group was a long face growth pattern (i.e., maxillary vertical excess with Class II malocclusion), which was seen in 17 out of 43 patients (40%). Simultaneous maxillofacial procedures completed in addition to the Le Fort I osteotomy, septoplasty, and inferior turbinate reduction varied. Twenty-nine of the 43 patients (67%) underwent segmentation of the maxilla to widen the arch width or to correct the curve of Spee. Forty-two of the patients (98%) underwent simultaneous sagittal split ramus osteotomies, 16 (37%) underwent the simultaneous removal of the third molars, and 7 (16%) also underwent suction-assisted lipectomy of the neck. Thirty-seven patients (86%) underwent oblique osteotomy of the chin with reshaping (i.e., osseous genioplasty).

The mean weighted NOSE score before surgery was 63.7. At the 3-month postoperative interval, the mean NOSE score had dropped to 6.9. On the basis of the non-parametric Wilcoxon signed-rank test, this is a significant finding (P < .001). The mean NOSE score at 6 months after surgery dropped even further to 6.3. This improvement in nasal breathing remained both clinically and statistically significant as compared with what was found before surgery. The findings confirmed an improved nasal airway by 3 months after surgery among patients who had undergone combined septoplasty, inferior turbinate reduction, and Le Fort I osteotomy; these improvements continued and were maintained at 6 months. All study patients experienced improvements in nasal breathing as a result of the combination of procedures that were carried out.

The incidence of complications that resulted from the intranasal procedures performed simultaneously with the Le Fort I osteotomy as reported by Posnick and colleagues was minimal and not greater than those reported in the literature for isolated procedures. Posnick and colleagues also reported about the incidence of Le Fort I osteotomy–specific complications in the same cohort. The complications were few and not greater than those reported when a Le Fort I osteotomy was carried out as an isolated procedure.

Approaching the Nasal Airway Through Le Fort I Down-Fracture ( Video 1 and 2)

A Le Fort I osteotomy provides excellent access to the nasal septum, the inferior turbinates, the pyriform rims, the nasal floor, the anterior nasal spine, the maxillary sinus cavities, and the ostium, thereby allowing for the correction of any presenting nasal airway obstruction or maxillary sinus pathology at the time of down-fracture (see Figs. 10-9, 10-10, and 10-11).^82,83 Interestingly, most otolaryngologists/head and neck surgeons are not used to viewing these structures from this perspective (i.e., through the down-fracture), whereas orthognathic surgeons are. There are several technical details to consider when completing septoplasty or inferior turbinate reduction through the exposure provided by the Le Fort I osteotomy. As always, care is taken to maintain the integrity of the nasal mucosa when down-fracturing the maxilla. Nevertheless, tears in the mucosa are common. After the down-fracture and disimpaction of the maxilla, an elevator is used to achieve the submucosal exposure of all buckled and deviated portions of the cartilaginous and bony septum. With the use of a rongeur, the buckled or deviated portions of the cartilaginous and bony septum are removed (i.e., submucosal resection); however, adequate dorsal and caudal components of the cartilaginous septum are preserved for structural support. If a cosmetic rhinoplasty is a future consideration, then the preservation of as much useful septal cartilage as possible for later tip grafting is important. Next, an incision that is parallel and just below each inferior turbinate is completed through the nasal mucosa. If the nasal mucosa was torn during the down-fracture, then the exposure provided is used and extended as needed for the additional visualization of each inferior turbinate. With the use of a scissors (e.g., Mayo scissors), the inferior aspect of each enlarged inferior turbinate can be excised via partial resection. Other surgical techniques to reduce enlarged inferior turbinates are described, such as intramural ablation. The direct visualization of the more cephalic positioned nasotracheal tube within the surgical field limits the chance of injury during the turbinate reduction procedure. There is sufficient room for the surgeon to work around the endotracheal tube. With no oxygen leaks in the ventilation system, the cauterization of the exposed raw surface of each inferior turbinate is completed. Suture repair of the nasal floor mucosa is then accomplished. No nasal packs or splints are required for postoperative management. With this approach, the author has not experienced significant intraoperative bleeding or postoperative airway compromise.

Management of Residual Postoperative Nasal Obstruction

When the baseline presurgical nasal airway obstruction is clarified and then managed simultaneously through the Le Fort I down-fracture, residual nasal obstruction is uncommon. When a degree of postsurgical nasal obstruction persists, it is generally the result of an incomplete presurgical diagnosis or the inadequate operative correction of all of the aspects that are causing the blockage (e.g., constricted aperture, elevated floor, enlarged inferior turbinates, septal deviations). After septoplasty and inferior turbinate procedures and after routine postoperative intranasal swelling subsides, continued nasal obstruction may also occur as a result of scar formation.67,79,83 Should a degree of nasal obstruction persist, it is important to confirm that residual septal deviation, turbinate hypertrophy, and nasal valve (internal and external) stenosis are not factors. If these causes are ruled out and if postsurgical obstruction remains, scar bands of varied thickness are likely to be the cause. If so, the intranasal synechiae can extend from the operated septum to the inferior turbinates or to the healing areas along the nasal mucosal floor. The resulting scar bands are usually small to moderate in size, and they can often be corrected in the surgeon’s office with the use of local spray anesthesia and scissors transaction under endoscopic visualization. Occasionally, dense, thick synechiae occur; these may contract a straightened septum into a lateralized position. For more extensive scar bands and when further septoplasty or turbinate reduction is required, management in the operating room via an intranasal approach (with the placement of a separating splint between the septum and the lateral nose to prevent the adjacent fresh mucosal edges from re-creating the scar contracture) is preferred.

Effects of Maxillary Arch Expansion and Nasal Floor Recontouring on the Airway

Comprehensive Approach to Chronic Nasal Airway Obstruction

The fact that Posnick and colleagues showed a more significant symptomatic improvement in nasal breathing in their study patients as compared with that found by Stewart and colleagues when septoplasty only was carried out is not surprising.¹⁰⁰ This likely resulted from the strict patient selection process and the other procedures that were simultaneously carried out (e.g., inferior turbinate reduction, transverse widening of the maxilla, horizontal maxillary advancement, lowering the nasal floor by recontouring).

An interesting observation emerged from the COG-ENT chronic rhinosinusitis study that was completed in 2001.98–101 The COG-ENT researchers found that patients who were undergoing functional endoscopic sinus surgery in combination with septoplasty and inferior turbinate reduction showed even greater clinical improvement in nasal breathing as compared with those undergoing functional endoscopic sinus surgery alone. This confirms the added value to the airway (i.e., the improved breathing) related to carefully selected diagnosis-driven procedures being simultaneously carried out.^{19,35,50,54,70,72,78}

Conclusions

Orthognathic surgeons have the opportunity to improve disease-specific quality-of-life issues for their patients at the time of Le Fort I osteotomy by performing diagnosis-driven intranasal procedures in those with symptomatic chronic nasal airway obstruction and sinus drainage difficulties. The improvement of nasal airflow often enhances the patient’s sense of smell, sinus drainage, sleep comfort, daytime alertness, dental health, and ability to perform exercise. Ignoring any baseline nasal floor and pyriform rim skeletal deformities at the time of orthognathic surgery is also likely to result in suboptimal facial aesthetics.

References