Editorial Type:
Article Category: Case Report
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Online Publication Date: 30 Jan 2019

An orthodontic-orthognathic patient with obstructive sleep apnea treated with Le Fort I osteotomy advancement and alar cinch suture combined with a muco-musculo-periosteal V-Y closure to minimize nose deformity

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Page Range: 946 – 952
DOI: 10.2319/052818-406.1
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ABSTRACT

In some severe skeletal Class III patients, mandibular setback surgery using sagittal split ramus osteotomy (SSRO) is performed to correct mandibular protrusion. However, in patients diagnosed with obstructive sleep apnea syndrome (OSAS), the risk of OSAS worsening as a result of the SSRO is very high. Maxillary advancement could reduce the degree of mandibular retropositioning and expand the skeletal framework in the pharyngeal region, leading to enlargement of the airway. However, nasal deformity is an undesirable outcome of the procedure. This case report describes a 23-year-old man with a retruded maxilla and OSAS. The maxillary retrusion was treated using Le Fort I osteotomy with an alar cinch suture and a muco-musculo-periosteal V-Y closure (ACVY). After treatment, better occlusal relationships and improvement in OSAS were observed. Thus, an ACVY could minimize nasolabial deformity.

Keywords: Skeletal Class III; Le Fort I osteotomy; OSAS; ACVY; Nasolabial deformity

INTRODUCTION

Orthognathic surgery is often performed in skeletal Class III patients to treat maxillo-mandibular misalignments. However, mandibular setback surgery can reduce the oropharyngeal area and induce or worsen obstructive sleep apnea syndrome (OSAS). Therefore, maxillary advancement combined with backward placement of the mandible is often performed to treat Class III patients with OSAS to reduce the extent of mandibular retropositioning. Although the Le Fort I osteotomy and maxillary advancement improve facial profile and expand the nasopharyngeal area, Le Fort I osteotomies, whether for retropositioning, advancement, or maintenance, result in some undesirable outcomes, such as widening of alar bases, loss of vermilion, and downward sloping of the commissures.1,2 This is because the Le Fort I osteotomy affects the zygomaticus major, levator labii superioris alaeque nasi, and nasalis muscles.3 A previous study4 indicated that a Le Fort I osteotomy with alar cinch sutures and muco-musculo-periosteal V-Y closure (ACVY) could minimize the nasal deformities.

OSAS is characterized by recurrent episodes of complete or partial obstruction of the upper airway during sleep, leading to oxygen desaturation, fragmented sleep, and daytime somnolence.5 A previous study reported that Japanese OSAS patients have lesser prevalence of obesity than do Europeans and Americans, and OSAS in Japanese patients is considered to be related to craniofacial morphology.6,7 Polysomnography (PSG) is the recommended method for assessing OSAS.8,9 The apnea-hypopnea index (AHI) is defined as the number of apnea and hypopnea events occurring per hour of sleep. The diagnosis of OSAS is based on an AHI score of >5, which is often further subdivided into mild (5 ≤ AHI < 15), moderate (15 ≤ AHI < 30), and severe (AHI ≥ 30) OSAS.10,11

The patient in this case report presented with a retrusive maxilla and sleep apnea disorder (AHI = 15.3). A successful outcome was achieved by performing a Le Fort I osteotomy advancement. An alar cinch suture combined with an ACVY was performed to minimize nasolabial deformities.

Diagnosis and Etiology

The patient was a 23-year-old man with total crossbite without any previous orthodontic treatment. The patient's chief complaint was an unsatisfactory facial profile and difficulty in chewing with the anterior teeth. Additionally, the patient suffered from snoring and sleep disorders. No other family members had a history of malocclusion. Pretreatment facial photographs showed a concave profile and retruded upper lip relative to the E-line (upper lip: −7.0 mm, lower lip: −3.0 mm; Figure 1). The maxillary midline deviated 4.0 mm to the left relative to the facial midline, while the mandibular midline deviated 1.0 mm to the right relative to the facial midline. Chin deviation of 1.0 mm to the right was also evident. The patient had a Class III molar relationship on both sides (Figure 2), a 0-mm overbite, and a 0-mm overjet. The apnea hypopnea index (AHI) was 15.3 (above the upper limit of the normal range = 5).12–14

Figure 1. . Pretreatment facial and intraoral photographs.Figure 1. . Pretreatment facial and intraoral photographs.Figure 1. . Pretreatment facial and intraoral photographs.
Figure 1 Pretreatment facial and intraoral photographs.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 2. . Pretreatment dental cast.Figure 2. . Pretreatment dental cast.Figure 2. . Pretreatment dental cast.
Figure 2 Pretreatment dental cast.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Lateral and anteroposterior cephalometric radiographs and a panoramic radiograph were obtained prior to treatment (Figure 3). All four second premolars were congenitally missing. The cephalometric analysis (Table 1) and tracing (Figure 4) demonstrated a Class III skeletal relationship (ANB = −2.6°), primarily due to a retrusive maxilla. The SNA angle was 74.6°, and the SNB angle was 77.1°. Nasion was located anteriorly and superiorly to the Japanese standard (Figure 4). The angle between the maxillary incisors and the SN plane was 102.9°, the angle between the lower incisors and the mandibular plane was 74.9°, and the interincisal angle was 136.5°. Based on these findings, the patient was diagnosed with skeletal Class III (retruded maxilla) with OSAS.

Figure 3. . Pretreatment lateral and posteroanterior cephalometric and panoramic radiographs.Figure 3. . Pretreatment lateral and posteroanterior cephalometric and panoramic radiographs.Figure 3. . Pretreatment lateral and posteroanterior cephalometric and panoramic radiographs.
Figure 3 Pretreatment lateral and posteroanterior cephalometric and panoramic radiographs.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Table 1 Changes in Cephalometric Variablesa
Table 1
Figure 4. . Superimposed cephalometric tracing of the patient on the standard for Japanese adult males.Figure 4. . Superimposed cephalometric tracing of the patient on the standard for Japanese adult males.Figure 4. . Superimposed cephalometric tracing of the patient on the standard for Japanese adult males.
Figure 4 Superimposed cephalometric tracing of the patient on the standard for Japanese adult males.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Treatment Objectives

The treatment objectives for this patient were to (1) correct the concave facial profile and provide relief from OSAS (reflecting the patient's chief complaints); (2) correct the total crossbite; (3) establish Class I molar and canine relationships; (4) correct the shifted midline; and (5) obtain ideal occlusion with an appropriate overbite and overjet.

Treatment Alternatives

In general, bimaxillary maxillo-mandibular advancement is recommended as the first treatment option from the respiration perspective. However, from an esthetic point of view, mandibular advancement was not suitable, as shown in Figure 4. The patient refused genioplasty.

Treatment Progress

Preadjusted edgewise appliances with a 0.018 × 0.025-inch slot (Dentsply-Sankin, Tokyo, Japan) were bonded to the bilateral maxillary lateral segments and to the mandibular teeth; 0.016 × 0.022-inch Improved superelastic nickel-titanium wires (ISWs; L&H, Tomy International Inc, Tokyo, Japan) and 0.016-inch nickel-titanium (Ni-Ti) alloy wires (Sentalloy blue, Tomy International Inc) were used for levelling. The maxillary third molars were extracted bilaterally.

A Le Fort I osteotomy was performed to improve the anterior-posterior and transverse deficiency, which was fixed with titanium mini-plates. Because the FMA was high, it was possible to perform surgical superior repositioning of the maxilla with counterclockwise mandibular autorotation. However, since the OSAS was recognized, the maxilla was moved forward in a parallel direction so as not to narrow the nasal cavity. The treatment team selected the ACVY technique (Figure 5). The alar cinch suture was performed through an intraoral incision using a 4-0 nylon suture passing through the fibromuscular tissue of the alar base from anterior to posterior, on both sides. The mucosa was closed with a 4-0 nylon suture. ISWs (0.018 × 0.025-inch) were used for detailing. After 3 years of edgewise appliance treatment (2 years after surgery), a circumferential-type retainer was placed in the maxilla, and a Hawley-type retainer was placed in the mandible. Patient compliance was excellent throughout the treatment. At the completion of treatment, the AHI score was 2.8 (within the normal range) (Figure 6). Bite force changed from 446 N to 610.3 N.

Figure 5. . (A) Alar cinch suture. (B) muco-musculo-periosteal V-Y closure.Figure 5. . (A) Alar cinch suture. (B) muco-musculo-periosteal V-Y closure.Figure 5. . (A) Alar cinch suture. (B) muco-musculo-periosteal V-Y closure.
Figure 5 (A) Alar cinch suture. (B) muco-musculo-periosteal V-Y closure.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 6. . Polysomnography (PSG) raw data (pre- and postorthodontic treatment).Figure 6. . Polysomnography (PSG) raw data (pre- and postorthodontic treatment).Figure 6. . Polysomnography (PSG) raw data (pre- and postorthodontic treatment).
Figure 6 Polysomnography (PSG) raw data (pre- and postorthodontic treatment).

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Treatment Results

After surgical orthodontic treatment, the patient's facial profile improved and an acceptable interincisal relationship was obtained. The protrusive mandible and crowding, which were the patient's chief complaints, were resolved. The dental midlines were aligned with the facial midline (Figure 7). The occlusal relationships improved, and a Class I canine and molar relationship was established, along with ideal overbite and overjet relationships (Figure 8). The posttreatment cephalometric and panoramic radiographs are shown in Figure 9. Posttreatment cephalometric analysis is shown in Table 1.

Figure 7. . Posttreatment facial and intraoral photographs.Figure 7. . Posttreatment facial and intraoral photographs.Figure 7. . Posttreatment facial and intraoral photographs.
Figure 7 Posttreatment facial and intraoral photographs.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 8. . Posttreatment dental cast.Figure 8. . Posttreatment dental cast.Figure 8. . Posttreatment dental cast.
Figure 8 Posttreatment dental cast.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 9. . Posttreatment lateral and posteroanterior cephalometric and panoramic radiographs.Figure 9. . Posttreatment lateral and posteroanterior cephalometric and panoramic radiographs.Figure 9. . Posttreatment lateral and posteroanterior cephalometric and panoramic radiographs.
Figure 9 Posttreatment lateral and posteroanterior cephalometric and panoramic radiographs.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Superimposition of the radiographs taken before and after treatment (Figure 10) showed that PNS advanced 4.0 mm after treatment. The mandibular central incisor was extruded 2.0 mm. Facial esthetics improved, with decreased upper lip protrusion; the height of nose tip increased by 1.0 mm because of the nasal alar cinch suture (E-line: upper lip: −3.0 mm; lower lip: 0 mm). Posttreatment occlusion stability was observed for 2 years (Figures 11 through 14); the occlusion was acceptable from the end of treatment. In this case, the nasal alar base width changed from 37.5 mm to 38.5 mm. Alar cinch sutures are often applied to prevent nasal widening associated with the Le Fort I osteotomy. The patient was able to sleep well.

Figure 10. . Superimposed tracings of the pretreatment (black line) and posttreatment (red line) cephalometric radiographs.Figure 10. . Superimposed tracings of the pretreatment (black line) and posttreatment (red line) cephalometric radiographs.Figure 10. . Superimposed tracings of the pretreatment (black line) and posttreatment (red line) cephalometric radiographs.
Figure 10 Superimposed tracings of the pretreatment (black line) and posttreatment (red line) cephalometric radiographs.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 11. . Facial and intraoral photographs at 2-year retention.Figure 11. . Facial and intraoral photographs at 2-year retention.Figure 11. . Facial and intraoral photographs at 2-year retention.
Figure 11 Facial and intraoral photographs at 2-year retention.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 12. . Dental cast at 2-year retention.Figure 12. . Dental cast at 2-year retention.Figure 12. . Dental cast at 2-year retention.
Figure 12 Dental cast at 2-year retention.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 13. . Lateral and posteroanterior cephalometric and panoramic radiographs at 1-year retention.Figure 13. . Lateral and posteroanterior cephalometric and panoramic radiographs at 1-year retention.Figure 13. . Lateral and posteroanterior cephalometric and panoramic radiographs at 1-year retention.
Figure 13 Lateral and posteroanterior cephalometric and panoramic radiographs at 1-year retention.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

Figure 14. . Superimposed tracings of the posttreatment (red line) and 1-year postretention (green line) cephalometric radiographs.Figure 14. . Superimposed tracings of the posttreatment (red line) and 1-year postretention (green line) cephalometric radiographs.Figure 14. . Superimposed tracings of the posttreatment (red line) and 1-year postretention (green line) cephalometric radiographs.
Figure 14 Superimposed tracings of the posttreatment (red line) and 1-year postretention (green line) cephalometric radiographs.

Citation: The Angle Orthodontist 89, 6; 10.2319/052818-406.1

DISCUSSION

Although the patient's facial profile was concave, according to the cephalometric analysis, the SNA angle was less than normal, while the SNB angle was within normal range. Additionally, although the patient was thin (body mass index was 18.6), the initial AHI was 15.3 and the diagnosis was moderate OSAS. A previous study15 suggested that mandibular retropositioning of more than 5 mm can significantly reduce the posterior airway space and cause mild to moderate OSAS. In this case, it was thought that the retrusive maxilla was one of the primary causes of the patient's OSAS. Therefore, a single Le Fort I advancement was planned, and the AHI dramatically improved.

Although an airway collapse can occur during rapid eye movement (REM) and non–REM sleep, obstructive episodes are more severe during REM sleep, when the upper airway tone is reduced, similar to the characteristic atonia of the posture muscles.16 The patient's AHI-REM/AHI–non-REM ratio was 3.9 (greater than the normal range). In this case, the maxilla was advanced by 4.5 mm and the pharyngeal area increased by 4 mm. Both REM and non–REM-AHI improved (REM-AHI: 35.3 to 7.3; non–REM-AHI: 9.1 to 1.6). The arousal index (number of arousals per hour) also improved (from 19 to 14.2). Oxygen saturation (SaO2) (97%) was constant (SaO2: 91 to 90) (Figure 6). Therefore, this surgical technique increased the nasopharyngeal airway space and improved the patient's sleep.

There is little consensus regarding large Le Fort I advancement stability and retention. Previous studies17 reported that Le Fort I maxillary osteotomies with an advancement of 1 cm or more (average = 14 mm, range = 10–22 mm) were safe and stable. In this case, an advancement of approximately 4.5 mm was performed at PNS, and the relapse was 0.5 mm at PNS. Therefore, this outcome supports the previous studies.

Another risk associated with a Le Fort I osteotomy is nasal deformity and associated loss of vermillion show of the upper lip.3,18 Many orthodontists misconstrue that the nasolabial soft tissue deformity results from the amount or direction of maxillary movement. However, Le Fort I osteotomies result in widening of the alar base, regardless of anterior or posterior movement of the maxillary bone.1 When the periosteum is lifted from the maxilla, the muscles get detached from their insertions, causing immediate retraction of the regional muscles. This is the major cause of nasal deformities, especially widening of the alar base, after Le Fort I osteotomy. Retraction of these muscles also results in flattening and thinning of the upper lips.3 A previous study investigating the effect of ACVY closure on the soft tissue after Le Fort I osteotomy concluded that a Le Fort I osteotomy with ACVY reduced undesirable outcomes.4 In this case, the alar base changed from 37.5 mm to 38.5 mm, while the upper lip and nasolabial soft tissue dynamics did not change.

A previous study reported that neurosensory deficits were a common complication after orthognathic surgery.19–23 To check for neurosensation in the current patient, the team assessed skin perception at three points with von Frey hairs (0.008–100 g, TOUCH TEST, North Coast Medical Inc, Morgan Hill, Calif): the top of the vermillion border of the upper lip and the zygomatic area. The skin perception completely recovered within 2 months, and the skin nociception recovered within 6 months. However, the patient complained that the perception of the gingiva was dull, although it resolved within a year.

The indication for single Le Fort I advancement is small canting of the mandibular plane and a symmetric mandibular arch. Therefore, severe mandible deviation is not an indication for single-jaw Le Fort I advancement. In this case, the maxillary arch wire was bent to fit the mandibular arch; therefore, the skewed Ni-Ti arch wire was bent and torqued to fit the mandibular arch.

CONCLUSION

  • In this report, the successful treatment of a skeletal Class III patient with OSAS (maxillary deficiency) by Le Fort I osteotomy advancement combined with ACVY is described. Treatment improved the patient's facial profile and the OSAS. Le Fort I osteotomy with ACVY could minimize nasal deformity.

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Copyright: © 2019 by The EH Angle Education and Research Foundation, Inc.
<bold>Figure 1</bold>
Figure 1

Pretreatment facial and intraoral photographs.

<bold>Figure 2</bold>
Figure 2

Pretreatment dental cast.

<bold>Figure 3</bold>
Figure 3

Pretreatment lateral and posteroanterior cephalometric and panoramic radiographs.

<bold>Figure 4</bold>
Figure 4

Superimposed cephalometric tracing of the patient on the standard for Japanese adult males.

<bold>Figure 5</bold>
Figure 5

(A) Alar cinch suture. (B) muco-musculo-periosteal V-Y closure.

<bold>Figure 6</bold>
Figure 6

Polysomnography (PSG) raw data (pre- and postorthodontic treatment).

<bold>Figure 7</bold>
Figure 7

Posttreatment facial and intraoral photographs.

<bold>Figure 8</bold>
Figure 8

Posttreatment dental cast.

<bold>Figure 9</bold>
Figure 9

Posttreatment lateral and posteroanterior cephalometric and panoramic radiographs.

<bold>Figure 10</bold>
Figure 10

Superimposed tracings of the pretreatment (black line) and posttreatment (red line) cephalometric radiographs.

<bold>Figure 11</bold>
Figure 11

Facial and intraoral photographs at 2-year retention.

<bold>Figure 12</bold>
Figure 12

Dental cast at 2-year retention.

<bold>Figure 13</bold>
Figure 13

Lateral and posteroanterior cephalometric and panoramic radiographs at 1-year retention.

<bold>Figure 14</bold>
Figure 14

Superimposed tracings of the posttreatment (red line) and 1-year postretention (green line) cephalometric radiographs.

Contributor Notes

Corresponding author: Dr Takayoshi Ishida, Orthodontic Sciences, Department of Orofacial Development and Function, Division of Oral Health Sciences, Graduate School, Tokyo Medical Dental University, Tokyo, Japan (e-mail: takaorts@tmd.ac.jp)
Received: 01 May 2018
Accepted: 01 Nov 2018
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