Accepted Manuscript

Impact on the upper airway space of different types of orthognathic surgery for the
correction of skeletal class III malocclusion: A systematic review and meta-analysis

Jinlong He, Yunji Wang, Hongtao Hu, Liao Qian, Weiyi Zhang, Xuerong Xiang,
Xiaoping Fan

PII: S1743-9191(16)31198-0
DOI: 10.1016/j.ijsu.2016.12.033
Reference: IJSU 3331

To appear in: International Journal of Surgery

Received Date: 24 August 2016

Revised Date: 9 November 2016
Accepted Date: 18 December 2016

Please cite this article as: He J, Wang Y, Hu H, Qian L, Zhang W, Xiang X, Fan X, Impact on the
upper airway space of different types of orthognathic surgery for the correction of skeletal class III
malocclusion: A systematic review and meta-analysis, International Journal of Surgery (2017), doi:
10.1016/j.ijsu.2016.12.033.

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 ACCEPTED MANUSCRIPT

Impact on the upper airway space of different types of orthognathic

surgery for the correction of skeletal class III malocclusion: A

systematic review and meta-analysis

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Jinlong He1, Yunji Wang1, Hongtao Hu, Liao Qian, Weiyi Zhang, Xuerong Xiang*, Xiaoping Fan*

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College of Stomatology, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory for Oral Diseases and

Biomedical Sciences, Chongqing, China; Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education,

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Chongqing, China

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1 These authors contributed equally to this work.

* Corresponding author. 426#Songshibei Road, Yubei District, Chongqing 401147, China

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Email: fanxp666@163.com(FXP); cqzxfxp@sina.com(XXR)

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Impact on the upper airway space of different types of orthognathic

surgery for the correction of skeletal class III malocclusion: A

systematic review and meta-analysis

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Abstract
Objective

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This study is aimed at assembling, through a systematic review and meta-analysis, scientific evidence

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related to the effects of mandibular setback (MdS) surgery and bimaxillary surgery for the correction of

Class III malocclusion on the cross-sectional area (CSA) and volume of the upper airway as assessed

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using CT.

Methods
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An electronic search was conducted on Cochrane Library, EMBASE, PubMed, Scopus and Web of

Science up to June 20, 2016. The inclusion criteria were prospective or retrospective studies, with the
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aim of comparing the impact on the upper airway space of orthognathic surgery for the treatment of

the skeletal class III malocclusion. The methodological index for non-randomized studies (MINORS)
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was chosen as the evaluation instrument and Revman5.3 was used for the meta-analysis.
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Results
A total of 1213 studies were retrieved, of which only 18 met the eligibility criteria. The results of
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meta-analysis showed that the mean decrease in the upper airway volume after MdS surgery was 3.24

cm3 [95%CI (-5.25,-1.23), p =0.85]; the mean decrease in minimum CSA after a combined surgery of
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maxillary advancement with mandibular setback (MdS+MxA) was 27.66 mm2 [95%CI (-52.81,-2.51), p
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=0.51], but there was no significant decrease in upper airway volume (mean 0.86 cm3); comparison

between MdS+MxA and isolated MdS showed significant differences in the CSA of the posterior nasal

spine plane (PNS) and epiglottis plane (EP); statistically significant differences in nasopharynx volume

(P<0.0001) and upper airway total volume (P=0.002) were observed, but no statistically meaningful

variations existed in oropharynx volume (P=0.08) and hypopharynx volume (P=0.64).

Conclusion
The results of this study suggest that bimaxillary surgery promotes less decrease on the upper airway

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than mandibular setback surgery alone for the correction of the skeletal class III malocclusion.

Introduction
Skeletal class III malocclusion is common in clinical cases [1-3], In the 1920s surgery began to be

used for the treatment of skeletal class III malocclusion, and by the 1960s maxillary LeFort I

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osteotomy had become the treatment of choice, because it was more effective than mandibular

setback in terms of improving patients’ alignment of jaws and their overall facial symmetry [4].

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Malocclusion problems may reoccur after surgery due to the traction of soft tissues and muscle

forces produced during function, therefore, in the 1970s orthodontic treatment was combined

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with orthognathic surgery to correct malocclusion, stable and desirable effects were achieved [5].

Currently, combined orthodontic and orthognathic surgical therapy has proved the most

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effective for the treatment of skeletal class III malocclusion when it comes to enhancing function
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and aesthetics. Skeletal changes caused by the surgery, however, can alter the positions and

traction of the surrounding soft tissues, tongue, soft palate, hyoid bone and muscles, and can
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change airway volume and the size of oral and nasal cavities [6-9]. According to most previous

studies [10-12], mandibular setback surgery may affect the relationship between the soft and
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skeletal tissues, subsequent increase in upper airway resistance and decrease in upper airway

space. Besides, bimaxillary surgical caused a smaller decrease in airway space compared to
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mandibular setback surgery. On the other hand, some studies [13-15] concluded that bimaxillary

orthognathic surgery for the correction of Class III malocclusion resulted in increased total airway
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volume. Therefore, changes in the upper airway space resulting from different types of

orthognathic surgery still remain controversial.

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Moreover, no meta-analysis that compares changes in the airway dimensions resulting from
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different types of orthognathic surgery for the correction of skeletal class III malocclusion

exclusively using 3D examination has been documented in the literature. Three previous

systematic reviews [2, 16, 17] have investigated based on data from two-dimensional images，as

some articles using three dimensional images were not comparable, didn't perform meta analysis.

Therefore, the present meta-analysis focused only on studies that used CT airway evaluation,

particularly cone beam CT (CBCT). This study is aimed at assembling, through a meta-analysis,

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scientific evidence related to the effects of MdS and bimaxillary surgery for the correction of Class

III malocclusion on the CSA and volume of the upper airway as assessed using 3D examination so

as to inform treatment planning for patients suffering skeletal class III malocclusion.

Materials and methods

1 Inclusion criteria and exclusion criteria

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The inclusion criteria were developed according to the PICOS criteria (Table 1). Exclusion criteria

were as follows: (1) Research type: animal studies, case reports, studies that did not provide the

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data needed to conduct meta-analysis; (2) Research object: patients with cleft palate, pharyngeal

airway dysfunction, wounds, burns or temporomandibular joint disorders, the syndrome of

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obstructive sleep apnea; (3) Intervention: orthognathic surgery combined with other surgeries,

such as genioplasty, maxillary impaction.

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Table 1. PICOS criteria for the systematic review.
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Population (P) Patients with a prognathic mandible and class III malocclusion who had undergone mandible
setback or bimaxillary surgery; age 15–50 years
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Intervention (I) Mandibular setback surgery (IVRO or BSSO), or bimaxillary surgery

Comparison (C) Between the different orthognathic surgeries or comparison between pre-surgery and
post-surgery parameters
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Outcome (O) Changes of the upper airway (three CSA parameters: PNS-CSA, SP-CSA and EP-CSA ; four
volume parameters :nasopharynx volume, oropharynx volume, hypopharynx volume, and
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upper airway total volume)

Study design (S) Prospective or retrospective studies with the aim of comparing upper airway space changes of
different surgical procedures or pre-surgery and post-surgery parameters for the prognathic
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mandible
Question What are the effects of different orthognathic surgeries for the correction of the prognathic
mandible on the dimensions of the upper airways assessed using CT?
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IVRO，intraoral vertical ramus osteotomy; BSSO, bilateral sagittal split osteotomy.

2 Literature search strategy

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This systematic review and meta-analysis were conducted following the statement of PRISMA [18]

(Preferred Reporting Items for Systematic Reviews and Meta-Analyses). An electronic search in

Cochrane Library, EMBASE, PubMed, Scopus and Web of Science, until June 20, 2016. An

additional manual search of references in the included studies was also conducted. We used the

search terms combination [“Malocclusion, Angle Class III” OR “mandible” OR “maxilla” OR

“Orthognathic Surgery” AND (“Pharynx” OR “Nasopharynx” OR “Hypopharynx” OR

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“Oropharynx”)].

3 Data extraction
An initial screening through titles and abstracts was conducted independently by two reviewers

(HJL, WYJ), who then cross-checked and reviewed the text in full to decide whether they were

eligible. Disagreements were resolved through discussion, when necessary, by seeking the

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opinion of a third reviewer. The following data were extracted from the studies included in the

final analysis: title, author, year of publication, study design, age and gender of research objects,

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sample size, surgical procedure, evaluation parameters and other statistical data.

4 Quality assessment of the included studies

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Prospective or retrospective studies reporting on the upper airway space change upon

orthognathic surgery were selected. Quality of included studies were assessed using MINORS[19],

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which is tailored to quality evaluation of non-randomized controlled studies and is comprised of
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twelve items, with each item scored from 0 to 2. So the total score is 24. On the basis of other

researchers, 0-12 showed high risk of bias, 13 to 18 for moderate risk of bias, and 19-24 for low risk
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of bias. Quality of included studies were assessed independently by two reviewers in accordance

to MINORS and a conclusion was reached after disagreements were resolved through discussion.
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5 Statistical analysis
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Extracted data were statistically analyzed using Review Manager 5.3. All available data extracted

from the included studies were continuous variables, mean and standardized mean difference
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(SMD) or weighted mean difference (WMD) with a 95% confidence interval was used to estimate

treatment effect. Cochrane’s test (I2 statistic) was used to evaluate heterogeneity. Low
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heterogeneity (P>0.10, I2<50%) means fixed-effects model should be employed to conduct the
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meta-analysis. If heterogeneity was substantial (P≤0.10, I2 ≥50%), then random-effects model was

adopted. The statistical significance for the testing of hypotheses was set at p<0.05. Funnel plots

were used to detect publication bias and a symmetrical plot indicated low risk publication bias.

Fig 1. Study selection flow diagram.

Results
1 Characteristics of the included studies
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A total of 1213 studies were retrieved independently by the two reviewers following the

previously defined search strategy. We examined 20 studies that had been identified for inclusion

in our meta-analysis. After the full articles were retrieved, we excluded two studies for not

presenting the difference in pre- and post-surgery volumes in absolute values. At last, only 18

studies [11-15, 20-32] met all eligibility criteria. Fig 1 shows the process of selecting studies for

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meta-analysis. The included studies were published from 2008 to 2016; the mean age of patients in

each study was approximate. In the 18 included studies, eight showed a low risk of bias, while the

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rest exhibited a moderate risk of bias. The results of essential features and methodological quality

assessment are listed in Table 2.

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Table 2. Essential features and methodological quality of the included studies.

Author & year Type of No. and Age Type of Comparison Measurements Quality

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study sex (years) surgery Area (CSA) Volume score

Azevêdo et al.(2016)[20] R 9M 5F 17-40y MdS+MxA Before-after Min CSA Total 14

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Burkhard et al.(2014)[13] R 3M 8F 26y MdS+MxA Before-after -- Total 13
Degerliyurt et al.(2008)[32] R 13M 34F 23.3y MdS MdS+MxA SP,EP -- 19
Jakobsone et al.(2010)[15] P 8M 6F 20.3y MdS+MxA Before-after RP,OP,HP NP,OP,HP,Total 15
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Gokce SM et al.(2014)[14] R 25M 21.6y MdS+MxA Before-after RP,OP,HP total 15

Hatab et al.(2015)[24] P 9M 11F 21.7y MdS MdS+MxA PNS,SP,EP,Min NP,OP,HP,Total 20
Hong et al.(2011)[11] R 14M 7F 26.6y MdS MdS+MxA PNS,SP,EP Total 19
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Hart PS et al.(2015)[25] R 31M 40F 18.8y MdS+MxA Before-after Min CSA NP,OP,Total 14
Hsieh YJ et al.(2015)[23] R 18M 54F 24.0y MdS+MxA Before-after Min CSA NP,OP,HP,Total 19
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Kim HS et al.(2015)[22] P 16M 22F 23.84y MdS+MxA Before-after Min CSA Total 15
Kim MA et al.(2014)[26] R 14M 11F 23.72y MdS+MxA Before-after -- NP,OP,HP,Total 14
Kim NR et al.(2010)[27] R 12M 8F 21.53y MdS Before-after -- NP,OP,HP,Total 13
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Li YM et al.(2014)[28] R 29F 23.6y MdS+MxA Before-after PNS,SP,EP NP,OP,Total 19

Park JW et al.(2010)[29] R 5M 7F 25.5y MdS Before-after PNS NP,OP,Total 14
Park SB et al.(2012)[30] R 23M 13F 22.97y MdS MxA+ MdS PNS,SP,EP NP,OP,HP,Total 20
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Uesugi T et al.(2014)[12] P 21M 19F 23y MdS MxA+MdS PNS,SP,EP NP, OP, total 19
Wang HW et al.(2015)[21] P 13M 15F 19.17y MdS Before-after -- NP,OP,HP,Total 15
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Zhang R et al.(2011)[31] P 19M 22F 23.4y MdS MxA+MdS PNS,SP,EP NP,OP,HP,Total 20

Abbreviations: R: retrospective study; P: Prospective study; M: male; F: female; y: years; MdS: mandibular setback; MxA:

maxillary advancement; Before-after: comparison between pre-surgery and post-surgery parameters; Min CSA: minimum

cross-sectional area; PNS: posterior nasal spine; SP, soft palate; EP: epiglottis plane; NP: nasopharynx volume; OP:

oropharynx volume; HP: hypopharynx volume.

2 MdS surgery
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The included studies showed that there was a statistically significant decrease in the upper airway

volume after MdS surgery. Eight studies enrolling a total of 134 patients assessed the changes in

upper airway volume after MdS surgery (Fig 2). The mean decrease was 3.24 cm3 [95%CI

(-5.25,-1.23), p =0.85], and heterogeneity test among those studies showed homogeneity (x2 = 3.41,

df = 7, P = 0.85; I2 = 0%).

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Fig 2. Forest plot: mandibular setback surgery, upper airway total volume.

3 MdS+MxA and CSA

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In the MdS+MxA surgery comparison group, five studies enrolling a total of 134 patients assessed

the changes in minimum CSA, with the mean decrease in minimum CSA being 27.66 mm2 [95%CI

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(-52.81,-2.51), p =0.03]. Heterogeneity test among studies showed homogeneity (x2 = 3.29, df = 4, P

= 0.51; I2 = 0%); 14 studies enrolling a total of 307 patients evaluated the changes in upper airway

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total volume, showing there was no significant decrease (mean -0.86 mm3) [95%CI (-2.19,-0.47), p
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=0.21].The test of heterogeneity among studies showed homogeneity (x2 =12.59, df =13, P =0.48; I2

= 0%),as is shown in Fig 3.

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Fig 3. Forest plot: mandibular setback surgery, minimum CSA and upper airway total volume.

4 Differences in CSA between MdS group and MdS+MxA group

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Fixed-effects model, as is shown in Fig 4, was chosen for the comparison between MdS group and

MdS+MxA group because of the low heterogeneity (I2 from 0% to 9%). Three CSA parameters
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were evaluated: PNS-CSA (SMD=-0.59, 95%CI=-0.97–-0.22, P=0.002), SP-CSA (SMD=-0.28,

95%CI=-0.57–0.00, P=0.05) and EP-CSA (SMD=-0.46, 95%CI=-0.75–-0.17, P=0.002). These results

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showed that, compared to isolated mandibular setback surgery, MdS+MxA caused smaller

changes in the CSA of PNS and EP, whereas no significant differences existed in SP-CSA changes
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between these two surgical procedures for the treatment of skeletal class III malocclusion.
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Fig 4. Forest plot: one-jaw surgery versus two-jaw surgery, PNS-CSA, SP-CSA, EP-CSA.

5 Differences in upper airway volume between MdS group and MdS+MxA group
Due to low heterogeneity (I2 from 0% to 16%), fixed-effects model was chosen for this

meta-analysis to compare the impact on the upper airway space between MdS group and

MdS+MxA group, as is shown in Fig 5. The above-mentioned four parameters were assessed:

nasopharynx volume (WMD=-1.4, 95%CI=-2.10–-0.71, P<0.0001), oropharynx volume

(WMD=-0.99, 95%CI=-2.09–0.12, P=0.08), hypopharynx volume (WMD= -0.38, 95%CI=-1.95–1.20,

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P=0.64) and upper airway total volume (WMD=-3.41, 95%CI=-5.59–-1.24, P= 0.002). There were

no markedly differential in statistics in the oropharynx volume and hypopharynx volume

between the two groups, but statistically significant differences in nasopharynx volume and

upper airway total volume were observed.

Fig 5. Forest plot: one-jaw surgery versus two-jaw surgery, Nasopharynx Volume, Oropharynx Volume, Hypopharynx

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Volume, Upper airway total Volume.

6 Publication bias

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A funnel plot was used to assess the publication bias of the literature. Symmetrical graphical

funnel plots were obtained from all included studies (Fig 6).

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Fig 6. Graphical funnel plots of the included studies. These symmetrical plots indicate the absence of publication bias in the

present meta-analysis.

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Discussion
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Surgeons and orthodontists have been showing a growing interest in the upper airways, because

they constitute the anatomical structures that can greatly influence people’s health and quality of
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life. This interest is generated by the direct relationship between the upper airways and the

syndrome of obstructive sleep apnea (OSA) [33-35]. Changes in the upper airway resulting from
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different types of orthognathic surgery still remain contested, with some studies reporting no

changes, while others showing a decrease in upper airway volume, in addition, these previous
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studies [36-40] analyzed data obtained from two dimensional cephalograms. In a previous

systematic review, the authors suggested that more studies needed to be conducted using CT to
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assess the effects of orthognathic surgery on the airways. Therefore, this systematic review is

carried out with the aim to verify the impact of MdS and MdS+MxA surgery on the upper
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airways, included only studies that used CT to evaluate airway dimensions.

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Two dimensional cephalograms cannot capture the three-dimensional structure of the airway

and its accuracy is usually undermined by image distortion. With progress in the imaging

techniques and computer technology, CT and cone beam CT (CBCT) have emerged as new

alternatives for developing the three-dimensional configuration of upper airway, and as a result,

the upper airway indicators can be accurately measured both horizontally and vertically [41-44],

however, the radiation doses of CT scans are generally higher than those for conventional dental

radiography, which must be one of the dentist's greatest concerns.

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We conducted meta-analysis to assess the effectiveness of two surgical procedures,

comparing before and after treatment. The results showed that: the mean decrease in upper

airway volume was 3.24 cm3 after MdS surgery; the mean decrease in minimum CSA was 27.66

mm2 after MdS+MxA surgery; but there was no significant decrease in the total volume of the

upper airway (mean 0.86 mm3). The result is in some aspects similar to the previous study [45],

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but major differences still exist. The comparison between MdS group and MdS+MxA group was

performed using three CSA parameters and four volume parameters. Results of the meta-analysis

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showed that: statistically important differences in PNS-CSA, EP-CSA, nasopharynx volume and

upper airway total volume were observed; whereas no significant differences existed in SP-CSA,

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oropharynx volume and hypopharynx volume changes between these two surgical procedures.

But, decrease in the nasopharynx volume and oropharynx volume is still observed after

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bimaxillary surgery for the correction of the skeletal class III malocclusion, especially when
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patients are predisposed to the development of breathing problems. Orthodontic and

orthognathic surgeons should assess preoperative and postoperative changes in the airway so as
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to prevent excessive airway stenosis and avoid the development of iatrogenic OSA.

Among the studies that were included in the meta-analysis, eight showed a low risk of bias,
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while the rest exhibited a moderate risk of bias; symmetrical graphical funnel plots were obtained

using data extracted from all included studies; sensitivity analysis by excluding individual study
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or changing the statistical model showed that the change of combined index was not significant.

All of these indicated the reliability of the results of the meta-analysis. But the present study also
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had certain limitations as follows: 1) randomized clinical trials represent the ideal study type for

meta-analysis. Surgical procedures cannot be randomized since the patients must receive the best
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treatment available to them, therefore, non-randomized clinical studies were selected in this study;
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2) the gender difference and the wide age range of the samples reduce the accuracy of the change

in the upper airway space caused by orthognathic surgery; 3) the sample size of included studies

was small and the total sample size of the meta-analysis is not big enough either. As a result,

inspection efficiency may be inadequate; 4) changes in the magnitude of surgical repositioning

among studies were not assessed; 5) to assess the upper airway, several software programs were

used to analyze digital imaging communications in medicine files for the included studies,

besides, different uses of software programs may impact the measurement results of upper
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airway space. Due to the constraints of the present meta-analysis, the conclusion still needs to be

verified and tested by future clinical trials of higher quality and larger size.

Conclusion
To sum up, this systematic review and meta-analysis indicated that the upper airway volume

decreases significantly after isolated MdS surgery, and the minimum CSA decreases significantly

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after bimaxillary surgery, while upper airway volume does not decrease significantly after

MdS+MxA surgery based on the 3D images, two-jaw surgery caused a smaller reduction in the

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PNS-CSA, EP-CSA, nasopharynx volume and upper airway total volume compared with one-jaw

surgery. Therefore, bimaxillary surgery promotes less decrease on the upper airway than

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mandibular setback surgery alone for the correction of the skeletal class III malocclusion.

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Ethical approval
Not relevant (Review article).
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Sources of funding
This research is funded by Chongqing Research Program of Basic Research and Frontier
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Technology (cstc2013jcyjA10010), and the Science Project of the health and family planning

commission of Chongqing (2015MSXM053).

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Author Contributions
Conceived and designed the experiments: FXP XXR. Performed the experiments: HJL WYJ.
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Analyzed the data: HJL HHT LQ. Contributed reagents/materials/analysis tools: FXP XXR.

Wrote the paper: HJL HHT. Study selection: HJL WYJ. Quality assessment: HJL WYJ FXP. Data
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extraction: HJL WYJ. Data analysis: HJL WYJ ZWY. Write and revise: HJL HHT.
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References
[1] M. Santagata, U. Tozzi, E. Lamart, G. Tartaro, Effect of Orthognathic Surgery on the Posterior
Airway Space in Patients Affected by Skeletal Class III Malocclusion. J Maxillofac Oral Surg. 14(3)(2015)
682-686.
[2] C.T. Mattos, G.N. Vilani, E.F. Sant'anna, A.C. Ruellas, L.C. Maia, Effects of orthognathic surgery on
oropharyngeal airway: a meta-analysis. Int J Oral Maxillofac Surg. 40(12)(2011) 1347-1356.
[3] Z. Wang, L. Zhu, L. Zhou, B. Yi, Feasibility of integrating 3D photos and cone-beam computed
tomography images used to evaluate changes of soft and hard tissue after orthognathic surgery.

9
 ACCEPTED MANUSCRIPT

Beijing da xue xue bao Yi xue ban= Journal of Peking University Health sciences. 48(3)(2016) 544.
[4] A. Cortese. Le Fort I Osteotomy for Maxillary Repositioning and Distraction Techniques: INTECH
Open Access Publisher(2012).
[5] E. Panou, M. Motro, M. Ates, A. Acar, N. Erverdi, Dimensional changes of maxillary sinuses and
pharyngeal airway in Class III patients undergoing bimaxillary orthognathic surgery. Angle Orthod.
83(5)(2013) 824-831.
[6] N.D.A. Qahtani, Impact of different orthodontic treatment modalities on Airway: A literature
review. Pak J Med Sci. 32(1)(2016) 249-252.

PT
[7] Y.Y. Jiang, Correlation between hyoid bone position and airway dimensions in Chinese adolescents
by cone beam computed tomography analysis. Int J Oral Maxillofac Surg. 45(7)(2016) 914-921.
[8] N. Ihan Hren, U. Barbič, Tongue volume in adults with skeletal Class III dentofacial deformities.

RI
Head Face Med. 12(2016).
[9] O.E. Becker, R.L. Avelar, J.G. Goelzer, N. Dolzan Ado, O.L. Haas, Jr., R.B. De Oliveira, Pharyngeal

SC
airway changes in Class III patients treated with double jaw orthognathic surgery--maxillary
advancement and mandibular setback. J Oral Maxillofac Surg. 70(11)(2012) 639-647.
[10] R. Foltan, J. Hoffmannova, F. Donev, M. Vlk, J. Sedy, R. Kufa, et al., The impact of Le Fort I
advancement and bilateral sagittal split osteotomy setback on ventilation during sleep. Int J Oral

U
Maxillofac Surg. 38(10)(2009) 1036-1040.
AN
[11] J.S. Hong, Y.H. Park, Y.J. Kim, S.M. Hong, K.M. Oh, Three-dimensional changes in pharyngeal
airway in skeletal class III patients undergoing orthognathic surgery. J Oral Maxillofac Surg.
69(11)(2011) 401-408.
[12] T. Uesugi, T. Kobayashi, D. Hasebe, R. Tanaka, M. Ike, C. Saito, Effects of orthognathic surgery on
M

pharyngeal airway and respiratory function during sleep in patients with mandibular prognathism. Int
J Oral Maxillofac Surg. 43(9)(2014) 1082-1090.
D

[13] J.P. Burkhard, A.D. Dietrich, C. Jacobsen, M. Roos, H.T. Lubbers, J.A. Obwegeser, Cephalometric
and three-dimensional assessment of the posterior airway space and imaging software reliability
TE

analysis before and after orthognathic surgery. J Craniomaxillofac Surg. 42(7)(2014) 1428-1436.
[14] S.M. Gokce, S. Gorgulu, H.S. Gokce, A.O. Bengi, U. Karacayli, F. Ors, Evaluation of pharyngeal
airway space changes after bimaxillary orthognathic surgery with a 3-dimensional simulation and
EP

modeling program. Am J Orthod Dentofacial Orthop. 146(4)(2014) 477-492.

[15] G. Jakobsone, L. Neimane, G. Krumina, Two-and three-dimensional evaluation of the upper
airway after bimaxillary correction of Class III malocclusion. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology, and Endodontology. 110(2)(2010) 234-242.
C

[16] L. Fernandez-Ferrer, J.M. Montiel-Company, T. Pinho, J.M. Almerich-Silla, C. Bellot-Arcis, Effects of

AC

mandibular setback surgery on upper airway dimensions and their influence on obstructive sleep
apnoea - a systematic review. J Craniomaxillofac Surg. 43(2)(2015) 248-253.
[17] E. Al-Moraissi, S. Al-Magaleh, R. Iskandar, E. Al-Hendi, Impact on the pharyngeal airway space of
different orthognathic procedures for the prognathic mandible. International journal of oral and
maxillofacial surgery. 44(9)(2015) 1110-1118.
[18] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, P. Group, Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. PLoS Med. 6 (7) (2009) e1000097.
[19] K. Slim, E. Nini, D. Forestier, F. Kwiatkowski, Y. Panis, J. Chipponi, Methodological index for
non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg.
73(9)(2003) 712-716.

10
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[20] M.S. Azevêdo, A.W. Machado, S. Barbosa Ida, L.S. Esteves, C. Rocha V , M.a.V. Bittencourt,
Evaluation of upper airways after bimaxillary orthognathic surgery in patients with skeletal Class III
pattern using cone-beam computed tomography. Dental Press J Orthod. 21(1)(2016) 34-41.
[21] H. Wang, S. Qi, M. Yan, C. Zhang, S. Ren, J. Zhang, [Cone-beam computed tomography evaluation
of upper airway change in skeletal Class III patients after orthodontic-mandibular setback surgery].
Zhonghua Kou Qiang Yi Xue Za Zhi. 50(10)(2015) 615-618.
[22] H.S. Kim, G.T. Kim, S. Kim, J.W. Lee, E.C. Kim, Y.D. Kwon, Three-dimensional evaluation of the
pharyngeal airway using cone-beam computed tomography following bimaxillary orthognathic surgery

PT
in skeletal class III patients. Clin Oral Investig. (2015).
[23] Y.J. Hsieh, Y.C. Chen, Y.A. Chen, Y.F. Liao, Y.R. Chen, Effect of bimaxillary rotational setback surgery
on upper airway structure in skeletal class III deformities. Plast Reconstr Surg. 135(2)(2015) 361-369.

RI
[24] N.A. Hatab, V.S. Konstantinovic, J.K. Mudrak, Pharyngeal airway changes after mono- and
bimaxillary surgery in skeletal class III patients: Cone-beam computed tomography evaluation. J

SC
Craniomaxillofac Surg. 43(4)(2015) 491-496.
[25] P.S. Hart, B.P. Mcintyre, O. Kadioglu, G.F. Currier, S.M. Sullivan, J. Li, et al., Postsurgical volumetric
airway changes in 2-jaw orthognathic surgery patients. Am J Orthod Dentofacial Orthop. 147(5)(2015)
536-546.

U
[26] M.A. Kim, B.R. Kim, J.K. Youn, Y.J. Kim, Y.H. Park, Head posture and pharyngeal airway volume
AN
changes after bimaxillary surgery for mandibular prognathism. J Craniomaxillofac Surg. 42(5)(2014)
531-535.
[27] N.-R. Kim, Y.-I. Kim, S.-B. Park, D.-S. Hwang, Three dimensional cone-beam CT study of upper
airway change after mandibular setback surgery for skeletal Class III malocclusion patients. Korean
M

Journal of Orthodontics/Daehan ci'gwa gyojeong haghoeji. 40(3)(2010).

[28] Y.M. Li, J.L. Liu, J.L. Zhao, J. Dai, L. Wang, J.W. Chen, Morphological changes in the pharyngeal
D

airway of female skeletal class III patients following bimaxillary surgery: a cone beam computed
tomography evaluation. Int J Oral Maxillofac Surg. 43(7)(2014) 862-867.
TE

[29] J.-W. Park, N.-K. Kim, J.-W. Kim, M.-J. Kim, Y.-I. Chang, Volumetric, planar, and linear analyses of
pharyngeal airway change on computed tomography and cephalometry after mandibular setback
surgery. American Journal of Orthodontics and Dentofacial Orthopedics. 138(3)(2010) 292-299.
EP

[30] S.B. Park, Y.I. Kim, W.S. Son, D.S. Hwang, B.H. Cho, Cone-beam computed tomography evaluation
of short- and long-term airway change and stability after orthognathic surgery in patients with Class III
skeletal deformities: bimaxillary surgery and mandibular setback surgery. Int J Oral Maxillofac Surg.
41(1)(2012) 87-93.
C

[31] R. Zhang. 3-dimensional morphological changes of pharyngeal airway after orthognathic surgery
AC

for patients with Skeletal Class III dentomaxillofacial deformity and its comparative study. Thesis,
Shanghai Jiaotong University,(2011). Available:http://d.wanfangdata.com.cn/Thesis/Y2525299.
[32] K. Degerliyurt, K. Ueki, Y. Hashiba, K. Marukawa, K. Nakagawa, E. Yamamoto, A comparative CT
evaluation of pharyngeal airway changes in class III patients receiving bimaxillary surgery or
mandibular setback surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 105(4)(2008) 495-502.
[33] D.M. Cui, D.M. Han, B. Nicolas, C.L. Hu, J. Wu, M.M. Su, Three-dimensional Evaluation of Nasal
Surgery in Patients with Obstructive Sleep Apnea. Chin Med J (Engl). 129(6)(2016) 651-656.
[34] R. Tabrizi, F. Pourdanesh, M. Soleimanpour, E. Shafie, Evaluation of Mandibular Wing Osteotomy
in Obstructive Sleep Apnea Cases with Retrognathia. J Maxillofac Oral Surg. 14(1)(2015) 46-50.
[35] K. Annapurna, S. Suganya, R. Vasanth, P.R. Kumar, Prosthodontic Approach to Treat Obstructive

11
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Sleep Apnea. Ann Med Health Sci Res. 4(4)(2014) 481-486.

[36] V.A. Pereira-Filho, L.M. Castro-Silva, M. De Moraes, M.F. Gabrielli, J.A. Campos, P. Juergens,
Cephalometric evaluation of pharyngeal airway space changes in class III patients undergoing
orthognathic surgery. J Oral Maxillofac Surg. 69(11)(2011) 409-415.
[37] R. Efendiyeva, H. Aydemir, H. Karasu, U. Toygar-Memikoglu, Pharyngeal airway space, hyoid bone
position, and head posture after bimaxillary orthognathic surgery in Class III patients: long-term
evaluation. Angle Orthod. 84(5)(2014) 773-781.
[38] F. Chen, K. Terada, Y. Hua, I. Saito, Effects of bimaxillary surgery and mandibular setback surgery

PT
on pharyngeal airway measurements in patients with Class III skeletal deformities. Am J Orthod
Dentofacial Orthop. 131(3)(2007) 372-377.
[39] S. Hwang, C.J. Chung, Y.J. Choi, J.K. Huh, K.H. Kim, Changes of hyoid, tongue and pharyngeal

RI
airway after mandibular setback surgery by intraoral vertical ramus osteotomy. Angle Orthod.
80(2)(2010) 302-308.

SC
[40] H. Aydemir, U. Memikoglu, H. Karasu, Pharyngeal airway space, hyoid bone position and head
posture after orthognathic surgery in Class III patients. Angle Orthod. 82(6)(2012) 993-1000.
[41] L. Li, H. Liu, H. Cheng, Y. Han, C. Wang, Y. Chen, et al., CBCT evaluation of the upper airway
morphological changes in growing patients of class II division 1 malocclusion with mandibular

U
retrusion using twin block appliance: a comparative research. PLoS One. 9(4)(2014) e94378.
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[42] G. Di Carlo, A. Polimeni, B. Melsen, P.M. Cattaneo, The relationship between upper airways and
craniofacial morphology studied in 3D. A CBCT study. Orthod Craniofac Res. 18(1)(2015) 1-11.
[43] A. Weissheimer, L.M. Menezes, L. Koerich, J. Pham, L.H.S. Cevidanes, Fast three-dimensional
superimposition of cone beam computed tomography for orthopaedics and orthognathic surgery
M

evaluation. Int J Oral Maxillofac Surg. 44(9)(2015) 1188-1196.

[44] Y.S.N. Jayaratne, R.A. Zwahlen, The Oropharyngeal Airway in Young Adults with Skeletal Class II
D

and Class III Deformities: A 3-D Morphometric Analysis. PLoS One. 11(2)(2016).
[45] I.O. Christovam, C.O. Lisboa, D.M. Ferreira, A.A. Cury-Saramago, C.T. Mattos, Upper airway
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dimensions in patients undergoing orthognathic surgery: a systematic review and meta-analysis. Int J
Oral Maxillofac Surg. 45(4)(2016) 460-471.
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Highlights:

the upper airway volume decreases significantly after isolated MdS surgery and

the minimum CSA decreases significantly after bimaxillary surgery, upper airway

volume does not decrease significantly after MdS+MxA surgery based on the 3D

images.

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two-jaw surgery caused a smaller reduction in the PNS-CSA, EP-CSA,

nasopharynx volume and upper airway total volume compared with one-jaw surgery.

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bimaxillary surgery promotes less decrease on the upper airway than mandibular

setback surgery alone for the correction of the skeletal class III malocclusion.

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