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BRIEF CLINICAL STUDIES
Evaluation of Sinonasal Change
After Lefort I Osteotomy Using
Cone Beam Computed
Tomography Images
Seung Woo Baeg, DDS, Yun Pyo Hong, DDS,
Dong Hyun Cho, DDS, Jeong Keun Lee, DDS, PhD,
and Seung Il Song, DDS, PhD
Abstract: Orthognathic surgery including Le Fort I osteotomy
involves changes in the nasal septum and maxillary sinus. This
study assesses nasal septum changes after Le Fort I osteotomy using
cone beam computed tomography images and evaluates mucosal
changes in the maxillary sinus after the surgery.
This was a retrospective study of 33 patients who underwent
orthognathic surgery including Le Fort I osteotomy. To assess the
maxillary sinus, changes in the mucosa of the maxillary sinus were
analyzed by volume and geometry. We measured the air cavity per
se and mucosal thickening of the maxillary sinus using SIMPLANT
(Materialise, Belgium) software. And the geometry of the distribu-
tion of the mucosa was analyzed using cone beam computed
tomography images.
The septal angle was decreased after surgery, but not signifi-
cantly (P > 0.05). The volume reduction of the air cavity per se and
the volume increase associated with mucosal thickening were
statistically significant (P < 0.05). Mucosal thickening was ob-
served in the posterior-inferior direction.
In this study, nasal septum deviation was not statistically
significant after Le Fort I osteotomy. Decrease of the air cavity
per se, decrease of the total volume of the maxillary sinus, and
increase of mucosal thickening were prominent. Furthermore, the
mucosal thickening that occurs after surgery appears to be mainly in
the posterior lower part of the maxillary sinus.
Key Words: Le fort, maxillary sinus, nasal septum, osteotomy
I n the realm of oral maxillofacial surgery, orthognathic surgery
including Le Fort I osteotomy has been performed to resolve
dentofacial deformities and to recover occlusal function. The
movement of the maxilla affects nasal structures, and various
complications have been reported.1,2 Le Fort I osteotomy was first
introduced in 1867 and was standardized by Bell in 1975. It is
widely used in oral and maxillofacial surgeries, such as orthog-
nathic surgery.3 Owing to the nature of the surgery, the maxillary
From the Department of Oral and Maxillofacial Surgery, Institute of Oral
Health Science, Ajou University School of Medicine, Suwon, Korea.
Received March 7, 2017.
Accepted for publication June 9, 2017.
Address correspondence and reprint requests to Seung Il Song, DDS, PhD,
Department of Oral and Maxillofacial Surgery, Institute of Oral Health
Science, Ajou University School of Medicine, 164, Worldcup-ro,
Yengto-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea;
E-mail: seungilsong@daum.net
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000004001
The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
sinus area is included in the osteotomy line, and the surgery may
also affect the nasal septum above the maxilla.
The nasal septum is made up of various components, especially
septal cartilage, the perpendicular plate of the ethmoid bone, and the
vomer, with different developmental origins.4 Structural problems
in the nasal septum are one of the most common conditions
encountered in otolaryngology. Therefore, many studies have been
done on patients with nasal obstructions; studies on the relationship
between septal deviation and the inferior turbinate are typical.5
There have been few studies on nasal septum deviation associ-
ated with Le Fort I osteotomy. Instead, examinations have focused
on insufficient resection of the septal cartilage during Le Fort I
osteotomy, nasotracheal intubation, and dislocation of the septal
cartilage by an incompletely deflated cuff during extubation.6,7
In Le Fort I osteotomy, the maxillary bone is completely separated
from the midface. The maxillary sinus is necessarily included in the
osteotomy line. Therefore, the physiology of the maxillary sinus may
be changed by the surgery. Sinusitis is a very common disease in the
United States; it usually refers to maxillary sinusitis, which affects
16% of the population annually.8 There have been many reports that
maxillary sinusitis can occur after surgery.9,10 Pereira-Filho et al11
reported the incidence of maxillary sinusitis after Le Fort I osteotomy
as 4.76%. Nevertheless, evaluation of the maxillary sinus before and
after surgery is not generally done. The published studies on the
maxillary sinus mainly report on, in this order of frequency, postop-
erative complications, treatment, and the causal relationship between
surgery and complications.1,11–13
In the area of dentistry, computerized tomography (CT) is
becoming an essential tool for diagnosis. Especially, cone beam
computed tomography (CBCT) has advantages such as lower doses
of radiation, higher resolution, and lower price than existing multi-
slice CT protocol.14 In addition, plain-film photographs such as
orthopantomograph and cephalogram have provided excellent in-
formation for diagnosis. But there is a limitation that only 2-
dimensional information can be obtained. Especially, diagnostic
interpretations of maxillary sinus and nasal septum are usually
complex because various anatomic structures are superimposed.15
In a variety of areas of dental care, Harris et al14 published the
guidelines of CBCT for diagnostic imaging and described various
considerations including sinus lift and computer-assisted planning.
The purpose of this study is to quantitatively evaluate the
changes of nasal septum and maxillary sinus using CBCT. And
the usefulness of CBCT has been supported through various
published studies. Lana et al16 described the anatomic variation
including maxillary sinus septa and the lesion of the maxillary sinus
represented by mucosal thickening. Smith et al17 reported the
prevalence of concha bullosa and septal deviation using CBCT,
and also studied the relationship between the septal deviation and
maxillary sinusitis. The maxillary sinusitis is an inflammatory
change that occurs in the maxillary sinus mucosa and can be
classified as odontogenic or nonodontogenic depending on the
origin. The diagnosis of maxillary sinusitis is important not only
for clinical symptoms such as facial pain and posterior nasal drip but
also for radiological evaluation.18–20 As in this study, CBCT has
been a good tool for evaluation of maxillary sinus after the surgery
such as sinus elevation and Le Fort I osteotomy.13,21,22
In addition to the septal deviation and sinusitis described above,
various types of complications associated with maxillary sinus anato-
my may occur. Preoperative diagnostic images can prevent complica-
tions associated with maxillary sinus anatomy such as underwood
septa and alveolar antral artery. Various studies have reported that
CBCT is an important tool for preoperative evaluation.23–25
The purpose of this study is to predict postoperative complica-
tions related to the nasal septum and to observe changes in the
maxillary sinus to identify potential problems during the follow-up
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Brief Clinical Studies The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017

TABLE 1. Demographic Data of the Study Subjects TABLE 3. Summary of Maxillary Movement in Each Patient

Patient Characteristics n Patient Number Characteristics of Maxillary Movement

Cases (n) 33 #1 Advance 5 mm, right 5 mm up and left 4 mm up

Sex #2 Right 3 mm up and left 3 mm up
Male 17 #3 Total impaction 5 mm
Female 16 #4 Left 3 mm up
Mean age, y 24.1 #5 Advance 6 mm
Mean follow-up CT interval, mo 5.1 #6 Advance 5 mm
#7 Advance 5 mm
CT indicates computed tomography. #8 Advance 4 mm
#9 Right 7 mm up and left 4 mm up
#10 Right 4 mm up and left 4 mm up
#11 ANS 2 mm up, right 7 mm up and left 5 mm up
period. This study may provide insight into changes in the nasal #12 Right 6 mm up and left 4 mm up
septum and maxillary sinus using CBCT that are associated with Le #13 Right 5 mm up, total setback 2 mm
Fort I osteotomy. In addition, anticipation of the side effects of the #14 ANS 3 mm up, right 6 mm up and left 6 mm up
surgery will help to establish a proper surgical plan to prevent #15 Right 5 mm up and left 2 mm up
the complications. #16 Right 5 mm up and left 2 mm up
#17 Left 3 mm up
#18 Total impaction 3 mm and 5 mm side shift to the left
MATERIALS AND METHODS #19 Advance 5 mm, right 5 mm up and left 5 mm up
The subjects of this study consisted of patients who visited the #20 Advance 5 mm, right 3 mm up and left 3 mm up
Department of Oral and Maxillofacial Surgery at Ajou University #21 Right 6 mm up, left 6 mm up, total setback 4 mm
Hospital (South Korea) between September 2009 and June 2016 and #22 Right 5 mm up and left 5 mm up
had orthognathic surgery including Le Fort I Osteotomy. All #23 Right 5 mm up and left 2 mm up
patients had a treatment plan established at the orthognathic con- #24 Right 5 mm up and left 2 mm up
ference. The type of surgical procedure to be used in Le Fort I #25 Right 6 mm up and left 6 mm up
osteotomy was determined according to the treatment plan. Le Fort #26 Right 3 mm up and left 5 mm up
I osteotomy was performed as usual. To prevent nasal septum #27 Right 5 mm up
deviation after surgery, the nasal septal cartilage, vomer, and lateral #28 Right 5 mm up and left 5 mm up
wall of the nasal cavity were carefully separated from the maxilla #29 Advance 5 mm, right 5 mm up and left 5 mm up
with fine osteotomes. By down-fracturing the maxilla, the septum #30 Right 6 mm up and left 4 mm up
and the floor of the nose were exposed and then the septal cartilage #31 Right 6 mm up and left 6 mm up
was resected with heavy scissors. All patients underwent fixation #32 Right 5 mm up and left 4 mm up
with L-shaped titanium plates and screws. Intermaxillary fixation #33 Right 5 mm up and left 5 mm up
by wire was maintained for at least 2 weeks. Patients with
both preoperative and postoperative CBCT images available were ANS indicates anterior nasal spine.
included in this study. Demographic data on the patients are shown
in Table 1.
For statistical analysis, the patients were divided according to movement of the maxilla was the same on the left and right sides.
the extent and characteristics of maxillary movement after Le Fort I Fourth, patients were divided into a total impaction group and a no
osteotomy. First, patients were divided into impaction groups: total impaction group. Patient grouping and the characteristics of
impaction >5 mm or <4 mm based on the maxillary first molar. maxillary movement are shown in Tables 2 and 3.
Second, patients were divided into a horizontal movement group Preoperative and follow-up CBCT images in the coronal view
and a no horizontal movement group. Patients in whom the maxilla were used to measure changes in septal angle before and after Le
were transversally moved, such as anterior-posteriorly or laterally Fort I Osteotomy. The septal angle was calculated in coronal
for midline correction, were classified into the horizontal movement computed tomography images at the same ostiomeatal unit level.
group. Third, patients were divided into a symmetrical movement The base of the crista galli was used as the vertex. The other 2 points
group and a no symmetrical movement group. Patients were measured were the most protruded septal mucosa and the palatal
classified into the symmetrical movement group when the suture (Fig. 1A). This method was highly reproducible. Two

TABLE 2. Patient Groups According to the Extent and Characteristics of Maxillary Movement After Le Fort I Osteotomy
More than 5 mm impaction group Less than 4 mm impaction group
#1, #3, #9, #11, #12, #13, #14, #15, #16, #19, #21, #22, #23, #24, #25, #26, #2, #4, #5, #6, #7, #8, #10, #17, #18, #20
#27, #28, #29, #30, #31, #32, #33
Horizontal movement group No horizontal movement group
#1, #5, #6, #7, #8, #13, #18, #19, #20, #21, #29, #32, #33 #2, #3, #4, #9, #10, #11, #12, #14, #15, #16, #17, #22, #23, #24,
#25, #26, #27, #28, #30, #31
Asymmetry movement group Symmetry movement group
#1, #9, #11, #12, #13, #15, #16, #17, #23, #24, #26, #27, #30, #32 #2, #3, #4, #5, #6, #7, #8, #10, #14, #18, #19, #20, #21, #22, #25, #28, #29, #31, #33
Total impaction group No total impaction group
#3, #11, #14, #18 #1, #2, #4, #5, #6, #7, #8, #9, #10, #12, #13, #15, #16, #17, #19, #20,
#21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32

2 # 2017 Mutaz B. Habal, MD

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
FIGURE 1. (A) The mean preoperative septal angle was 10.65 degree. (B) The
mean postoperative septal angle was 10.13 degree. The decrease was not
statistically significant. (C) Select the desired regions on the CBCT coronal
images with the appropriate Hounsfield unts. (D) Reconstruced 3D image of the
air cavity per se. (E) Reconstruced 3D image of mucosal thickening. (F) 3D
reconstructed images of the air cavity per se and the mucosal thickening. The
decrease of the volume of the air cavity per se and the increase of the volume of
mucosal thickening were significant. (G) Analysis method of vertical and
posterior-anterior distribution of mucosal thickening. (H) Analysis method of
lateral-mesial distribution of mucosal thickening. (I) Plane geometrical
distribution of the mucosal thickening after the surgery in the vertical and
posterior-anterior directions and (J) in the lateral-mesial direction. (K) Illustration
of mucosal thickening after Le Fort I osteotomy. Mucosal thickening was
observed mainly in the floor and the posterior lower part of the maxillary sinus.
CBCT indicates cone beam computed tomography; Lat., the direction of the
lateral wall of the maxillary sinus; Mes., the direction of the medial wall of the
maxillary sinus; Posterior-anterior, the posterior nasal spine direction and the
anterior nasal spine direction, respectively; Vertical, the top-to-bottom direction
of the maxillary sinus.
different examiners took measurements using the same points and
the average value was defined as the septal angle.
Changes in the maxillary sinus before and after Le Fort I
osteotomy were analyzed by volume and geometry.
For volumetric analysis, the data were analyzed using the
SIMPLANT (Materialise, Belgium) software program. In a user-
defined area, the tool for selecting only the pixels (Fig. 1C) within a
preset range of Hounsfield units (HU) (minimum, 1024; maxi-
mum, 600) was used to select the pixels regarded as the maxillary
sinus on all coronal and axial images, the selected pixels were
remodeled into 3-dimensional images, and, finally, the volume was
calculated. We measured the air cavity per se and mucosal thick-
ening of the maxillary sinus. Different HUs were used for the 2
measurements. The air cavity was selected as 1024 to 250 HU.
The mucosa was selected as 250 to 300 HU. A 3-dimensional
image was reconstructed and the volume was calculated (Figs. 1D
and 1E). Two different examiners calculated and mean values,
which were used to reduce error.
For plane geometric analysis of mucosal thickening in the
maxillary sinus, the distribution of mucosal thickening in the
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
maxillary sinus was divided into vertical, posterior-anterior (P-
A), and lateral-mesial (L-M). Vertical indicates the top-to-bottom
direction, and the length was divided into 3 equal parts (Fig. 1G).
For example, if the mucosal thickening was located only in the
lower third of the sinus, 1 point was assigned to the one-third area,
and if the mucous was distributed from the lower third to the upper
third, 3 points were given to each one-third (1 point per site). The P-
A aspect of the sagittal CBCT image indicates the directions of the
posterior nasal spine and the anterior nasal spine, respectively.
Again, the length was divided into 3 equal parts (Fig. 1G). For
example, if the mucosal thickening was located only in one-third of
the sinus closest to the posterior nasal spine, 1 point was assigned to
that one-third. And, if the mucous was spread all the way from the
posterior nasal spine to the anterior nasal spine, 3 points were given,
1 to each one-third of the sinus. L-M refers to the direction of the
lateral and medial wall of the maxillary sinus (Fig. 1H). For
example, if the mucosal thickening was distributed only in the
one-third containing the lateral wall of the maxillary sinus or in the
one-third containing the medial wall of the maxillary sinus, 1 point
was given to the appropriate one-third of the sinus. And, if the
mucosal change was located from the lateral wall to the medial wall
of the maxillary sinus, 3 points were given, 1 to each one-third of the
sinus. The scores were summed and displayed in a plane. This
method was used to analyze the location of the mucosal thickening
or mucous retention in the maxillary sinus after Le Fort I osteotomy.
The t test, Mann-Whitney U test, and Kruskal-Wallis test were
used to assess statistical differences. All the statistical analyses were
done using Predictive Analytics SoftWare (PASW) version 22.0
(SPSS Inc, Chicago, IL)
RESULTS
Changes of the Septal Angle
With the septal angle measurement method used in this study, a
decrease in septal angle after surgery indicates a decrease in septal
deviation and an increase in septal angle indicates an increase in
septal deviation after surgery (Figs. 1A and 1B).
Septal angle increased in 10 patients after surgery, and the mean
value was 1.42. There were 23 patients with decreased septal angle
after surgery, with an average value of 1.47. The mean preoperative
septal angle was 10.65 degree and the mean postoperative septal angle
was 10.13 degree. The mean septal angle decreased after surgery, but
the decrease was not statistically significant (Table 4). Also, there was
no statistically significant difference in the postoperative changes in
septal angle according to the extent of maxillary movement or the
characteristics of that movement (Table 5).
Changes of the Maxillary Sinus—Volumetric
Analysis
With respect to the changes of the maxillary sinus, the volume
reduction of the air cavity per se and the volume increase of the
mucosal thickening were statistically different before and after the
TABLE 4. Changes in Septal Angle
N Max. (degree) Min. (degree) Mean (degree)
Increased 10 4.19 0.12 1.42
Decreased 23 4.38 0.16 1.47
P ¼ 0.135
Max indicates maximum; min, minimum; op, operation. Pre op mean septal angle:
10.65 degree, post op mean septal angle: 10.13 degree.

t Test.
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TABLE 5. Change in Septal Angle According to Groups

Group N Pre Op (degree) Post Op (degree) Mean Decrease (degree) P

Impaction group 0.315

More than 5 mm impaction group 23 10.7 10.0 0.7
Less than 4 mm impaction group 10 10.7 10.4 0.3
Horizontal movement group 0.397
Horizontal movement group 13 10.2 9.9 0.3
No horizontal movement group 20 10.9 10.3 0.6
Total impaction group 0.424
Total impaction group 4 7.9 7.7 0.2
No total impaction group 29 11.0 10.5 0.5
Symmetry movement group 0.771
Symmetry movement group 14 10.4 9.8 0.6
No symmetry movement group 19 11.0 10.6 0.4

Op indicates operation.

Mann-Whitney U test.

surgery (Table 6). The increase in the amount of mucosal thickening Geometric Analysis of the Mucosal Thickening
was not significant when classified according to the amount and By analyzing plane geometry (Figs. 1I and 1J), we found that
characteristics of the maxilla (Table 7). mucosal thickening was observed in the posterior-inferior direction
In addition, the total volume of the maxillary sinus was statisti- in the vertical and P-A analyses and there was an even distribution
cally significantly reduced after the surgery (Table 8). The volume in the L-M analysis (Table 11). The mucosal thickening was
changes of the air cavity per se and the mucosal thickening are observed mainly in the floor and the posterior lower part of the
shown in Figure 1F. maxillary sinus once the mucosal thickening was established
(Fig. 1K).
Prevalence of the Mucosal Thickening
Mucosal thickening in the maxillary sinus is present around
about 82% of the screws used for plate fixation, and mucosal
TABLE 8. Volumetric Measurements of the Maxillary Sinus
thickening around the wall of the maxillary sinus is present in
about 85% of all maxillary sinuses after surgery (Table 9). The Maxillary Sinus (Mean) Volume (mm3)
difference between groups was not significant when the increase in
mucosal thickening was compared according to the time of the Pre Op 20,512
follow-up CBCT taken after surgery (Table 10). Post Op 17,560
P ¼ 0.001

TABLE 6. Volumetric Measurements of the Maxillary Sinus Op indicates operation.


t Test.
Volume (mm3) Ratio (%)

Air cavity per se (mean)

Pre Op 19,851 96.7 TABLE 9. Distribution of Mucosal Thickening
Post Op 15,206 85.6
P ¼ 0.002 Yes No
Mucosal thickening (mean)
Mucosal intervention through screws, n (%) 54 (82%) 12 (18%)
Pre Op 661 3.3
Mucosal thickening around maxillary sinus
Post Op 2354 14.4
Pre Op, n (%) 16 (24%) 50 (76%)
P ¼ 0.003
Post Op, n (%) 56 (85%) 10 (15%)
Op indicates operation.
 Op indicates operation.
t Test.

TABLE 7. Volumetric Measurements of Mucosal Thickening According to TABLE 10. Volumetric Measurements of Mucosal Thickening According to
Group Follow-up Period
Increasing of Mucosal Thickening (Mean) P Mucosal Thickening (Mean) FU 2 MC FU 3–6 MC FU 7–15 MC

Impaction group 0.532 Sinus (n) 34 28 14
Horizontal movement group 0.838 P ¼ 0.548
Symmetry movement group 0.223
FU indicates follow-up; MC, monthly check.
 
Mann-Whitney U test. Kruskal-Wallis test.

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The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017
TABLE 11. Location of Mucosal Thickening
Post Op Mucosal Thickening Distribution Points (%)
Vertical
1/3 36 (54.5%)
1/3–2/3 6 (9.0%)
1/3–1 6 (9.0%)
Posterior-anterior
1/3 23 (34.8%)
1/3–2/3 2 (3.0%)
1/3–1 23 (34.8%)
Lateral-mesial
1/3 3 (4.5%)
1 2 (4.3%)
1/3–2/3 7 (10.5%)
1/3–1 34 (52.1%)
Op indicates operation.
DISCUSSION
This study quantitatively analyzed the changes of nasal septum and
maxillary sinus after Le Fort I osteotomy. Nasal septum including
the nasal mucosa can be easily identified after a down fracture of Le
Fort I osteotomy,6 so that it is possible to prevent possible com-
plications. Postoperative nose deformity may be affected by several
factors. First, if the concomitant resection of the septal cartilage is
insufficient, the nasal contour may appear asymmetric or distorted6.
The second consideration is the periosteum and muscle dissected
for Le Fort I osteotomy. Changes in the appearance of the nose
including the alar base may occur. Alar cinch suture is often used to
prevent this kind of deformation.6,26 And a possible reason for a
cartilaginous septum deviation after Le Fort I osteotomy is dislo-
cation by a partially deflated cuff during extubation.26 Some authors
have reported the usefulness of submental intubation in orthog-
nathic surgery because accurate assessment of maxillary canting,
midline discrepancy, and especially the contour of the nasolabial
complex is difficult with conventional endotracheal intubation.27,28
The possible deformations of the nasal septum after Le Fort I
osteotomy are well documented in some literature. However, as far
as author knows, few studies have evaluated whether Le Fort I
osteotomy affects nasal septum. Kramer et al1 published a study on
complications after Le Fort I osteotomy. Of 1000 cases, 2.6% were
associated with anatomical changes, and the nasal septum
accounted for the highest percentage of those changes. Shin
et al7 published a case series discussing successful correction of
nasal septum deviation owing to complications after Le Fort I
osteotomy. In this study, we evlauated the septal angle in coronal
computed tomography images at the same ostiomeatal unit level
before and after Le Fort I osteotomy. The change in septal deviation
before and after the surgery was not statistically significant. Moroi
et al29 evaluated changes in the nasal septum after Le Fort I
osteotomy. Similar results as the ones in this study were presented,
but there was a limitation regarding the lack of reproducibility of the
measurements. In addition, the cut on the evaluated computed
tomography does not necessarily include the ostiomeatal unit, so
an absence of the physiological characteristics of the maxillary
sinus is observed.
The normal maxillary sinus has mucociliary action. Therefore,
secretions are released into the ostium. Moses et al12 suggested a
‘‘fall back phenomenon’’ in the maxillary sinus after Le Fort I
osteotomy. This is caused by the formation of a shelf, or plica, in the
maxillary sinus after surgery, which limits the movement of the
natural discharge.
# 2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
The present study and the previously published studies exam-
ined changes in the clinical symptoms of the maxillary sinus after
surgery, and various methods for evaluating clinical symptoms have
already been introduced.11,13,22 Methods for evaluating these clini-
cal symptoms include the rhinosinusitis outcome measure-31 ques-
tionnaire, visual analogue scale, and sinonasal outcome-20
questionnaire. The results of the changes in clinical symptoms as
determined using the abovementioned methods were different.
Pereira-Filho et al11 reported only 1 case of acute sinusitis in a
6-month follow-up, representing a 4.76% incidence of sinusitis, as
evidenced by endoscopic evaluation. There was no significant
difference between preoperative and postoperative clinical symp-
toms. Also, a study published by Valstar et al13 showed no
statistically significant differences in peak nasal inspiratory flow
before and after Le Fort I osteotomy. But Nocini et al22 reported that
an observed increase in sinonasal outcome scores after a mean
follow-up of 32.4 months was statistically significant. The authors
of the above-mentioned study explained that the reason for the lack
of clinical symptoms was that they did not have a longer follow-up
period (>1 year). In fact, Pereira-Filho’s follow-up period was 6 to
8 months, and Valstar’s follow-up period was 2 months. It seems
that the longer the duration of the follow-up period, the more
patients will report symptoms related to maxillary sinusitis.
Otherwise, the results of studies on changes to the maxillary
sinus as assessed by radiographs were similar. The present study
and others have shown that postoperative mucosal change or
mucosal thickening is always present regardless of the duration
of the follow-up period.13
Toskala and Rautiainen30 evaluated maxillary sinus mucosa by
Scanning Electron Microscopy and Transmission Electron Micros-
copy TEM after sinus surgery. That study showed that pathologic
conditions remained up to 6 months postoperatively, suggesting that
the recovery of the maxillary sinus after surgery may be slow and
the changes are sometimes irreversible. Our study showed that there
was no significant difference in the increase of mucosa according to
the length of the follow-up period.
Taken together, this study and previously published studies
suggest that changes in maxillary sinus after Le Fort I osteotomy
are inevitable. Clinical symptoms vary according to the length of
the follow-up period. Although maxillary sinusitis, which is char-
acterized by blockage of the ostium or purulent discharge, does not
necessarily occur after Le Fort I osteotomy, mucosal changes are
always present on radiological examinations.
After the Le Fort I osteotomy, changes in the maxillary sinus, as
represented by mucosal thickening, are inevitable, so oral and
maxillofacial surgeons should not miss the regular follow-up after
the operation and may need consultation with ENT if necessary.31 It
is essential to reduce iatrogenic damage to prevent postoperative
complications, so oral and maxillofacial surgeons should pay some
attentions to the anatomy of the maxillary sinus. The first is
consideration of the membrane of the maxillary sinus, and the
second is consideration of antral artery anastomosis.
If the extraction site of maxillary posterior molar is not restored
in a proper time following teeth extraction, the pneumatization of
the maxillary sinus is proceeded. In this case, residual bone height
of the maxillary molar region is shortened and sinus floor elevation
with bone graft is required for implant placement. When performing
sinus floor elevation, most studies have shown that sinus membrane
perforation does not significantly affect implant stability, but
sinusitis can occur.32– 35 In particular, the presence of septum in
the maxillary sinus increases the risk of perforation of the sinus
membrane, and some modified techniques are used in the sinus floor
elevation.36 This suggests that changes in the maxillary sinus may
be inevitable in Le Fort I osteotomy, which involves the entire sinus
membrane rather than simple perforation. This study was planned
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Brief Clinical Studies The Journal of Craniofacial Surgery
based on this idea, and the maxillary sinus membrane was changed
into the form of mucosal thickening by comparison of the preoper-
ative and postoperative CBCT images. CT images are considered
criterion standard for the diagnosis of maxillary sinusitis by elimi-
nating the superimposition of anatomical structures and providing
high-contrast resolution. Maxillary sinusitis is mainly observed as
thickening of the sinus membrane in CT images.37 It is clear that
mucosal thickening is associated with the pathologic change of the
maxillary sinus, but the reference point differs from literature to
literature. Mild mucosal thickening is often asymptomatic. Mucosal
thickening below the 2 mm was selected as a normal range in some
studies.31,38,39 Pereira-Filho et al11 reported 4.76% of maxillary
sinusitis after Le Fort I osteotomy, and Nocini et al22 reported 1.6%
to 15.6% of sinusitis after Le Fort I osteotomy according to
symptoms. In the present study, decrease of the air cavity per se,
decrease of the total volume of the maxillary sinus, and increase of
mucosal thickening were prominent. And the mucosal thickening
was observed mainly in the floor and the posterior lower part of the
maxillary sinus. In this study, postoperative mucosal thickening was
observed in 85% of patients who have mucosal thickening before
surgery and 15% of patients who did not have mucosal thickening
before surgery (Table 9). Despite the reduction of air cavity per se
and the presence of mucosal thickening, none of the patients had
been treated further with maxillary sinusitis. This may be because
the ostium patency of the maxillary sinus are well secured and the
normal physiology of the maxillary sinus is maintained.31,40
Vascular consideration during surgery associated with maxillary
sinus is essential because of various complications caused by
vascular injury. These complications include minor bleeding, he-
matoma formation in the maxillary sinus, maxillary sinusitis,
wound dehiscence, periodontal defect, and teeth devitalization.1,41
A complete knowledge of the arterial supply associated with the
procedures involving the maxillary sinus, such as sinus floor
elevation with bone graft21 and reconstructive surgery including
trauma42 is important for oral and maxillofacial surgeon. Wound
healing after the surgery associated with sinus membrane depends
on the blood supply of the affected area.24 When the alveolar antral
artery is injured during surgery, the possibility of tearing of the
sinus membrane increases, which in turn the possibility of mucosal
swelling and hematoma formation in the maxillary sinus is inevita-
ble. If this leads to a reduction in the ostium patency, it may increase
the likelihood of postoperative sinusitis.40,43 Although the major
bleeding problem that may occur after Le Fort I osteotomy is
derived from the descending palatine artery,1 bleeding owing to
injury of the alveolar antral artery may also occur during osteotomy
of the lateral wall of the maxillary sinus.25,41,42,44,45 Therefore,
information about the alveolar antral artery should be considered in
preoperative evaluation to prevent postoperative complications.
Alveolar antral artery is composed of intraosseous and extraosseous
anastomosis. And they form a double arterial arcade of maxillary
sinus. Rosano et al44 reported that 100% of intraosseous anastomo-
sis and 30% of extraosseous anastomosis in 30 sinuses from 15
human cadavers were examined in the cadaveric study. Hur et al45
performed a study of intraosseous anastomosis of posterior superior
alveolar artery using 42 hemi faces from human cadavers. The
distance from the tooth cervix or sinus floor to the intraosseous
anastomosis was measured. The minimum height from tooth cervix
to intraosseous anastomosis was 15.4 mm and the mean value was
21.1 mm. Jung et al24 analyzed the position and prevalence of
endoosseous anastomosis using CBCT. Endoosseous anastomosis
was observed in 52.8% of patients and the mean length was the
smallest at 14.79 mm from the alveolar crest to the vascular canal in
the first molar region. Rysz et al46 analyzed for arterial anastomosis
using CT scan. The arterial anastomosis was observed in 50% of
101 patients. The length from the cervix to the vascular canal was
6 #
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 00, Number 00, Month 2017
the smallest at 15.9 mm in the first molar region. In Le Fort I
osteotomy, a typical osteotomy line begins at the base of the
pyriform aperture and extends to the lateral wall of the maxillary
sinus. Considering the root of the maxillary first molar, the osteot-
omy line is approximately 15 mm above the maxillary first molar.
According to the above studies, the alveolar antral artery may be
damaged when sawing along the osteotomy line, and may lead to
severe bleeding depending on the diameter of the antral alveolar
artery.25,42,43 This requires cautions when performing Le Fort I
osteotomy as well as sinus floor elevation, and modified surgical
techniques may be needed through preoperative CBCT evalua-
tion.25,47 There was no case of complications owing to injury of the
alveolar antral artery in this study. However, CBCT evaluation
before the surgery will also allow the reduction of the risk of the
damage to the alveolar antral artery.
In conclusion, orthognathic surgery not only treats a patient’s
occlusion, but is also an aesthetic procedure accompanied by
changes in the patient’s facial appearance, including nasal changes.
Oral and maxillofacial surgeons should be aware of the complica-
tions associated with facial changes that may occur postoperatively
and learn surgical techniques to prevent them. In this study, nasal
septum deviation after Le Fort I osteotomy was not significantly
altered, but it should be avoided through concurrent cartilage
resection, septoplasty, and turbinectomy. Decrease of the air cavity
per se, decrease of the total volume of the maxillary sinus, and
increase of the mucosal thickening were significant. And the
mucosal thickening was observed mainly in the floor and the
posterior lower part of the maxillary sinus in this study. Orthog-
nathic surgery usually involves structural and functional changes to
the upper airway, but evaluation of the maxillary sinus before and
after surgery is not routinely performed. The present study and
others show that mucosal changes of the maxillary sinus are present
in radiological evaluations but are clinically asymptomatic. There-
fore, long-term follow-up of at least 6 months is needed. Also, oral
and maxillofacial surgeons should be aware of the clinical symp-
toms of maxillary sinusitis and cope with postoperative
complications appropriately.
The present study only analyzed maxillary septa and maxillary
sinus with 3-dimensional reconstructed images. And the absence of
clinical correlation between the investigation of the maxillary sinus
change using questionnaire development or endoscope equipment
and CBCT data was also limitation of this study. Future prospective
studies should be designed and evaluated to include the clinical
sinonasal data.
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