Is Le Fort I Osteotomy Associated With

Maxillary Sinusitis?
Pier Francesco Nocini, MD, DDS,* Antonio D’Agostino, MD,y Lorenzo Trevisiol, MD,y
Vittorio Favero, MD,z Mattia Pessina, MD,z and Pasquale Procacci, MDx
Purpose: The purpose of the present study was to investigate the association between Le Fort I osteot-
omy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus.
Materials and Methods: Subjects who had undergone Le Fort I osteotomy from January 2008 to
December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability
of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure.
The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthog-
nathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome
variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhi-
nosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statis-
tics were computed for each variable, and paired analyses were used to compare the pre- and
postoperative values.
Results: The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months,
range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had
moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest
of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was
statistically significant (P = .016). Radiologic evidence of postoperative inflammatory processes affecting
the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-
Mackay scores were significantly greater (P = .0005). A 19% decrease was found in the mean postoperative
sinus volume, with a 37% incidence of iatrogenic injury.
Conclusions: The study results indicate that Le Fort I osteotomies can have an important impact on sinus
health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the inci-
dence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that
CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring.
Larger long-term studies are warranted to clarify the postoperative outcomes and complications.
Ó 2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 74:400.e1-400.e12, 2016

The effect of orthognathic surgery on the anatomy and
function of the upper airways has been studied exten-
sively.1 It has been seen that both linear and rotational
movements induce changes to the soft tissues of the
pharynx and the oral cavity and can have a dramatic
impact on the upper airway space. Maxillomandibular
advancement has also proved to be a valid treatment
option for obstructive sleep apnea syndrome.2-10
Despite these considerations, the effect of Le Fort I
osteotomy on the anatomy and function of the
maxillary sinuses is still not routinely assessed pre-,
peri-, and postoperatively in patients who have
undergone orthognathic surgery. Although the
estimated prevalence of rhinosinusitis symptoms11

Received from Section of Oral and Maxillofacial Surgery, Department Ludovico Antonio Scuro, 10 Verona 37134, Italy; e-mail: lorenzo.
of Surgery, University of Verona, Verona, Italy. trevisiol@univr.it
*Professor and Chief. Received March 2 2015
yAssociate Professor. Accepted October 7 2015
zMaxillo-Facial Surgeon. Ó 2016 American Association of Oral and Maxillofacial Surgeons
xAssistant Professor. 0278-2391/15/01369-5
Address correspondence and reprint requests to Dr Trevisiol: http://dx.doi.org/10.1016/j.joms.2015.10.006
Section of Oral and Maxillofacial Surgery, Department of Surgery,
University of Verona, Policlinico ‘ Giovanni Battista Rossi,’’ Piazzale

400.e1
NOCINI ET AL
and variations in the paranasal sinuses are high, little is
known about the real effect they have on the outcomes
of orthognathic surgical procedures. This can be ex-
plained in part by the relatively low rate of complica-
tions reported during the immediate postoperative
period.12 Acute sinusitis, for example, is an uncom-
mon, although possible, complication after Le Fort I
osteotomy.13 Several surgery-related factors can in-
duce maxillary sinus pathologic features. In contrast,
although infrequent, surgery-induced modifications
of the anatomy and physiology of the maxillary sinuses
also play a role in the outcomes, and the complications
include delayed consolidation of the osteotomy, hard-
ware infections, and postoperative bleeding.14,15
We hypothesized that Le Fort I osteotomy could
have a substantial effect on maxillary sinus physiology,
especially with regard to iatrogenic alterations to the
normal anatomy that might persist after the proce-
dure. More specifically, we evaluated the pre- and post-
operative clinical and radiologic signs of rhinosinusitis
using cone beam computed tomography (CBCT) scans
and the Sino-Nasal Outcome 20-item Test (SNOT-20) in
a relatively large group of patients who had undergone
Le Fort I osteotomy.
Materials and Methods
STUDY DESIGN
A longitudinal retrospective study was designed to
investigate the anatomic, radiologic, and symptomatic
modifications involving the maxillary sinus after Le
Fort I osteotomy. An electronic data search of all pa-
tients who had undergone orthognathic surgery at
the Oral and Maxillofacial Surgery Section of the Uni-
versity Hospital of Verona from January 2008 to
December 2013 was performed. The predetermined
inclusion criteria were a Le Fort I osteotomy for the
first time from January 2008 to December 2013 and
the availability of a preoperative CBCT scan (taken us-
ing a NewTom 3G device; QR srl, Verona, Italy) and a
postoperative CBCT scan taken 12 to 24 months later.
The exclusion criteria were the lack of medical re-
cords, tobacco use, and the use of other previous or-
thognathic surgical procedures.
CBCT scans, which generate 3-dimensional (3D) im-
ages of dental structures, soft tissues, nerve paths, and
bone in the craniofacial region, were acquired with
the patient maintaining a natural head position. Scans
were taken with a single rotation of the device; the
dose uptake for each patient was approximately
59 mSv. The preoperative CT scan was performed
1 week before surgery. Only CT scans taken 12 to
24 months after surgery were considered acceptable
for the purposes of our study.
The type of surgical intervention (1-piece or multi-
segment Le Fort I osteotomy) planned depended on
400.e2
each patient’s specific deformity. All the patients un-
derwent fixation with titanium miniplates and wires.
All the procedures were performed by the same sur-
geons (A.D’A. and L.T.). The radiologic and clinical an-
alyses were performed by 2 of us (P.F.N., V.F.). The
ethics committee of the University Hospital of Verona
approved the study, and all patients gave written
informed consent agreeing to participate in the pre-
sent study.
STUDY VARIABLES
The primary predictor variable was time. The pa-
tients were evaluated preoperatively 1 week before
the procedure was performed and postoperatively
approximately 12 to 24 months later. The patients’
gender, age, and follow-up duration were registered.
The type of dentoskeletal deformity in each patient
and the type of Le Fort I osteotomy (1-piece or multi-
segment) planned and performed were recorded.
Regarding the volumetric analysis, the data sets
were processed using ‘‘Dolphin 3D’’ software, version
11.5 (Dolphin Imaging, Chatsworth, CA), a powerful
tool that facilitates 3D data processing. Boundary lines
were drawn surrounding the sinus cavity in the axial,
coronal, and sagittal views to measure the individual
volumes within the software program. Seed points
were then placed within the sinus cavities and bound-
aries until the entire sinus was included. The sinus vol-
ume was then generated by clicking the ‘‘Update
Volume’’ tab. The pre- and postoperative maxillary si-
nus volumes were determined (Figs 1 and 2). The soft-
ware allowed us to calculate the air volume inside the
sinus cavities or the residual space, excluding hyper-
trophic inflammatory mucosal thickening.
With regard to the morphologic alterations, each pa-
tient’s pre- and postoperative CBCT scans were
analyzed to detect and evaluate any anatomic defects
or surgery-induced alterations that could lead to para-
nasal homeostasis disruption (Figs 3 and 4). The anal-
ysis focused, in particular, on any interruption or
deviation of the septum, discontinuities in the sinus
walls, and protrusion of hardware into the sinuses.
The Lund-Mackay rhinologic staging scale (LMS), a
widely used system to assess paranasal sinus abnormal-
ities visible on CT scans, was used to grade the pa-
tients’ scans.16,17 The scale analyzes the severity of
mucosal thickening or fluid retention of each cavity
(ie, maxillary, frontal, sphenoid, anterior ethmoid,
and posterior ethmoid) and the ostiomeatal complex
(ie, 6 sites on each side). Each sinus is scored as
0 (no abnormality), 1 (partial opacification), or 2
(total opacification); the ostiomeatal complex is
scored as 0 or 2 (the presence or absence of disease,
respectively). The possible score range is 0 to 24
(Figs 5 and 6).
400.e3
FIGURE 1. Volumetric analysis, bidimensional view.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.
Preoperatively and approximately 1 year after sur-
gery, the patients also completed the SNOT-20
(Table 1). The SNOT-20, a validated patient-reported
measure of sinonasal conditions, is one of the most
widely adopted tools for evaluating a range of health
and quality-of-life variables linked to rhinosinusitis is-
sues.18 Each of its 20 items receives a score ranging
from 0 (no limitation) to 5 (extreme limitation). The
final overall score range is 0 to 100. Higher scores
represent worse symptoms and poorer quality of life;
lower scores represent less symptoms and better qual-
ity of life. A score of 0 to 10 indicates no or minimal
problems, a score of 11 to 40 indicates mild to moder-
ate issues, a score of 41 to 70 indicates moderate to se-
vere problems, and a score greater than 70 is
considered indicative of severe or critical conditions
necessitating the attention of a specialist for possible
surgical intervention.
OUTCOME VARIABLES
The main outcome variables were variations in the
maxillary sinus volume, alterations in morphologic fea-
tures consequent to surgery, and radiologic evidence
and/or symptoms or signs of rhinosinusitis.
LE FORT OSTEOTOMY AND MAXILLARY SINUSITIS
STATISTICAL ANALYSIS
MedCalc statistical software (MedCalc Software
bvba, Ostend, Belgium) was used for the statistical an-
alyses. The D’Agostino-Pearson normality test was
used to assess the normality of data regarding the sinus
volumes, and the Lund-Mackay scores were used to
assess chronic rhinosinusitis. A normal distribution
was found for the former, but not for the latter. The
paired sample t test was used to analyze the differ-
ences in sinus volumes. The independent samples t
test was used to evaluate the differences in volume var-
iations in the patients who had undergone 1-piece or
multisegment osteotomy. The Wilcoxon signed rank
test for dependent variables was used to assess the dif-
ferences between the pre- and postoperative Lund-
Mackay CT scores. The Mann-Whitney U test for inde-
pendent samples was used to evaluate the differences
in the postoperative LMS scores in the 2 patient groups
(1-piece vs multisegment osteotomy). In all cases, the
level of significance was set at P < .05. The Kaplan-
Meier survival analysis was performed to examine dif-
ferences in the prevalence of maxillary symptomatic
sinusitis (SNOT-20 score >20) between the 2 patient
groups during the follow-up period.
NOCINI ET AL
FIGURE 2. Volumetric analysis of sinus volume.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.
Results
Of the 243 patients who had undergone Le Fort I os-
teotomy from January 2008 to December 2013 at our
institution, only 64 met the study’s inclusion criteria.
Of the 243 patients, 36 were excluded because of
the use of tobacco, 12 were excluded because they
had undergone previous orthognathic surgical proce-
dures, and 131 were excluded because they did not
have pre- and/or postoperative CBCT scans available.
The patient age ranged from 17 to 47 years (mean
27.06; mode 19). Of the 64 patients, 38 (59%) were fe-
male and 26 (41%) were male, and 40 patients pre-
sented with Class III dentoskeletal deformities and
24 with Class II dentoskeletal deformities. Finally, 22
patients underwent 1-piece and 42 multisegment Le
Fort I osteotomy (Table 2). The mean follow-up dura-
tion was 32.4 months (range 13 to 66).
VOLUMETRIC ANALYSIS
The mean preoperative maxillary sinus volume was
16,947.14  5,973.44 mm3, and the mean postoperative
400.e4
value was 13,675.34  5,875.38 mm3. The mean differ-
ence was 3,271.80  4,806.24 mm3, corresponding to
19% of the initial volume. The difference proved to be
statistically significant (P < .0001).
Of the 22 patients who had undergone 1-piece Le
Fort I osteotomy, the mean preoperative value was
15,061.11  4,352.34 mm3, and the mean postoper-
ative value was 11,182.64  5,792.20 mm3, corre-
sponding to a mean volume decrease of 3,878.48
 5,289.10 mm3 (26% of the initial volume). The
difference proved to be statistically significant
(P < .0001). The mean preoperative value of the
42 patients who underwent multisegment Le Fort I
osteotomy was 17,935.06  6,473.83 mm3 and the
mean postoperative value was 14,981.05 
5,515.39 mm3. The volume decrease in this group
was 2,954.01  4,533.82 mm3 (16% of the initial vol-
ume; Fig 7). The difference was statistically signifi-
cant (P < .0001). The difference in sinus volume
variations between the 2 groups, analyzed using an
independent samples t test, was not statistically sig-
nificant (P = .4).
400.e5
FIGURE 3. Radiologic findings: postoperative computed tomography scan displaying interruption of the medial walls.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.
MORPHOLOGIC ANALYSIS
Several alterations of the nasal cavities and the para-
nasal sinuses were noted during the postoperative
radiological evaluation. An analysis of the postopera-
tive CBCT scans uncovered a loss of continuity of
the lateral nasal wall, causing an iatrogenic communi-
cation between the nasal cavity and maxillary sinus in
13 patients (20.3%). In addition, 6 patients (9.4%) had
incomplete healing of the nasal septum with osteocar-
tilaginous deficits. Also, 5 patients (7.8%) showed a
markedly deviated nasal septum not noted before sur-
gery. Hardware had passed through the bony walls
into the sinus cavity in all the patients.
RADIOLOGIC ANALYSIS
Coronal CT scans of patients’ sinuses were graded
using the LMS. At the preoperative evaluation, 4 pa-
tients presented with mucosal thickening in the bilat-
eral maxillary sinuses (LMS score of 1), and 2
presented with bilateral maxillary sinus opacification
(LMS score of 2). Postoperatively, 3 of the 4 patients
with mucosal thickening showed radiological
improvement; however, the fourth patient’s condition
LE FORT OSTEOTOMY AND MAXILLARY SINUSITIS
had worsened. The 2 patients with sinus opacification
also showed an improvement. Overall, 12 of the 64 pa-
tients showed postoperative evidence of sinus opacifi-
cation (3 bilateral and 9 monolateral), and 20 showed
postoperative mucosal thickening (Table 3). The post-
operative LMS scores were higher, and the difference
with respect to the preoperative scores was statisti-
cally significant (P = .0005).
The difference in the postoperative LMS scores of
the patients who had undergone 1-piece or multiseg-
ment Le Fort I osteotomy was analyzed using the
Mann-Whitney U test for independent samples; the
scores were greater for the former group (P = .035).
The 22 patients who had undergone 1-piece Le Fort I
osteotomy, 1 had presented with preoperative evi-
dence of sinusitis. At 1 year after surgery, that patient
had relevant, although incomplete, improvement
and only mild residual mucosal thickening. Also, 6 pa-
tients had presented preoperatively with sinusitis (3
bilateral and 3 unilateral). In these patients, the
improvement in the LMS score was significant
(P = .015).
Of the 42 patients who had undergone multisegment
Le Fort I osteotomy, 1 presented with preoperative total
NOCINI ET AL
FIGURE 4. Radiologic findings: postoperative computed tomography scan displaying discontinuity of the nasal septum.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.
sinus opacification, which had disappeared after sur-
gery. Although 6 patients had postoperative unilateral
sinusitis, none presented with postoperative bilateral
sinusitis. Also, the improvement in the LMS score was
statistically significant (P = .013).
CLINICAL ANALYSIS
Of the 64 patients, 62 had a preoperative SNOT-20
score of 0 to 10 and 2 had a score of 11 to 20
(Table 4). Thus, none of the patients needed to consult
with a specialist for rhinosinusitis before orthognathic
surgery. At 1 year after surgery, 53 patients had a score
less than 10 and 10 a score of 11 to 40 (ie, moderate
rhinosinusitis). One patient had a score of 67, indi-
cating a moderate to severe problem. Although not
experiencing severe symptoms (total SNOT-20 score
of 22), 1 patient reported occasional episodes of
‘‘airplane headache.’’ The increase in the SNOT-20
scores after surgery was statistically significant (P =
.016). The Kaplan-Meier (Table 5 and Fig 8) disease-
free survival rate was 55.9  19.1% in the 1-piece Le
Fort I group and 67.1  12.6% in the multisegment
Le Fort I group. The difference between the 2 groups
(P = .74) was not statistically significant.
400.e6
Discussion
Orthognathic surgery is one of the main subspe-
cialties of oral and maxillofacial surgery, and numerous
procedures are currently performed routinely world-
wide. Although diverse studies have assessed the
long-term clinical outcomes and complications linked
to this type of surgery,19-22 a paucity of material is
available concerning the anatomic and symptomatic
alterations of the nasal cavity and paranasal sinuses
implicated in orthognathic procedures. The present
study sought to examine the anatomic, symptomatic,
and radiologic alterations in the maxillary sinuses
after Le Fort I osteotomy.
Although the estimated prevalence of sinusitis in the
United States ranges from 2 to 16%, definitive diag-
nostic criteria for sinusitis remain transient and contro-
versial. Some have suggested that chronic rhinosinusitis
should be defined as the group of disorders character-
ized by inflammation of the mucosal lining of the nasal
passage and paranasal sinuses lasting at least 12 consec-
utive weeks. Signs of inflammation include nasal
drainage, nasal polyps, polypoid swelling, edema or er-
ythema of the middle meatus or CT findings of isolated
400.e7
FIGURE 5. Lund-Mackay computed tomography system showing a score of 1 and 0 for the right and left ostiomeatal complex.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.
or diffuse mucosal thickening, bone changes, and air-
fluid level. In addition, symptoms consistent with rhino-
sinusitis such as those outlined in the SNOT-20 ques-
tionnaire should also be considered to classify the
disease as symptomatic or asymptomatic.23
However, the data emerging from our study high-
light the high incidence of postoperative inflammatory
processes and iatrogenic alterations that were
frequently asymptomatic and could easily be misdiag-
nosed in patients undergoing the procedure. After or-
thognathic surgery, patients are normally monitored
to evaluate the occlusal plane and postoperative joint
stability. The CBCT scan allowed us to focus on the
traditional dentoskeletal factors and to analyze the ele-
ments that influence sinus homeostasis. When used
with appropriate precautionary measures, CBCT scan
was found to be a safe, reliable tool to postoperatively
monitor patients to detect the signs of rhinosinusitis
complications.
Of the 64 patients meeting the study’s inclusion
criteria, 40 presented with Class III and 24 with Class
LE FORT OSTEOTOMY AND MAXILLARY SINUSITIS
II dentoskeletal deformities. Twenty-two underwent
one-piece and 42 multisegment Le Fort I osteotomy.
An analysis of the patients’ data showed that most
registered a decrease in sinus volume. Of the 128 si-
nuses considered, only 17 (13.28%) showed an in-
crease in volume after surgery: 3 of these had total
sinus opacification and 3 had mucosal thickening.
Thus, the calculated volume corresponded to the min-
imal residual sinus cavity air volume. These conditions
improved after surgery, with an increase in the sinus
cavity air volume. Of the 122 healthy preoperative si-
nuses, 11 (9%) showed an actual increase in volume
and 111 (91%) a decrease in air volume. The mean
decrease corresponded to 27% of the preoperative vol-
ume. All the patients underwent upper jaw advance-
ment: 36 were impacted and 28 were lowered. The
decrease in sinus volume can be explained by the
advancement movements, leading to a modification
in the posterior maxillary sinus wall, with a resulting
alteration in the sinus cavity morphology. Impaction,
in addition to advancement, enhances the decrease
NOCINI ET AL
FIGURE 6. Lund-Mackay computed tomography system showing a score of 2 for the right and left ostiomeatal complex.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.
in sinus volume by lowering the overall height of the
sinus walls.
The morphologic evaluation detected iatrogenic al-
terations in a relevant percentage of the patients.
The most frequent iatrogenic alterations were septal
deviation or discontinuity, turbinate hypertrophy, dis-
continuities of the sinus wall, and hardware infections.
Although these alterations have often been misdiag-
nosed by clinicians, together with mucociliary clear-
ance and debridement of healthy inferior sinus
mucosa, they might play a role in the onset of rhinosi-
nusitis pathologic features. This possibility should be
considered when the surgeon is deciding which pro-
cedure will be most appropriate for a particular pa-
tient. Subspinal osteotomy and stabilization with
sutures should always be adopted, and both preopera-
tive septum deviations and those consequent to maxil-
lary impaction should be corrected by septoplasty.
Turbinoplasty can be considered in the event of tur-
binate hypertrophy or, once again, in the event of
400.e8
impaction. An exception should be made for bone
grafting or preoperative mucosal hypertrophy; in
such cases, the sinus mucosa should be preserved after
osteotomy. Even if the protrusion of hardware into the
sinus, detected in all the patients examined, is some-
what unavoidable, it does not seem to necessarily
trigger an onset of postoperative sinusitis. We believe
that short screws should be used to avoid a potential
contributing factor to sinus homeostasis disruption.
CBCT analysis made it possible for us to assess the
sinus opacities. The results showed that 2 patients
with preoperative sinusitis had entirely recovered
and presented with postoperative sinus radiolucency
1 year postoperatively. Preoperatively, 4 patients pre-
sented with mild mucosal thickening. The condition
had improved after surgery in 3 and worsened in 1 pa-
tient. Of the 64 patients studied, 12 (18.75%) had
developed radiologic evidence of sinusitis 1 year after
surgery. Of the 128 sinuses, 15 obtained a LMS score of
2; 20, showing only mucosal thickening, received a
400.e9 LE FORT OSTEOTOMY AND MAXILLARY SINUSITIS

Table 1. SNOT-20 QUESTIONNAIRE Table 2. VARIABLES STUDIED

Question No. Description Variable Value

1 Need to blow nose Patients 64

2 Sneezing Gender
3 Runny nose Male 26 (40.6)
4 Cough Female 38 (59.4)
5 Postnasal discharge (dripping at back Age (yr)
of throat) Mean 27.06
6 Thick nasal discharge (snot) Range 17-47
7 Ear fullness Follow-up (mo)
8 Dizziness Mean 32.4
9 Ear pain Range 13-66
10 Facial pain/pressure Type of dentoskeletal deformity
11 Difficulty in falling asleep Class II 24 (37.5)
12 Waking up at night Class III 40 (62.5)
13 Lack of a good night’s sleep Type of osteotomy
14 Waking up tired One-piece Le Fort I 22 (34.4)
15 Fatigue osteotomy
16 Reduced productivity Multisegment Le Fort I 42 (65.6)
17 Reduced concentration osteotomy
18 Frustrated/restless/irritable Volumetric analysis, maxillary sinus (mm3)
19 Sad Average preoperative volume 16,947.14  5,973.44
20 Embarrassed Average postoperative 13,675.34  5,875.38
volume
Abbreviation: SNOT-20, Sino-Nasal Outcome 20-item Test.
Morphologic analysis
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Max- Loss of continuity of lateral 13 (20.3)
illofac Surg 2016. nasal wall
Septal discontinuity 6 (9.4)
score of 1. Overall, 30% of the patients showed evi- Septal deviations 5 (7.8)
dence of postoperative inflammatory processes Hardware protrusion into 64 (100)
affecting the paranasal sinuses. Because it is often maxillary sinuses
Radiologic analysis*
asymptomatic, the complication is frequently misdiag-
Preoperative LMS score
nosed and can lead to the development of more severe 0 116 (90.6)
conditions. The patients who underwent multiseg- 1 8 (6.25)
ment osteotomy presented with higher LMS scores 2 4 (3.15)
than those undergoing 1-piece osteotomy. It is not Postoperative LMS score
clear whether maxillary sinus volume reduction was 0 93 (72.7)
responsible for the onset of rhinosinusitis patho- 1 20 (15.6)
logic features. 2 15 (11.7)
Analysis of the SNOT-20 questionnaire results Clinical analysis
demonstrated that the rate of symptomatic patients Preoperative SNOT-20 score
was relatively low in the total patient group (3.13%), 0-10 62 (96.9)
11-40 2 (3.1)
but was higher in the subgroup with radiologic signs
41-70 0 (0)
(16.7%). Our data are consistent with those outlined 71-100 0 (0)
in the published data (range 0.24 to 20%). The type Postoperative SNOT-20 score
of osteotomy (1-piece vs multisegment osteotomy) 0-10 53 (82.8)
does not seem to affect the onset of sinus pathologic 11-40 10 (15.6)
features. We have deduced from these data that no ab- 41-70 1 (1.6)
solute contraindication exists to Le Fort I osteotomy 71-100 0 (0)
for patients with preoperative sinusitis as long as the Data presented as number of patients (%), unless otherwise
sinusitis is not associated with symptoms. If symptoms noted.
are present, the rhinosinusitis issues should be ad- Abbreviations: LMS, Lund-Mackay rhinologic staging scale;
dressed before the procedure is undertaken. The pa- SNOT-20, Sino-Nasal Outcome Test 20-item.
tients with improvement in rhinosinusitis status after * Data presented as number of sinuses (%).
orthognathic surgery probably benefitted from the Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Max-
illofac Surg 2016.
procedure and from the removal of the inflamed tissue
NOCINI ET AL 400.e10

Table 4. SNOT-20 SCORES

Patients (n) P Value

(Fisher’s
SNOT-20 Score Preoperative Postoperative Exact Test)

0-10 62 53 .009
11-40 2 10 .03
41-69 0 1 NA
70-100 0 0 NA
Abbreviations: NA, not applicable; SNOT-20, Sino-Nasal
Outcome 20-item Test.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Max-
illofac Surg 2016.

which has limited the possibility of detecting

rhinosinusitis pathologic features. The most significant
studies focusing on this topic were those by Pereira-
FIGURE 7. Average volume variation before and after Le Fort 1
(LF1) osteotomy.
Filho et al26 and Valstar et al.27 The former used a brief
questionnaire, radiographs (Waters views), and nasal
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Max-
illofac Surg 2016. endoscopy before surgery and 6 to 8 months postoper-
atively to evaluate the incidence of maxillary sinusitis in
21 adult patients who had undergone Le Fort I osteot-
from the lower part of the sinus, which had a positive omy. Their results, revealing a 4% incidence of maxillary
effect on the airflow within the maxillary sinus. sinusitis as a postoperative complication, suggested that
Although epidemiologic data concerning sinusitis on orthognathic surgery is not directly linked to the onset
a global scale does not seem to be particularly accurate of chronic or subacute sinusitis.26 The latter study
on this point, our study found a salient incidence of used validated questionnaires focusing on sinonasal
mostly asymptomatic, postoperative inflammatory complaints (Rhinosinusitis Outcome Measure-31 and vi-
processes affecting the maxillary sinuses. sual analog scale score), nasal endoscopy, peak nasal
To our knowledge, no studies have described the me- inspiratory flow, and CT to evaluate maxillary sinus
dium- or long-term symptomatic alterations of the para- and nasal ventilation in a group of 20 patients.27 The as-
nasal sinuses after Le Fort I osteotomy.15,24,25 This can sessments were performed preoperatively and 2 months
partially be explained by the inadequacy of the after surgery. Those investigators concluded that the Le
radiologic assessments. Most orthognathic procedures Fort I osteotomy did not influence already existing phys-
are planned using 2-dimensional imaging findings, ical or mental complaints and that patients’ nasal venti-
lation was not negatively affected.27
Our study, which was a preliminary report of a pop-
Table 3. PATIENTS’ PRE- AND POSTOPERATIVE LUND- ulation of 64 patients, is, to the best of our knowledge,
MACKAY RHINOLOGIC STAGING SCALE SCORES the largest to date to investigate the postoperative com-
Sinuses (n) P Value
plications linked to Le Fort I osteotomy. None of the
Description (Fisher’s cited studies have provided comprehensive data
(LMS Score) Preoperative Postoperative Exact Test) beyond 1 year postoperatively, a period we are
convinced is not sufficient to detect procedure-
Totally 116 (90.6) 93 (72.7) .0003 related rhinosinusitis complications. Transient rhinosi-
radiolucent (0) nusitis appears to be a direct consequence of the
Mucosal 8 (6.25) 20 (15.6) .026 anatomic modification.28 Regarding the diagnostic pro-
thickening (1) cess, unlike other studies, we chose to use CBCT scans
Completely 4 (3.15) 15 (11.7) .015 and the SNOT-20 questionnaire, without endoscopy.
opaque (2) Our choice was based on the assumption that endos-
copy is best used in patients affected with nasal
Data in parentheses are percentages, unless otherwise
noted. discharge or symptomatic sinusitis. We believe that
Abbreviation: LMS, Lund-Mackay rhinologic staging scale. monitoring these patients for periods longer than
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Max- 1 year and the routine use of CBCT, both novel aspects
illofac Surg 2016. of the present investigation, enabled us to efficaciously
400.e11 LE FORT OSTEOTOMY AND MAXILLARY SINUSITIS

Table 5. KAPLAN-MEIER SURVIVAL ANALYSIS OF SINUSITIS

Follow-Up One-Piece LF1 Multisegment LF1

Point (mo) Group At Risk (n) Survival (%) Group At Risk (n) Survival (%)

0 22 100 41 100
6 22 100 41 100
12 22 100 41 100
18 21 100 28 91.8  4.6
24 17 100 24 91.8  4.6
30 14 94.1  5.7 17 83.1  7.2
36 9 86.9  8.7 12 78.2  8.3
42 5 74.5  13.7 11 78.2  8.3
48 4 74.5  13.7 5 67.1  12.6
54 3 55.9  19.1 4 67.1  12.6
60 2 55.9  19.1 3 67.1  12.6

P value = .74, Mantel-Cox test.

Abbreviation: LF1, Le Fort I osteotomy.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Maxillofac Surg 2016.

detect pathologic conditions that might otherwise
have been misdiagnosed or underdiagnosed.
Although postoperative rhinosinusitis is often
asymptomatic, and patients are frequently misdiag-
nosed, our results have shown a high incidence of
complications in patients who undergo Le Fort I os-
teotomy. Our findings have also demonstrated that
the clinical follow-up examinations of orthognathic pa-
tients should focus, not only on the occlusal plane and
postoperative stability of the maxilla, but also on the
factors that might interfere with sinus homeostasis.
When used with appropriate precautionary measures,
CBCT proved to be a safe, reliable, long-term tool to
monitor these patients in an effort to detect signs of
FIGURE 8. Kaplan-Meier survival analysis for sinusitis in 1-piece
and multisegment Le Fort I (LF1) osteotomy.
Nocini et al. Le Fort Osteotomy and Maxillary Sinusitis. J Oral Max-
illofac Surg 2016.
rhinosinusitis complications. Future studies could
assess the effect that variations in the surgical tech-
nique might have on patients undergoing Le Fort
I osteotomy.
References
1. Mattos CT, Vilani GN, Sant’Anna EF, et al: Effects of orthognathic
surgery on oropharyngeal airway: A meta-analysis. Int J Oral
Maxillofac Surg 40:1347, 2011
2. Lye KW: Effect of orthognathic surgery on the posterior airway
space (PAS). Ann Acad Med Singapore 37:677, 2008
3. Stellini E, Stomaci D, Stomaci M, et al: Fracture strength of tooth
fragment reattachments with postpone bevel and overcontour
reconstruction. Dent Traumatol 24:283, 2008
4. Boyd SB: Management of obstructive sleep apnea by maxillo-
mandibular advancement. Oral Maxillofac Surg Clin North Am
21:447, 2009
5. Favero L, Giagnorio C, Cocilovo F: Comparative analysis of
anchorage systems for micro implant orthodontics. Prog Orthod
11:105, 2010
6. Maurer JT: Surgical treatment of obstructive sleep apnea: Standard
and emerging techniques. Curr Opin Pulm Med 16:552, 2010
7. Susarla SM, Thomas RJ, Abramson ZR, Kaban LB: Biomechanics
of the upper airway: Changing concepts in the pathogenesis of
obstructive sleep apnea. Int J Oral Maxillofac Surg 39:1149,
2010
8. Jacobson RL, Schendel SA: Treating obstructive sleep apnea: The
case for surgery. Am J Orthod Dentofacial Orthop 142:435, 2012
9. Varghese R, Adams NG, Slocumb NL, et al: Maxillomandibular
advancement in the management of obstructive sleep apnea.
Int J Otolaryngol 2012:373025, 2012
10. Faria AC, da Silva SN Jr, Garcia LV, et al: Volumetric analysis of the
pharynx in patients with obstructive sleep apnea (OSA) treated
with maxillomandibular advancement (MMA). Sleep Breath 17:
395, 2013
11. Halawi AM, Smith SS, Chandra RK: Chronic rhinosinusitis: Epide-
miology and cost. Allergy Asthma Proc 34:328, 2013
12. Morris DE, Lo LJ, Margulis A: Pitfalls in orthognathic surgery:
Avoidance and management of complications. Clin Plast Surg
34:e17, 2007
13. Steel BJ, Cope MR: Unusual and rare complications of orthog-
nathic surgery: A literature review. J Oral Maxillofac Surg 70:
1678, 2012
NOCINI ET AL
14. Perko M: Maxillary sinus and surgical movement of maxilla. Int J
Oral Surg 1:177, 1972
15. Bell CS, Thrash WJ, Zysset MK: Incidence of maxillary sinusitis
following Le Fort I maxillary osteotomy. J Oral Maxillofac Surg
44:100, 1986
16. Sharp HR, Rowe-Jones JM, Mackay IS: The outcome of endoscopic
sinus surgery: Correlation with computerized tomography score
and systemic disease. Clin Otolaryngol Allied Sci 24:39, 1999
17. Basu S, Georgalas C, Kumar BN, Desai S: Correlation between
symptoms and radiological findings in patients with chronic rhi-
nosinusitis: An evaluation study using the Sinonasal Assessment
Questionnaire and Lund-Mackay grading system. Eur Arch Oto-
rhinolaryngol 262:751, 2005
18. Lachanas VA, Woodard TD, Antisdel JL, Kountakis SE: Sino-nasal
outcome test tool assessment in patients with chronic rhinosi-
nusitis and obstructive sleep apnea. ORL J Otorhinolaryngol Re-
lat Spec 74:286, 2012
19. Panula K, Finne K, Oikarinen K: Incidence of complications and
problems related to orthognathic surgery: A review of 655 pa-
tients. J Oral Maxillofac Surg 59:1128, 2001
20. Bailey L, Cevidanes LH, Proffit WR: Stability and predictability of
orthognathic surgery. Am J Orthod Dentofacial Orthop 126:273,
2004
21. D’Agostino A, Trevisiol L, Gugole F, et al: Complications of or-
thognathic surgery: The inferior alveolar nerve. J Craniofac
Surg 21:1189, 2010
400.e12
22. Bacci C, Berengo M, Favero L, Zanon E: Safety of dental implant
surgery in patients undergoing anticoagulation therapy: A pro-
spective case-control study. Clin Oral Implants Res 22:151,
2011
23. Benninger MS, Ferguson BJ, Hadley JA, et al: Adult chronic
rhinosinusitis: Definitions, diagnosis, epidemiology, and path-
ophysiology. Otolaryngol Head Neck Surg 129(3 Suppl):S1,
2003
24. Moses JJ, Lange CR, Arredondo A: Endoscopic treatment of sino-
nasal disease in patients who have had orthognathic surgery. Br J
Oral Maxillofac Surg 38:177, 2000
25. Williams BJ, Isom A, Laureano Filho JR, O’Ryan FS: Nasal airway
function after maxillary surgery: A prospective cohort study us-
ing the nasal obstruction symptom evaluation scale. J Oral Max-
illofac Surg 71:343, 2013
26. Pereira-Filho VA, Gabrielli MF, Gabrielli MA, et al: Incidence of
maxillary sinusitis following Le Fort I osteotomy: Clinical, radio-
graphic, and endoscopic study. J Oral Maxillofac Surg 69:346,
2011
27. Valstar MH, Baas EM, Te Rijdt JP, et al: Maxillary sinus recovery
and nasal ventilation after Le Fort I osteotomy: A prospective
clinical, endoscopic, functional and radiographic evaluation.
Int J Oral Maxillofac Surg 42:1431, 2013
28. Garg S, Kaur S: Evaluation of post-operative complication rate of
Le Fort I osteotomy: A retrospective and prospective study.
J Maxillofac Oral Surg 13:120, 2014