Int. J. Oral Maxillofac. Surg.

2009; 38: 321–325

doi:10.1016/j.ijom.2009.01.006, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Changes in acoustic airway S. Haarmann1,5, A. S. Budihardja2,5,

K.-D. Wolff3,5, K. Wangerin4
1
Department of Oral and Maxillofacial

profiles and nasal airway

Surgery, Evangelisches Krankenhaus,
Hattingen, Germany; 2Department of Oral
and Maxillofacial Surgery, Gajahmada
University, Yogyakarta, Indonesia;

resistance after Le Fort I 3

Department of Oral and Maxillofacial-Plastic
Surgery, Technische Universität München,
Germany; 4Department of Oral and
Maxillofacial Surgery, Marienhospital

osteotomy and functional Stuttgart, Germany; 5At the time this

manuscript was written, Department of Oral
and Maxillofacial- Plastic Surgery Ruhr

rhinosurgery: A prospective University of Bochum, Germany

study
S. Haarmann, A. S. Budihardja, K.-D. Wolff, K. Wangerin: Changes in acoustic
airway profiles and nasal airway resistance after Le Fort I osteotomy and functional
rhinosurgery: A prospective study. Int. J. Oral Maxillofac. Surg. 2009; 38: 321–325.
# 2009 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to investigate the changes in nasal airways after
Le Fort I osteotomy and functional rhinosurgery. 49 patients were included in this
study to assess intranasal anatomical and functional changes resulting from a Le
Fort I osteotomy. The data were classified according to the three-dimensional
positioning of the maxilla: in group I the maxilla was impacted; in group II the
maxilla was inferior; and in group III only sagittal maxillary movement was
performed. Presurgical and 5 months postsurgical rhinological inspection, anterior
rhinomanometry and acoustic rhinometry were carried out. Additional
rhinosurgery, such as resection of the inferior concha or septoplastic intervention,
was performed to avoid functional problems in nasal breathing, particularly when
the maxilla was impacted. Rhinomanometric assessment showed a significant
improvement in nasal breathing in the whole group and each single group. Acoustic
rhinometry revealed an increase in typical cross-sectional intranasal areas. The
Keywords: Le Fort I osteotomy; rhinosurgery;
authors conclude that concerns about the respiratory consequences of this surgical nasal airway; rhinomanometry.
procedure appear unwarranted when functional rhinosurgery is undertaken
concomitantly, particularly in patients with increased preoperative nasal airway Accepted for publication 16 January 2009
resistance. Available online 23 February 2009

0901-5027/040321 + 05 $36.00/0 # 2009 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
322 Haarmann et al.
In the past decades, Le Fort I osteotomy
has been increasingly used for the correc-
tion of dentofacial deformities. In orthog-
nathic surgery this versatile technique is
widely used to correct maxillary hypopla-
sia and hyperplasia, and in the manage-
ment of skeletal anterior open-bite, as seen
in the long-face syndrome13,28. Correction
of these deformities often involves ante-
rior, inferior or superior repositioning of
the maxilla and a combination of these
movements25. Maxillary movement
always affects nasal breathing by chan-
ging the intranasal dimensions. Numerous
measurements of nasal airway resistance
before and after Le Fort I osteotomy have
been made since the introduction of the
‘down-fracture’ technique by Obwegeser
as a standard method in orthognathic sur-
gery2,10,14,15,17,19,25,26,27,29,30,31. Operative
displacement of the maxilla was originally
described by WASSMUND32 and AXHAUSEN1.
None of these studies described the
metric changes of the nasal cavity in rela-
tion to the surgical maxillary movement
because flow measurement only reflects
nasal resistance caused by the narrowest
site of the nose. Acoustic rhinometry was
introduced by Hilberg et al. in 1989 as an
objective method for examining the nasal
cavity18. It determines the cross-sectional
areas of the nose depending on the dis-
tance to the nostril. Software calculates the
cross-sectional areas on the basis of reflec-
tion time, change in frequency and ampli-
tude of sound waves applied to the nose.
Using this method intranasal airway
changes can be localized.
Studies that combine both methods are
rare. In 1997, Kunkel and Hochban were
the first to describe the effect of maxillary
movement on nasal volume using acoustic
rhinometry but without performing nasal
resistance measurements19. Erbe et al.
combined acoustic and aerodynamic
assessment in 2001, but only 21 patients,
in whom the maxilla was impacted and
advanced, were included in the study14.
The aim of this study was to investigate
changes in nasal airways after Le Fort I
osteotomy and concomitant functional
nasal surgery using anterior rhinomano-
metry and acoustic rhinometry.
Material and Methods
49 patients, aged 17–74 years (mean age
24.8 years), were included in this prospec-
tive study. They underwent orthognathic
surgery at the Department of Oral and
Maxillofacial Surgery, Marienhospital
Stuttgart, Germany, between May 2002
and February 2003. None of the patients
had had previous surgery on the internal or
Table 1. Group I: Le Fort I osteotomy with
impaction.
Group I
Impaction of maxilla [3.7 mm (0.53)] n = 21
Resection of the inferior concha 16
Shortening of the nasal septum 18
Contouring of pyriform aperture 10
Correction of the septum 2 orthopantomograms were taken and ana-
Table 2. Group II: Le Fort I osteotomy with
inferior repositioning of the maxilla.
Group II
Inferior repositioning of maxilla [2.7 mm
(0.38)] n = 21
Resection of the inferior concha 6 the canine region without affecting the
Shortening of the nasal septum 10
Contouring of pyriform aperture 3
Correction of the septum 4
Table 3. Group III: Le Fort I osteotomy with
no vertical maxillary displacement.
Group III
No vertical maxillary displacement
Only anterior sagittal movement [(2.1 mm 
0.4)] n = 7
Resection of the inferior concha 1 nasal airflow and resistance to airflow. The
Shortening of the nasal septum 4 pressure–flow relationship detected during
Contouring of pyriform aperture 4 respiration reflects the functional status of
Correction of the septum 4 the nasal airway. For this study the Rhin-
external nose. Metric maxillary movement
was determined by lateral cephalometric
radiographs and orthodontic treatment
plans. The data were classified according
to the positioning of the anterior maxilla:
in group I (n = 21) the maxilla was
impacted; in group II (n = 21) the maxilla
was inferior; and in group III (n = 7) only
sagittal maxillary movement was per-
formed. In group I the average amount
of impaction was 3.7 mm (0.53) with a
maximum of 12 mm; in group II there was
inferior repositioning of 2.7 mm (0.38)
with a maximum of 7 mm; in group III
only sagittal anterior movement
(2.1  0.4 mm) with a maximum of
4 mm was performed. Functional rhino-
surgery was performed in all groups,
including resection of the inferior concha,
shortening the nasal septum, contouring
the pyriform aperture and correction of the
nasal septum (Tables 1–3).
One week before surgery, all patients
underwent a standardized examination
including anterior rhinological examina-
tion, anterior rhinomanometry and acoustic
rhinometry. Conspicuous findings, such as
a deformity of the septum and hyperplasia
of the concha, were documented. Normal
nasal breathing was assumed at a total nasal
airflow of 800 ml/s and pressure values of
150 Pa. Indications for nasal surgery were
increased nasal resistance, an obvious
deviation of the septum, concomitance of
a bony groin or a hypoplastic inferior tur-
bine after decongestion with 0.01% napha-
zoline tamponade for 15 min. Lateral
cephalometric radiographs, models and
lysed preoperatively. To ensure complete
wound healing and a stable bony consoli-
dation all patients underwent the same
procedure 5 months after surgery.
In only 2 patients, interpositional bone
grafts were harvested from the hip (crista
illiaca anterior) to stabilize the maxilla in
nasal floor.
Nasal airflow measurements
To assess the nasal airflow of each patient
and to provide an objective quantification
of nasal airway resistance, a technique
known as anterior active mask rhinoma-
nometry was used. Rhinomanometry is a
well established and reliable technique
that measures nasal patency in terms of
nomanometer ATMOS 2000 (Medizin-
technik GmbH, Lenzkirch, Germany)
was used. Using a mask technique and a
pressure nozzle, placed to occlude one
nostril, it was possible to measure the
pressure difference between the non-
occluded nasal airway and the atmo-
sphere. The pressure difference (P) and
transnasal airflow (V) were measured at
the same time. The recorded values were
visualized by a dual channel recorder.
Transnasal airflow (ml/s) and pressure
values (Pa) are normally used to calculate
the uninasal resistance using Ohm‘s law.
Nasal resistance (R) is equal to the ratio of
pressure drop across the nose (DP) over
the volume rate of nasal airflow (V). Each
nasal cavity was investigated individually.
By transferring the pressure nozzle to the
other nostril the resistance value for the
contralateral side was obtained. The
values were used to calculate the total
nasal airway resistance. According to
the recommendations of the International
Committee on Standardization of Rhino-
manometry the authors used the flow mea-
surements at DP = 150 because at this
pressure difference there is a laminar air-
flow during inspiration.
To evaluate the intranasal dimensions
and to detect changes in geometry the
authors used acoustic rhinometry, intro-
duced by Hilberg et al (1989) as an
Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery 323

objective method for examining the nasal

cavity18. This technique is based on the
principle that a sound pulse propagating in
the nasal cavity is reflected by local
changes in acoustic impedance. These
measurements were obtained with the
acoustic rhinometer Rhinoklack 10001
(Stimotron, Medizinische Geräte GmbH,
Wendelstein, Germany).
A sound source emits a pressure wave
of 55 dB for 0.2 ms which is conducted to
the airway through a tube (100 cm length,
2 cm diameter) via a standardized nose-
piece 7.5 cm in length. The amplitude and
traveling time of the incident and reflected
pressure waves are recorded during a time
window of 10 ms to calculate an area–
distance function of the nasal cross-sec-
tional dimensions. To avoid the risk of
expanding the anterior valve area with the
conical nosepieces the authors applied Fig. 1. Pre- and postoperative measurements in cross-sectional area (cm2) in the isthmus area.
anatomical adapters that have a minor
sound leakage between the rim of the
nostril and the adapter. A series of records The cross-sectional areas of the nose ior to the sinus ostia, acoustic rhinometry
was taken 20 min after topical deconges- and airflow increased significantly after overestimates the cross-sectional area5.
tion with naphazolin for each nostril, to Le Fort I osteotomy. Consequently, the The most significant finding in this
exclude changes caused by mucosal swel- volume of the anterior nose also increased. study was an objective improvement in
ling. The smallest cross-sectional area on patients’ nasal airway function after max-
the measurement curve can be identified illary movement via Le Fort I osteotomy,
as I-notch and reflects the nasal isthmus regardless of the direction of movement.
Discussion
area. The second restriction in the nose, C- A significant increase in cross-sectional
notch, corresponds to the head of the lower Rhinomanometry and acoustic rhinometry areas was seen at the isthmus nasi and in
nasal concha and the intumescentia septi. are reliable and objective methods of the region of the concha nasalis inferior in
Statistical analysis was carried out determining functional and geometric cases where maxillary impaction (group
using Student’s t-test. Results are pre- changes in the nasal cavity after Le Fort I), inferior positioning (group II) or only
sented as mean  standard error of the I osteotomy4,6–9,24. The cross-sectional sagittal movement (group III) were per-
mean (SEM). Values of p < 0.05 were areas determined by acoustic rhinometry formed. Anterior nasal volume and airflow
considered significant. correlate well with computed tomography increased significantly in all three groups.
(CT) data particularly in the anterior nasal This improvement seems to be an unex-
cavity. There is some evidence that poster- pected finding, but it can be explained by
Results
Statistically significant changes in intra-
nasal dimensions and functional para-
meters were measured with both
rhinometric methods used in the present
study (p < 0.05). Acoustic rhinometry
revealed an increase of typical cross-sec-
tional intranasal areas. Postoperatively the
isthmus nasi and concha nasalis were
enlarged. Rhinomanometric assessment
showed a significant improvement in nasal
breathing in the whole group and in each
single group.
The results of cross-sectional and nasal
resistance measurements using acoustic
rhinometry and rhinomanometry preo-
peratively and 5 months postoperatively
are shown in Figs. 1–3.
The changes in cross-sectional areas of
the isthmus nasi and concha nasalis ante-
rior are shown in Figs. 1 and 2. Pre- and
postoperative nasal-resistance values are
shown in Fig. 3. Fig. 4 shows the changes Fig. 2. Pre- and postoperative measurements in cross-sectional area (cm2) in the concha inferior
in the anterior nasal volume after surgery. area.
324 Haarmann et al.
Fig. 3. Pre- and postoperative measurements of anterior nasal volume (cm3).
functional changes, especially in the ante-
rior nose.
The nasal valve area is the narrowest
portion of the nasal passage accounting
for most airflow resistance6,11. The nasal
valve area is teardrop shaped, bounded by
the nasal septum, the caudal ends of the
lateral cartilage, the soft fibro fatty tissue
overlying the pyriform aperture, and the
floor of the nose20. All these anatomical
structures were affected by Le Fort I osteot-
omy and additional rhinosurgery. Small
changes in the nasal valve area can produce
significant changes in nasal airflow3,16,20.
Maxillary movement leads to changes
in external nose dimensions, most com-
monly an increase in the alar base width.
This widening of the basal portion of the
Fig. 4. Pre- and postoperative measurements of airflow (cm3/s).
nasal valve might reduce nasal airway
resistance by opening the nasal valve.
Data from acoustic rhinometry show an
increase in diameter of the valve area
paradoxically when superior movement
of the maxilla is made. Maxillary advance-
ment tends to increase the nasolabial
angle, increasing the vertical axis of the
valve area. This results in a more favour-
able inflow of air into the nasal cavity and
respiratory resistance14. An increase in the
width of the alar base is commonly
observed especially after maxillary impac-
tion surgery. Supplementary surgical pro-
cedures, such as an alar cinch, may also
improve nasal breathing by changing the
external nares from narrow slits to more
ovoid forms postoperatively3.
In all the patients in this study, an alar
cinch suture with non-absorbable material
was undertaken. In accordance with the
laws of aerodynamics, the pressure differ-
ence in laminar flow is inversely propor-
tional to the diameter to the power of four,
and in the case of turbulent flow even to
the fifth power, thus respiratory resistance
can react highly sensitively to small struc-
tural changes21,22,24. The dimensions and
shape of the airway lumen and airflow
velocity determine the magnitude of resis-
tance to airflow. Resistance to airflow
varies inversely and exponentially with
lumen cross-sectional area and, since
lumen dimensions are small in the nasal
valve region, valve resistance is very sen-
sitive to structural and/or vascular mural
displacements23. After surgery, the most
anterior dimensions of the nose increased.
This can be explained by rhinosurgery and
additional surgical procedures, such as
transversal widening of the maxilla or
contouring of the apertura piriformis,
which were performed at the same time33.
Surgical correction of mechanical air-
way obstruction is commonly attempted
using septoplasty or turbinate resection.
These procedures have been devised to
increase nasal airflow7. After turbinect-
omy of the inferior nasal concha the entire
nasal flow can change its flow pattern
resulting in a better ventilated nasal cav-
ity12. It is widely accepted that inferior
turbinectomy is a safe and effective pro-
cedure to relieve nasal obstruction caused
by chronic obstructive inferior turbinates.
The main structure contributing to nasal
obstruction is the inferior turbinate, which
contains most of the nasal erectile tissue.
Turbinectomy was undertaken in many
patients (Tables 1–3), but mostly per-
formed in group I, when impaction of
the maxilla made enlargement of the inter-
ior nose space necessary.
According to the authors’ data it seems
obvious that functional changes to the
internal and external nose, performed
directly by rhinosurgery or indirectly by
maxillary movement, tend to improve
nasal breathing. This study indicates that
in the 49 patients studied, Le Fort I osteot-
omy usually decreases nasal resistance.
This finding corroborates other previous
aerodynamic studies suggesting that max-
illary repositioning opens internal nose
dimensions, thus reducing nasal resis-
tance, whether or not the nasal floor is
elevated by Le Fort I osteot-
omy15,17,27,28,29,30.
In conclusion, this study showed that
superior positioning of the maxilla did not
increase resistance to nasal breathing in
the patients studied, whether or not the
Changes in acoustic airway profiles and nasal airway resistance after Le Fort I osteotomy and functional rhinosurgery
surgical procedure elevated the floor of the
nose. Concern about the respiratory
effects of this surgical procedure appears
unwarranted when additional functional
rhinosurgery is undertaken. In cases of
maxillary impaction, functional rhinosur-
gery should be considered routinely, if
nasal breathing is reduced preoperatively.
The combination of rhinomanometry and
acoustic rhinometry allows better assess-
ment of the structure and function of the
nose. The methods complement each other
in their diagnostic outcome, particularly in
determining the area of airway resistance.
Funding
No funding
Competing interests
Nothing to declare.
Ethical approval
No ethical approval required.
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Address:
Andi Setiawan Budihardja.
E-mail: a_budihardja@hotmail.com