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Accepted Manuscript: 10.1016/j.ijsu.2016.12.033
Accepted Manuscript: 10.1016/j.ijsu.2016.12.033
Accepted Manuscript: 10.1016/j.ijsu.2016.12.033
Impact on the upper airway space of different types of orthognathic surgery for the
correction of skeletal class III malocclusion: A systematic review and meta-analysis
Jinlong He, Yunji Wang, Hongtao Hu, Liao Qian, Weiyi Zhang, Xuerong Xiang,
Xiaoping Fan
PII: S1743-9191(16)31198-0
DOI: 10.1016/j.ijsu.2016.12.033
Reference: IJSU 3331
Please cite this article as: He J, Wang Y, Hu H, Qian L, Zhang W, Xiang X, Fan X, Impact on the
upper airway space of different types of orthognathic surgery for the correction of skeletal class III
malocclusion: A systematic review and meta-analysis, International Journal of Surgery (2017), doi:
10.1016/j.ijsu.2016.12.033.
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Jinlong He1, Yunji Wang1, Hongtao Hu, Liao Qian, Weiyi Zhang, Xuerong Xiang*, Xiaoping Fan*
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College of Stomatology, Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory for Oral Diseases and
Biomedical Sciences, Chongqing, China; Chongqing Municipal Key Laboratory of Oral Biomedical Engineering of Higher Education,
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Chongqing, China
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1 These authors contributed equally to this work.
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Abstract
Objective
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This study is aimed at assembling, through a systematic review and meta-analysis, scientific evidence
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related to the effects of mandibular setback (MdS) surgery and bimaxillary surgery for the correction of
Class III malocclusion on the cross-sectional area (CSA) and volume of the upper airway as assessed
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using CT.
Methods
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An electronic search was conducted on Cochrane Library, EMBASE, PubMed, Scopus and Web of
Science up to June 20, 2016. The inclusion criteria were prospective or retrospective studies, with the
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aim of comparing the impact on the upper airway space of orthognathic surgery for the treatment of
the skeletal class III malocclusion. The methodological index for non-randomized studies (MINORS)
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was chosen as the evaluation instrument and Revman5.3 was used for the meta-analysis.
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Results
A total of 1213 studies were retrieved, of which only 18 met the eligibility criteria. The results of
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meta-analysis showed that the mean decrease in the upper airway volume after MdS surgery was 3.24
cm3 [95%CI (-5.25,-1.23), p =0.85]; the mean decrease in minimum CSA after a combined surgery of
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maxillary advancement with mandibular setback (MdS+MxA) was 27.66 mm2 [95%CI (-52.81,-2.51), p
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=0.51], but there was no significant decrease in upper airway volume (mean 0.86 cm3); comparison
between MdS+MxA and isolated MdS showed significant differences in the CSA of the posterior nasal
spine plane (PNS) and epiglottis plane (EP); statistically significant differences in nasopharynx volume
(P<0.0001) and upper airway total volume (P=0.002) were observed, but no statistically meaningful
Conclusion
The results of this study suggest that bimaxillary surgery promotes less decrease on the upper airway
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than mandibular setback surgery alone for the correction of the skeletal class III malocclusion.
Introduction
Skeletal class III malocclusion is common in clinical cases [1-3], In the 1920s surgery began to be
used for the treatment of skeletal class III malocclusion, and by the 1960s maxillary LeFort I
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osteotomy had become the treatment of choice, because it was more effective than mandibular
setback in terms of improving patients’ alignment of jaws and their overall facial symmetry [4].
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Malocclusion problems may reoccur after surgery due to the traction of soft tissues and muscle
forces produced during function, therefore, in the 1970s orthodontic treatment was combined
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with orthognathic surgery to correct malocclusion, stable and desirable effects were achieved [5].
Currently, combined orthodontic and orthognathic surgical therapy has proved the most
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effective for the treatment of skeletal class III malocclusion when it comes to enhancing function
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and aesthetics. Skeletal changes caused by the surgery, however, can alter the positions and
traction of the surrounding soft tissues, tongue, soft palate, hyoid bone and muscles, and can
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change airway volume and the size of oral and nasal cavities [6-9]. According to most previous
studies [10-12], mandibular setback surgery may affect the relationship between the soft and
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skeletal tissues, subsequent increase in upper airway resistance and decrease in upper airway
space. Besides, bimaxillary surgical caused a smaller decrease in airway space compared to
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mandibular setback surgery. On the other hand, some studies [13-15] concluded that bimaxillary
orthognathic surgery for the correction of Class III malocclusion resulted in increased total airway
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volume. Therefore, changes in the upper airway space resulting from different types of
Moreover, no meta-analysis that compares changes in the airway dimensions resulting from
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different types of orthognathic surgery for the correction of skeletal class III malocclusion
exclusively using 3D examination has been documented in the literature. Three previous
systematic reviews [2, 16, 17] have investigated based on data from two-dimensional images,as
some articles using three dimensional images were not comparable, didn't perform meta analysis.
Therefore, the present meta-analysis focused only on studies that used CT airway evaluation,
particularly cone beam CT (CBCT). This study is aimed at assembling, through a meta-analysis,
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scientific evidence related to the effects of MdS and bimaxillary surgery for the correction of Class
III malocclusion on the CSA and volume of the upper airway as assessed using 3D examination so
as to inform treatment planning for patients suffering skeletal class III malocclusion.
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The inclusion criteria were developed according to the PICOS criteria (Table 1). Exclusion criteria
were as follows: (1) Research type: animal studies, case reports, studies that did not provide the
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data needed to conduct meta-analysis; (2) Research object: patients with cleft palate, pharyngeal
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obstructive sleep apnea; (3) Intervention: orthognathic surgery combined with other surgeries,
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Table 1. PICOS criteria for the systematic review.
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Population (P) Patients with a prognathic mandible and class III malocclusion who had undergone mandible
setback or bimaxillary surgery; age 15–50 years
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Outcome (O) Changes of the upper airway (three CSA parameters: PNS-CSA, SP-CSA and EP-CSA ; four
volume parameters :nasopharynx volume, oropharynx volume, hypopharynx volume, and
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mandible
Question What are the effects of different orthognathic surgeries for the correction of the prognathic
mandible on the dimensions of the upper airways assessed using CT?
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This systematic review and meta-analysis were conducted following the statement of PRISMA [18]
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses). An electronic search in
Cochrane Library, EMBASE, PubMed, Scopus and Web of Science, until June 20, 2016. An
additional manual search of references in the included studies was also conducted. We used the
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“Oropharynx”)].
3 Data extraction
An initial screening through titles and abstracts was conducted independently by two reviewers
(HJL, WYJ), who then cross-checked and reviewed the text in full to decide whether they were
eligible. Disagreements were resolved through discussion, when necessary, by seeking the
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opinion of a third reviewer. The following data were extracted from the studies included in the
final analysis: title, author, year of publication, study design, age and gender of research objects,
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sample size, surgical procedure, evaluation parameters and other statistical data.
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Prospective or retrospective studies reporting on the upper airway space change upon
orthognathic surgery were selected. Quality of included studies were assessed using MINORS[19],
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which is tailored to quality evaluation of non-randomized controlled studies and is comprised of
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twelve items, with each item scored from 0 to 2. So the total score is 24. On the basis of other
researchers, 0-12 showed high risk of bias, 13 to 18 for moderate risk of bias, and 19-24 for low risk
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of bias. Quality of included studies were assessed independently by two reviewers in accordance
to MINORS and a conclusion was reached after disagreements were resolved through discussion.
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5 Statistical analysis
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Extracted data were statistically analyzed using Review Manager 5.3. All available data extracted
from the included studies were continuous variables, mean and standardized mean difference
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(SMD) or weighted mean difference (WMD) with a 95% confidence interval was used to estimate
treatment effect. Cochrane’s test (I2 statistic) was used to evaluate heterogeneity. Low
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heterogeneity (P>0.10, I2<50%) means fixed-effects model should be employed to conduct the
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meta-analysis. If heterogeneity was substantial (P≤0.10, I2 ≥50%), then random-effects model was
adopted. The statistical significance for the testing of hypotheses was set at p<0.05. Funnel plots
were used to detect publication bias and a symmetrical plot indicated low risk publication bias.
Results
1 Characteristics of the included studies
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A total of 1213 studies were retrieved independently by the two reviewers following the
previously defined search strategy. We examined 20 studies that had been identified for inclusion
in our meta-analysis. After the full articles were retrieved, we excluded two studies for not
presenting the difference in pre- and post-surgery volumes in absolute values. At last, only 18
studies [11-15, 20-32] met all eligibility criteria. Fig 1 shows the process of selecting studies for
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meta-analysis. The included studies were published from 2008 to 2016; the mean age of patients in
each study was approximate. In the 18 included studies, eight showed a low risk of bias, while the
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rest exhibited a moderate risk of bias. The results of essential features and methodological quality
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Table 2. Essential features and methodological quality of the included studies.
Author & year Type of No. and Age Type of Comparison Measurements Quality
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study sex (years) surgery Area (CSA) Volume score
Hart PS et al.(2015)[25] R 31M 40F 18.8y MdS+MxA Before-after Min CSA NP,OP,Total 14
Hsieh YJ et al.(2015)[23] R 18M 54F 24.0y MdS+MxA Before-after Min CSA NP,OP,HP,Total 19
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Kim HS et al.(2015)[22] P 16M 22F 23.84y MdS+MxA Before-after Min CSA Total 15
Kim MA et al.(2014)[26] R 14M 11F 23.72y MdS+MxA Before-after -- NP,OP,HP,Total 14
Kim NR et al.(2010)[27] R 12M 8F 21.53y MdS Before-after -- NP,OP,HP,Total 13
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Uesugi T et al.(2014)[12] P 21M 19F 23y MdS MxA+MdS PNS,SP,EP NP, OP, total 19
Wang HW et al.(2015)[21] P 13M 15F 19.17y MdS Before-after -- NP,OP,HP,Total 15
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Abbreviations: R: retrospective study; P: Prospective study; M: male; F: female; y: years; MdS: mandibular setback; MxA:
maxillary advancement; Before-after: comparison between pre-surgery and post-surgery parameters; Min CSA: minimum
cross-sectional area; PNS: posterior nasal spine; SP, soft palate; EP: epiglottis plane; NP: nasopharynx volume; OP:
2 MdS surgery
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The included studies showed that there was a statistically significant decrease in the upper airway
volume after MdS surgery. Eight studies enrolling a total of 134 patients assessed the changes in
upper airway volume after MdS surgery (Fig 2). The mean decrease was 3.24 cm3 [95%CI
(-5.25,-1.23), p =0.85], and heterogeneity test among those studies showed homogeneity (x2 = 3.41,
df = 7, P = 0.85; I2 = 0%).
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Fig 2. Forest plot: mandibular setback surgery, upper airway total volume.
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In the MdS+MxA surgery comparison group, five studies enrolling a total of 134 patients assessed
the changes in minimum CSA, with the mean decrease in minimum CSA being 27.66 mm2 [95%CI
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(-52.81,-2.51), p =0.03]. Heterogeneity test among studies showed homogeneity (x2 = 3.29, df = 4, P
= 0.51; I2 = 0%); 14 studies enrolling a total of 307 patients evaluated the changes in upper airway
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total volume, showing there was no significant decrease (mean -0.86 mm3) [95%CI (-2.19,-0.47), p
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=0.21].The test of heterogeneity among studies showed homogeneity (x2 =12.59, df =13, P =0.48; I2
Fig 3. Forest plot: mandibular setback surgery, minimum CSA and upper airway total volume.
Fixed-effects model, as is shown in Fig 4, was chosen for the comparison between MdS group and
MdS+MxA group because of the low heterogeneity (I2 from 0% to 9%). Three CSA parameters
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showed that, compared to isolated mandibular setback surgery, MdS+MxA caused smaller
changes in the CSA of PNS and EP, whereas no significant differences existed in SP-CSA changes
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between these two surgical procedures for the treatment of skeletal class III malocclusion.
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Fig 4. Forest plot: one-jaw surgery versus two-jaw surgery, PNS-CSA, SP-CSA, EP-CSA.
5 Differences in upper airway volume between MdS group and MdS+MxA group
Due to low heterogeneity (I2 from 0% to 16%), fixed-effects model was chosen for this
meta-analysis to compare the impact on the upper airway space between MdS group and
MdS+MxA group, as is shown in Fig 5. The above-mentioned four parameters were assessed:
P=0.64) and upper airway total volume (WMD=-3.41, 95%CI=-5.59–-1.24, P= 0.002). There were
between the two groups, but statistically significant differences in nasopharynx volume and
Fig 5. Forest plot: one-jaw surgery versus two-jaw surgery, Nasopharynx Volume, Oropharynx Volume, Hypopharynx
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Volume, Upper airway total Volume.
6 Publication bias
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A funnel plot was used to assess the publication bias of the literature. Symmetrical graphical
funnel plots were obtained from all included studies (Fig 6).
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Fig 6. Graphical funnel plots of the included studies. These symmetrical plots indicate the absence of publication bias in the
present meta-analysis.
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Discussion
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Surgeons and orthodontists have been showing a growing interest in the upper airways, because
they constitute the anatomical structures that can greatly influence people’s health and quality of
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life. This interest is generated by the direct relationship between the upper airways and the
syndrome of obstructive sleep apnea (OSA) [33-35]. Changes in the upper airway resulting from
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different types of orthognathic surgery still remain contested, with some studies reporting no
changes, while others showing a decrease in upper airway volume, in addition, these previous
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studies [36-40] analyzed data obtained from two dimensional cephalograms. In a previous
systematic review, the authors suggested that more studies needed to be conducted using CT to
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assess the effects of orthognathic surgery on the airways. Therefore, this systematic review is
carried out with the aim to verify the impact of MdS and MdS+MxA surgery on the upper
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Two dimensional cephalograms cannot capture the three-dimensional structure of the airway
and its accuracy is usually undermined by image distortion. With progress in the imaging
techniques and computer technology, CT and cone beam CT (CBCT) have emerged as new
alternatives for developing the three-dimensional configuration of upper airway, and as a result,
the upper airway indicators can be accurately measured both horizontally and vertically [41-44],
however, the radiation doses of CT scans are generally higher than those for conventional dental
comparing before and after treatment. The results showed that: the mean decrease in upper
airway volume was 3.24 cm3 after MdS surgery; the mean decrease in minimum CSA was 27.66
mm2 after MdS+MxA surgery; but there was no significant decrease in the total volume of the
upper airway (mean 0.86 mm3). The result is in some aspects similar to the previous study [45],
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but major differences still exist. The comparison between MdS group and MdS+MxA group was
performed using three CSA parameters and four volume parameters. Results of the meta-analysis
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showed that: statistically important differences in PNS-CSA, EP-CSA, nasopharynx volume and
upper airway total volume were observed; whereas no significant differences existed in SP-CSA,
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oropharynx volume and hypopharynx volume changes between these two surgical procedures.
But, decrease in the nasopharynx volume and oropharynx volume is still observed after
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bimaxillary surgery for the correction of the skeletal class III malocclusion, especially when
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patients are predisposed to the development of breathing problems. Orthodontic and
orthognathic surgeons should assess preoperative and postoperative changes in the airway so as
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to prevent excessive airway stenosis and avoid the development of iatrogenic OSA.
Among the studies that were included in the meta-analysis, eight showed a low risk of bias,
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while the rest exhibited a moderate risk of bias; symmetrical graphical funnel plots were obtained
using data extracted from all included studies; sensitivity analysis by excluding individual study
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or changing the statistical model showed that the change of combined index was not significant.
All of these indicated the reliability of the results of the meta-analysis. But the present study also
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had certain limitations as follows: 1) randomized clinical trials represent the ideal study type for
meta-analysis. Surgical procedures cannot be randomized since the patients must receive the best
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treatment available to them, therefore, non-randomized clinical studies were selected in this study;
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2) the gender difference and the wide age range of the samples reduce the accuracy of the change
in the upper airway space caused by orthognathic surgery; 3) the sample size of included studies
was small and the total sample size of the meta-analysis is not big enough either. As a result,
among studies were not assessed; 5) to assess the upper airway, several software programs were
used to analyze digital imaging communications in medicine files for the included studies,
besides, different uses of software programs may impact the measurement results of upper
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airway space. Due to the constraints of the present meta-analysis, the conclusion still needs to be
verified and tested by future clinical trials of higher quality and larger size.
Conclusion
To sum up, this systematic review and meta-analysis indicated that the upper airway volume
decreases significantly after isolated MdS surgery, and the minimum CSA decreases significantly
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after bimaxillary surgery, while upper airway volume does not decrease significantly after
MdS+MxA surgery based on the 3D images, two-jaw surgery caused a smaller reduction in the
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PNS-CSA, EP-CSA, nasopharynx volume and upper airway total volume compared with one-jaw
surgery. Therefore, bimaxillary surgery promotes less decrease on the upper airway than
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mandibular setback surgery alone for the correction of the skeletal class III malocclusion.
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Ethical approval
Not relevant (Review article).
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Sources of funding
This research is funded by Chongqing Research Program of Basic Research and Frontier
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Technology (cstc2013jcyjA10010), and the Science Project of the health and family planning
Author Contributions
Conceived and designed the experiments: FXP XXR. Performed the experiments: HJL WYJ.
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Analyzed the data: HJL HHT LQ. Contributed reagents/materials/analysis tools: FXP XXR.
Wrote the paper: HJL HHT. Study selection: HJL WYJ. Quality assessment: HJL WYJ FXP. Data
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extraction: HJL WYJ. Data analysis: HJL WYJ ZWY. Write and revise: HJL HHT.
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Highlights:
the upper airway volume decreases significantly after isolated MdS surgery and
the minimum CSA decreases significantly after bimaxillary surgery, upper airway
volume does not decrease significantly after MdS+MxA surgery based on the 3D
images.
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two-jaw surgery caused a smaller reduction in the PNS-CSA, EP-CSA,
nasopharynx volume and upper airway total volume compared with one-jaw surgery.
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bimaxillary surgery promotes less decrease on the upper airway than mandibular
setback surgery alone for the correction of the skeletal class III malocclusion.
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