ORIGINAL ARTICLE

Effects of bimaxillary surgery and mandibular

setback surgery on pharyngeal airway
measurements in patients with Class III
skeletal deformities
Fengshan Chen,a Kazuto Terada,b Yongmei Hua,a and Isao Saitoc
Shanghai, China, and Niigata, Japan

Introduction: The purpose of this study was to compare the short-term and long-term effects of bimaxillary
surgery with those of mandibular setback surgery concerning pharyngeal airway measurements at 3 levels:
nasopharynx, oropharynx, and hypopharynx. Methods: The sample included 66 Japanese women in
2 groups who had been diagnosed with Class III skeletal deformities and had undergone surgical-orthodontic
treatment. Those in group A (35 patients) underwent bilateral sagittal split ramus osteotomies; those in group
B (31 patients) underwent LeFort I procedures with bilateral sagittal split ramus osteotomies. Lateral
cephalograms were assessed within 6 months before surgery and at short-term (3-6 months after surgery)
and long-term (at least 2 years after surgery) follow-ups. Results: In group A, the pharyngeal airway was
constricted significantly at the oropharyngeal and hypopharyngeal levels at both the short-term and the
long-term follow-ups. In group B, significant changes were shown at the 3 pharyngeal levels at the short-term
follow-up, whereas no significant changes were shown at the long-term follow-up. Conclusions: These
results indicate that, when possible, bimaxillary surgery rather than only mandibular setback surgery is preferable
to correct a Class III deformity to prevent narrowing of the pharyngeal airway space, a possible predisposing
factor in the development of obstructive sleep apnea. (Am J Orthod Dentofacial Orthop 2007;131:372-7)

C
lass III skeletal deformity is the result of mandib-
ular prognathism or maxillary deficiency.1 His-
torically, the surgical correction of Class III
deformities was achieved by mandibular setback sur-
gery alone. With advances in knowledge and tech-
niques, corrective surgery progressed to include bimax-
illary procedures. In the last decade, mandibular
setback surgery declined in frequency to fewer than
10% of Class III patients, whereas bimaxillary surgery
is used in about 40% of Class III patients.2
Both mandibular setback surgery and bimaxillary
surgery can improve occlusion, masticatory function,
and esthetics by markedly changing the position of the
mandible. The positions of the hyoid bone and the
a
Vice professor, Department of Orthodontics, Dental School, Tongji Univer-
sity, Shanghai, China.
b
Assistant professor, Department of Orthodontics, Niigata University, Niigata,
Japan.
c
Professor and chairman, Division of Orthodontics, Graduate School of
Medical and Dental Sciences, Niigata University, Niigata, Japan.
Reprint requests to: Fengshan Chen, Division of Orthodontics, Graduate School
of Medical and Dental Sciences, Niigata University Medical and Dental Hospital,
1-754 Asahimachi-dori, Niigata, Japan 951-8520; e-mail, chenfengshan@
hotmail.com.
Submitted, February 2005; revised and accepted, June 2005.
0889-5406/$32.00
Copyright © 2007 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.06.028
372
tongue are also changed, with consequent narrowing of
the pharyngeal airway space3 (PAS). PAS narrowing
might be a factor in obstructive sleep apnea (OSA)4
OSA is considered a risk factor for systemic and
pulmonary hypertension and cardiac arrhythmias, and
might increase morbidity and mortality.5-7
Several studies attempted to investigate the effect of
orthognathic surgery on the PAS in patients with Class
III skeletal deformities.3,8-12 However, most of these
investigated only the effects of mandibular setback sur-
gery for correcting mandibular prognathism. The effects
of bimaxillary surgery for correcting Class III deformities
have not been sufficiently explored, and, therefore, a study
of changes in upper airway measurements to examine the
effects of bimaxillary surgery is needed.
The purpose of this study was to determine the
changes in pharyngeal airways in Japanese patients
with Class III skeletal deformities over the short and
long terms after bimaxillary surgeries, and to compare
these with changes after mandibular setback surgery.
MATERIAL AND METHODS
The subjects for this study were 66 Japanese
women selected from the files of the orthodontic clinic,
Niigata University Medical and Dental Hospital, Ni-
American Journal of Orthodontics and Dentofacial Orthopedics Chen et al 373
Volume 131, Number 3

igata, Japan. All patients were diagnosed as having

Class III skeletal deformities and underwent surgical-
orthodontic treatment. They were divided into 2 surgi-
cal groups based on the type of orthognathic surgery
they had received: group A (35 patients) underwent
bilateral sagittal split ramus osteotomy (BSSO with
rigid fixation); group B (31 patients) underwent LeFort
I surgery with BSSO. The average lengths of orthodon-
tic treatment were 16.6 months (preoperative) and 10.6
months (postoperative).
Lateral cephalograms were taken by a standard
technique with the jaws in centric occlusion. The film
was exposed during relaxed tidal breathing after swal-
lowing. The distance from the anode to the patient’s
midsagittal plane was 150 cm, and the distance from
the midsagittal plane to the film was 15 cm. Included
were cephalographs taken at T1 (within 6 months
before surgery), T2 (short-term follow-up, 3-6 months
after surgery), and T3 (long-term follow-up, at least 2
years after surgery). Exclusion criteria included previ-
ous orthognathic surgery, marked mandibular bone Fig. Landmarks used in study. A, A-point; ANS, ante-
asymmetry, habitual snoring, OSA, chronic upper air- rior nasal spine; B, B-point; Ba, basion; Co, condylion;
way diseases, previous tonsillectomy or adenoidec- Gn, gnathion; Go, gonion; Me, menton; N, nasion; PNS,
tomy, and excessive obesity. posterior nasal spine; S, sella; Ptm, pterygomaxillary
fissure; U, tip of soft palate; V, vallecula; UPW, upper
Cepholmetric analysis pharyngeal wall, intersection of line Ptm-Ba and poste-
All lateral cephalometric radiographs were traced rior pharyngeal wall; MPW, middle pharyngeal wall,
by hand onto acetate paper and scanned and imported to intersection of perpendicular line from U with posterior
analysis software (Igensoft, Shanghai, China). The pharyngeal wall; LPW, lower pharyngeal wall, intersec-
landmarks were digitized by an author (F.C.), and tion of perpendicular line from V with posterior pharyn-
geal wall.
linear and angular items were measured by the com-
puter.
The method for cephalometric measurement was a All statistical analyses were performed with a
modification of the methods of Liukkonen et al11 and software package (SPSS for Windows 98, version 10.0,
Samman et al13 and was used in other studies.9,14 The SPSS, Chicago, Ill). The arithmetic mean and standard
landmarks used in the study are shown in the Figure. deviation were calculated for each variable. A paired-
The following items were measured. Dentofacial samples t test was used to evaluate the treatment
measurements: ANB, angle formed by the planes na- changes in each group.
sion-Point A and nasion-Point B; SNA, angle formed Twenty cephalograms were selected at random and
by the planes sella-nasion and nasion-Point A; SNB, traced, digitized, and measured again 10 days later. In
angle formed by the planes sella-nasion and nasion- addition, a paired-samples t test was applied to the first
Point B; SN-GoGn, angle formed by the planes sella- and second measurements; the difference between the
nasion and gonion-gnathion; SN-ANS-PNS, angle first and second measurements of the 20 radiographs
formed by the planes sella-nasion and ANS-PNS; was insignificant. The standard deviations ranged from
Co-Gn, distance from condylion to gnathion; N-Me, 0.30 to 0.35 mm for the distances and from 0.25° to
distance from nasion to menton. Pharyngeal airway 0.45° for the angles.
measurements: Ptm-UPW, distance from pterygomax-
illary fissure to upper pharyngeal wall, representing the RESULTS
nasopharyngeal airway space; U-MPW, distance from Table I shows the dentofacial and pharyngeal air-
tip of the soft palate to middle pharyngeal wall, way measurements for group A at T1, T2, and T3, and
representing the oropharyngeal airway space; V-LPW, the results of the paired t tests of changes from T1 to
distance from vellicula to lower pharyngeal wall, rep- T2, T2 to T3, and T1 to T3. Changes in the dentofacial
resenting the hypopharyngeal airway space. measurements from T1 to T2 and from T1 to T3
374 Chen et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2007

Table I. Measurements for group A

T1 T2 T3 T1-T2 T1-T3 T2-T3

Dentofacial
ANB (°) –5.01 ⫾ 2.10 0.37 ⫾ 2.38 –1.61 ⫾ 2.83 * *
SNA (°) 79.37 ⫾ 3.57 79.24 ⫾ 3.52 79.63 ⫾ 3.94
SNB (°) 84.38 ⫾ 3.82 79.61 ⫾ 3.49 81.24 ⫾ 5.35 * *
SN-GoGn (°) 35.96 ⫾ 5.03 39.89 ⫾ 4.89 38.58 ⫾ 4.07
SN-ANS-PNS (°) 9.10 ⫾ 2.14 9.45 ⫾ 2.78 9.27 ⫾ 3.21
Co-Gn (mm) 123.40 ⫾ 7.64 116.25 ⫾ 7.27 117.75 ⫾ 7.48 * *
N-Me (mm) 129.31 ⫾ 3.89 127.89 ⫾ 6.98 129.91 ⫾ 7.30
Pharyngeal airway
Ptm-UPW (mm) 20.34 ⫾ 2.87 20.06 ⫾ 2.81 19.66 ⫾ 3.10
U-MPW (mm) 13.01 ⫾ 3.71 8.75 ⫾ 2.17 10.16 ⫾ 3.51 * *
V-LPW (mm) 17.62 ⫾ 3.81 11.91 ⫾ 3.82 13.80 ⫾ 4.94 * *

*P ⬍.05.

Table II. Measurements for group B

T1 T2 T3 T1-T2 T1-T3 T2-T3

Dentofacial
ANB (°) –5.18 ⫾ 3.30 0.38 ⫾ 1.25 –1.76 ⫾ 1.06 * *
SNA (°) 78.43 ⫾ 4.55 81.85 ⫾ 4.67 81.64 ⫾ 4.36 * *
SNB (°) 84.04 ⫾ 4.06 80.47 ⫾ 3.78 81.85 ⫾ 3.41 * *
SN-GoGn (°) 34.53 ⫾ 4.89 37.26 ⫾ 4.48 37.39 ⫾ 3.46
SN-ANS-PNS (°) 10.62 ⫾ 4.33 11.73 ⫾ 2.88 10.03 ⫾ 3.59
Co-Gn (mm) 121.48 ⫾ 5.81 116.92 ⫾ 5.54 117.11 ⫾ 5.42 * *
N-Me (mm) 128.13 ⫾ 6.63 128.91 ⫾ 6.33 129.19 ⫾ 6.20
Pharyngeal airway
Ptm-UPW (mm) 21.34 ⫾ 3.91 24.48 ⫾ 3.71 22.21 ⫾ 3.58 *
U-MPW (mm) 14.46 ⫾ 4.19 11.51 ⫾ 3.58 12.96 ⫾ 3.51 *
V-LPW (mm) 17.20 ⫾ 2.73 14.58 ⫾ 2.35 15.95 ⫾ 1.48 *

*P ⬍.05.

showed significant differences (P ⬍.05) for ANB, DISCUSSION

SNB, and Co-Gn, whereas no significant changes from
T2 to T3 was observed. Changes in the pharyngeal
airway measurements showed significant differences
from T1 to T2 and from T1 to T3 in U-MPW and
V-LPW (P ⬍.05), whereas changes from T2 to T3
showed no significant changes.
Table II shows the dentofacial measurements and
pharyngeal airway measurements for group B at T1,
T2, and T3, and the results of the paired t tests of
changes from T1 to T2, T2 to T3, and T1 to T3.
Changes in the dentofacial measurements from T1 to
T2 and T1 to T3 showed significant differences
(P ⬍.05) for ANB, SNA, SNB, and Co-Gn, but no
significant changes from T2 to T3 were found.
Changes in pharyngeal airway measurements showed
significant differences from T1 to T2 in Ptm-UPW,
U-MPW, and V-LPW (P ⬍.05), whereas changes
from T1 to T3 and from T2 to T3 showed no
significant differences.
PAS narrowing after orthognathic surgery has
drawn increasing attention in recent decades. A main
reason for this is that PAS narrowing might be a
predisposing factor for OSA. The objective of this
investigation was to compare the short-term and long-
term PAS changes after BSSO with those after 2-jaw
surgery consisting of BSSO and LeFort I surgery. Our
results should aid orthodontists, oral surgeons, and
plastic surgeons in selecting the surgical method.
It is important to choose patients who have com-
pleted maxillofacial growth when evaluating the
changes by surgical treatment. The women in this study
were aged 18.6 ⫾ 0.5 years at T1 and 19.1 ⫾ 0.7 years
at T2, so that the growth of the dentoface and pharyn-
geal airway was obviously completed; therefore, they
were appropriate subjects for morphologic evaluations.
Only women were selected because sex differences in
pharyngeal airway changes were evident.15 There was
no significant difference in any morphologic feature
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 131, Number 3
between the preoperation values of the 2 groups. The
subjects had mainly mandibular hyperpasia and minor
maxillary hypoplasia. Different operations were per-
formed because of factors such as profiles, personal
willingness, and duration of surgery. Moreover, the
LeFort I osteotomy had not yet become a routine
procedure at Niigata University 10 years ago.
We evaluated airway size by analyzing cephalo-
grams. Although a cephalogram provides only a 2-di-
mensional image of the pharyngeal airway, it has been
used extensively in the assessment of sleep apnea and
craniofacial form.16 The advantages of a cephalometric
analysis include its wide availability, simplicity, low
expense, and ease of comparison with extensive nor-
mative data and other studies.17 Furthermore, good
correlation between airway dimensions measured on
lateral cepholmetric radiographs and on 3-dimensional
computed tomography was reported,18 validating the
usefulness of cephalograms in airway size analysis.
Obstruction of the upper airway has been reported to
occur at various levels: nasopharynx, oropharynx, and
hypopharynx. Similar to previous studies, Ptm-UPW,
U-MPW, and V-LPW were selected to represent the
upper airway dimensions at the levels of nasopharynx,
oropharynx, and hypopharynx, respectively.13,14 Adap-
tive changes are likely to occur in the soft and hard
tissues after osteotomies,8 so all subjects were exam-
ined at short and long terms postoperatively.
No significant difference was shown in the dento-
facial measurements from T2 to T3, whereas significant
differences were shown from T1 to T2 and from T1 to
T3. These results showed that the dentofacial measure-
ments after orthognathic surgery remained stable in the
long term. These results agree with those of previous
studies on stability of orthognathic surgery to correct
Class III skeletal deformities.2,19
Tselnik and Pogrel9 studied the lateral cephalo-
grams of 14 adults and found that the PAS was
constricted at the oropharyngeal level after mandibular
setback surgery. Hochban et al10 evaluated the effect of
mandibular setback surgery on the PAS of 16 patients
with mandibular hyperplasia and showed that the PAS
decreased considerably at the oropharyngeal and hypo-
pharyngeal levels. Liukkonen et al11 reported that
mandibular setback surgery caused a statistically sig-
nificant decrease in airway size at the oropharyngeal
and hypopharyngeal levels, and that no significant
change was noted at the nasopharyngeal level. Our
findings essientially agreed with these studies.
Saitoh3 also found significant pharyngeal airway
narrowing at the levels of the oropharynx and hypo-
pharynx 3 to 6 months after mandibular setback sur-
gery; the PAS narrowed by 2.7 and 3.9 mm, respec-
Chen et al 375
tively, 2 years postoperatively, but he found no
significant changes. However, we also found that the
PAS was narrowed at the levels of the oropharynx and
hypopharynx by about 2.85 and 3.62 mm, respectively,
but a significant difference was noted in the long term
after mandibular setback surgery. A possible reason for
this difference was that Saitoh3 used the distances from
certain points on the anterior airway wall to the
posterior reference line other than the posterior wall to
represent the airway dimension. The posterior reference
line is perpendicular to the Frankfort plane and passes
through porion. Another reason might be fewer sub-
jects— only 10 —whereas 35 patients were used in this
study.
Samman et al13 compared pre- and postbimaxillary
surgery measurements at 6 months follow-up regarding
changes in pharyngeal airway dimensions in 19 women
and showed statistically significant decreases at the
oropharyngeal and hypopharyngeal levels. Cakarne
et al14 found a significant increase in nasopharyngeal
airway space after bimaxillary surgery (8 months fol-
low-up). These findings are nearly consistent with our
results.
Unlike mandibular setback surgery, there were no
significant upper airway changes 2 years after bimax-
illary surgery. A reason might be that the advancement
of the velum and velopharyngeal muscle caused by
LeFort I osteotomy partly decreased the constricted
effect of BSSO.13 Significant maxillary advancement
was obtained from the LeFort I osteotomy, whereas no
significant change was obtained in group B. Another
reason might be that the extent of mandibular setback
was less in bimaxillary surgery than in mandibular
setback surgery.2 Although there was no significant
difference in mandibular retraction in the 2 groups after
surgery, a trend for less retraction was shown.
The exact cause of OSA remains unclear, and
controversy surrounds its pathogenesis, which seems to
have a multifactorial origin. Some have theorized that
changes in either the neurologic control of the upper
airway20,21 or the pharyngeal structures are responsible
for this ailment.22 Obesity is a significant issue for
OSA, and some studies suggest that fat deposition
adjacent to the pharyngeal airway plays a role in the
pathogenesis of OSA.23 It was postulated that the inflam-
matory process increases the thickness of the velum and
narrows the upper airway. Sekosan et al24 and Zakkar et
al25 showed that decreases in neutral endopeptidase
results in soft palate and uvular submucosal inflamma-
tion and upper airway obstruction in patients with OSA.
However, Berger et al26 indicated that pathologic
changes such as vascular engorgement, fibrosis, edema,
and inflammatory cell infiltration were probably the
376 Chen et al
sequelae of airway obstruction rather than its cause.
Although the cause of OSA remains poorly understood,
it is well established that, in apneic patients, pharyngeal
airway volumes are smaller than in normal subjects and
are associated with increased airway resistances.23
Studies were also performed to quantify normal
values for the PAS and values in patients with
OSA.27,28 Based on lateral cepholmetric analysis, many
studies indicate that the anatomic alterations for OSA
are inferior displacement of the hyoid bone and, con-
sequently, posterior displacement of the base of the
tongue. Pertinent et al27 noted in 157 OSA patients that
those with PAS widths of less than 5 mm (measured
from the base of the tongue to the posterior pharyngeal
wall along a line drawn through Point B and gonion)
and a mandibular plane to hyoid distance greater than
24 mm had the highest respiratory distress index. Riley
et al28 showed that a PAS of less than 11 mm and a
mandibular plane to hyoid distance greater than 15.4
mm indicated OSA.
Although it was reported that decreases in pharyn-
geal airway size after orthognathic surgery rarely lead
to OSA,13 4 patients in group A reported temporary
snoring after surgery. PAS narrowing is possibly a
predisposing factor for OSA. According to this study,
we could expect less narrowing in the oropharyngeal
and hypopharyngeal areas after bimaxillary surgery in
comparison with mandibular setback surgery alone.
Therefore, the surgeon should prefer bimaxillary sur-
gery rather than only mandibular setback surgery to
correct a Class III deformity. This holds true especially
if the patient has other predisposing factors for the
development of OSA, such as obesity, short neck,
macroglossia, large uvula, or excessive soft tissue
around the nasopharyngeal area.29
Although our subjects all underwent BSSO, there
are other operations for orthognathic surgery such as
the transoral vertical oblique ramus osteotomy. Future
studies should investigate long-term PAS changes with
other orthognathic surgeries.
CONCLUSIONS
1. Cephalometic evaluation of patients undergoing
mandibular setback surgery showed a significant
reduction at the oropharyngeal and hypopharyngeal
levels over the short and long terms.
2. In contrast, bimaxillary surgery caused an increase
at the nasopharyngeal level and decreases at the
oropharyngeal and hypopharyngeal levels only in
the short term, whereas no significant change was
seen in the long term.
American Journal of Orthodontics and Dentofacial Orthopedics
March 2007
Bimaxillary surgery therefore might have less effect
on reduction of the pharyngeal airway than mandibular
setback surgery only. The surgeon should consider
bimaxillary surgery rather than mandibular setback
surgery to correct a Class III deformity to prevent the
development of OSA.4
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