Accepted Manuscript

Effects of bimaxillary orthognathic surgery on pharyngeal airway and respiratory

function at sleep in patients with class III skeletal relationship

Tahsin Tepecik, Ümit Ertaş, Metin Akgün

PII: S1010-5182(18)30022-2
DOI: 10.1016/j.jcms.2018.01.009
Reference: YJCMS 2893

To appear in: Journal of Cranio-Maxillo-Facial Surgery

Received Date: 19 October 2017

Revised Date: 18 December 2017
Accepted Date: 22 January 2018

Please cite this article as: Tepecik T, Ertaş Ü, Akgün M, Effects of bimaxillary orthognathic surgery on
pharyngeal airway and respiratory function at sleep in patients with class III skeletal relationship, Journal
of Cranio-Maxillofacial Surgery (2018), doi: 10.1016/j.jcms.2018.01.009.

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 ACCEPTED MANUSCRIPT
Effects of bimaxillary orthognathic surgery on pharyngeal airway and respiratory

function at sleep in patients with class III skeletal relationship

Tahsin Tepecik, Ümit Ertaş, Metin Akgün

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Tahsin Tepecik, DDS, Research Assistant, Atatürk University Faculty of Dentistry,

Department of Oral and Maxillofacial Surgery, Erzurum, Turkey

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Ümit Ertaş, PhD, DDS, Professor, Atatürk University Faculty of Dentistry, Department of

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Oral and Maxillofacial Surgery, Erzurum, Turkey
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Metin Akgün, MD, Professor, Atatürk University Faculty of Medicine, Department of

Pulmonary Diseases, Erzurum, Turkey

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Corresponding Author: Tahsin Tepecik, DDS, Atatürk University, Faculty of Dentistry,

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Yakutiye, 25240, Erzurum, Turkey.

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Tel: 0090 544 551 15 21, Fax: 0090 442 236 13 75, e-mail; tahsintepecik@gmail.com
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Summary

Purpose: The aim of this study was to examine the effects of bimaxillary orthognathic

surgery on pharyngeal airway space (PAS) and respiratory function during sleep.

Materials and Methods: The subjects were 21 patients with class III skeletal relationship,

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and all of the patients underwent bimaxillary surgery (Le Fort I advancement and bilateral

sagittal split ramus setback osteotomies simultaneously). Pharyngeal volumes of

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nasopharyngeal (V-NPA), retropalatal (V-RPA), retrolingual (V-RLA), oropharyngeal (V-

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ORO) and total pharyngeal airways (V-TOT); minimum axial areas of retropalatal (MA-

RPA), retrolingual (MA-RLA) and oropharyngeal airways (MA-ORO); and position of the

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hyoid were studied in order to detect dimensional PAS changes using cone-beam computed
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tomography (CBCT) with Dolphin 11.8 software immediately before surgery (T1) and during

a period of 6-12 months postoperatively (T2) in all of the patients. Apnea–hypopnea index
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(AHI), respiratory disturbance index (RDI) and apnea in supine position (SupAHI) parameters
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were measured with a Compumedics E series full polysomnography system.

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Results: In volumetric measurements, the V-ORO parameter decreased significantly (p<0,05)

while there was no statistically significant change in the rest of the volumetric parameters
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(p>0,05). All of the minimum axial area parameters were decreased significantly (p<0,01).

Hyoid bone moved inferiorly (p<0,05) and posteriorly (p<0,05). None of the
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polysomnographic parameters changed significantly (p>0,05).

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Conclusion: Bimaxillary orthognathic surgery significantly narrowed PAS dimensions but

did not cause an increase in AHI, which is a critical determinant parameter for obstructive

sleep apnea syndrome.

Keywords: airway, cone beam CT, orthognathic surgery, OSAS, polysomnography

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INTRODUCTION

Orthognathic surgery is widely used to correct a variety of facial and jaws

discrepancies in which the position, esthetics, and functional capabilities of jaws and teeth are

not in harmony. Mandibular setback using bilateral sagittal split ramus osteotomy (BSSRO)

alone, or bimaxillary orthognathic surgery, which is a combination of BSSRO setback and Le

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Fort I advancement osteotomies, have commonly been used to treat skeletal class III

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malocclusion. Surgical skeletal movements change the positions of the jaws and soft tissues to

achieve necessary maxillomandibular relationship and esthetics, while they may also cause

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changes in the pharyngeal airway space (PAS) by pushing and stretching of soft tissues (Lye,

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2008; Hatab et al., 2015). AN
The issue of PAS size is important in orthognathic surgery patients who have skeletal

class III malocclusion, since the constriction might be the predisposing factor for obstructive
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sleep apnea syndrome (OSAS) (Chen et al., 2007; Lye, 2008). Guilleminault et al. first
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reported the development of OSAS in two patients who had previously undergone mandibular
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setback surgery for the treatment of mandibular prognatism in 1985, and since then, the

attention given to this subject has been growing (Guilleminault et al., 1985). The diagnosis is
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made by polysomnography (PSG), preferably laboratory-based, full-channel PSG, which is a

gold standart for evaluating OSAS.

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Many investigators have evaluated the patients who had undergone bimaxillary
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orthognatic surgery for the correction of class III skeletal relationship to evaluate the PAS size

or respiratory parameters during sleep for OSAS, but the number of studies investigating both

parameters simultaneously are very limited (Foltan et al., 2009; Demetriades et al., 2010;

Hasebe et al., 2011; Gokce et al., 2012; Gokce et al., 2014; Uesugi et al., 2014). Moreover,

only 2 of these studies used a 3D imaging technique (Gokce et al., 2014; Uesugi et al., 2014).

In order to assess the association between OSAS and PAS size, simultaneous evaluation of
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two parameters is necessary. The aim of this study was to evaluate the effects of bimaxillary

orthognathic surgery on the pharyngeal airway using CBCT scan, and respiratory function

with the full channel laboratory-based PSG during sleep in patients with class III skeletal

relationship.

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MATERIALS AND METHODS

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This prospective study included 21 consecutive patients (14 female, 7 male ) who had

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skeletal class III malocclusion and were treated with bimaxillary orthognathic surgery

(BSSRO setback and Le Fort I advancement) at Atatürk University, Faculty of Dentistry,

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Department of Oral and Maxillofacial Surgery, during the period July 2015 to August 2016.
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All patients provided written informed consent. Patients with craniofacial anomalies,

syndromes, and systemic diseases were excluded. All operations were performed by the same
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oral and maxillofacial surgeon (Ü.E.).

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All of the patients underwent CBCT examinations (NewTom FP, Quantitative

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Radiology, 110 kVp, 15 mA, 5.4 s typical X-ray emission time, 17-cm diameter and 13-cm

height scan volume; Verona, Italy) for assessment of surgical skeletal and pharyngeal airway
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changes 1 week before surgery (T1) and at more than 6 months after surgery (mean 8.10 ±
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2.23 months, range 6–12 months) (T2). The mean age of the patients at surgery was 23.19 ±
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6.53 years. The slice thickness was set at 0.5 mm. The patients were in supine position with a

pillow beneath the neck to facilitate adjusting Frankfort horizontal plane (FHP) perpendicular

to the floor. The patients were told to maintain head position, to keep the teeth in centric

occlusion, to not swallow, and to breathe smoothly during the scanning.

The CBCT data were converted into DICOM (Digital imaging and communication in

medicine) format, and 3D images of the craniofacial and pharyngeal airway morphology were
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reconstructed with a Dolphin Imaging software (Dolphin Imaging, Version 11.8, Chatsworth,

CA, USA). First, head orientation was performed using three-point plane. Horizontal

reference was the FHP, and it was obtained by uniting three points: the right and left orbitale

landmarks, which are the most inferior points of the orbital rims; and the right porion, which

is the uppermost point of the roof of the bony external auditory meatus. The midsagittal plane

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(MSP) was vertically oriented to the FHP and defined by the basion point, which is the most

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anterior point of the foramen magnum, and vomer bone. A plane perpendicular to the FHP

and MSP through the basion point served as a vertical reference plane (VRP).

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For the measurement of surgical skeletal changes and hyoid positions, 4 points were

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used on MSP: A-point, which is the most concave point of anterior maxilla; PNS, which is the
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posterior nasal spine; Pogonion (Pg), which is the most anterior point of the mandibular

symphysis; and Hyoidale (Hyo), which is the most antero-superior point of the hyoid bone.
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For the horizontal position analysis, perpendicular distances from A, Pg and Hyo points to

VRP were measured (A-H, Pg-H and Hyo-H) (Fig. 1). For the vertical position analysis,
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perpendicular distances from A, Pg, Hyo and PNS points to FHP were measured (A-V, Pg-V,
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Hyo-V and PNS-V) (Fig. 2). After the measurements were made on both the T1 and T2 scans,

the values of T1 were subtracted from T2 (T2-T1 = ∆T) so that surgical skeletal and hyoid
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changes were obtained.

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For the volume assessment, PAS was divided into 3 segments using the “sinus/airway”
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tool of the software (Fig. 3). These are the nasopharyngeal airway volume (V-NPA) (Fig. 4),

retropalatal airway voume (V-RPA) (Fig. 5), and the retrolingual airway volume (V-RLA)

(Fig. 6). The total pharyngeal airway volume (V-TOT) was obtained by the sum of all three

airway segments’ volumes. The oropharyngeal airway volume (V-ORO) was obtained by the

sum of V-RPA and V-RLA parameters. So we had 3 airway volume segments but 5 volume

parameters and the boundaries of these regions are described in figure 3. For the appropriate
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analysis of the pharyngeal airway, all 21 DICOM data were pre-analyzed on Dolphin

software, and the appropriate threshold values were calculated to reflect the optimal airway

boundaries for each patient. The average of all patients' thresholds of airway sensitivity was

found to be 50, and we set this value for each case. Then the volumes of each PAS segments

were measured by the Dolphin software on T1 and T2 scans.

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For the assessment of the maximum constriction of the pharynx, minimum axial area

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of the PAS was studied. Retropalatal minimum axial area (MA-RPA) and retrolingual

minimum axial area (MA-RLA) parameters were measured automatically by the software.

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The minimum axial area segmentation borders are the same as the ones determined for the

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volumetric measurements of spesific parameter. The lowest value among MA-RPA and MA-
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RLA was taken as an extra parameter which is the orofaringeal minimum axial area (MA-

ORO) (Figs. 4-6).

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Overnight full PSG monitoring was performed with the Compumedics E series Sleep
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System (Compumedics Sleep: Melbourne, Australia), at times T1 and T2 in the sleep

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laboratory of Atatürk University Research Hospital, Department of Pulmonary Diseases.

Apnea was defined as continuous cessation of airflow that lasts for ≥10 seconds, and
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hypopnea was defined as at least 50% reduction of airflow for ≥10 seconds with an oxygen

desaturation of ≥3% or an electroencephalogram-indicated arousal from sleep. Respiratory

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effort−related arousal (RERA) was defined as an event that does not meet the criteria of either
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apnea or hypopnea and that is characterized by reduction of airflow for ≥10 seconds, which

leads to electroencephalogram-indicated arousal without causing oxygen desaturation. The

apnea-hypopnea index (AHI) was calculated as the sum of apnea and hypopnea events per

hour of sleep. The respiratory disturbance index (RDI) was calculated as the sum of apneas,

hypopneas and RERAs per hour of sleep. AHI in supine position (SupAHI) was also
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calculated. These PSG data were evaluated by one researcher who is a specialist in pulmonary

diseases and sleep medicine (M.A.).

The ∆T values of all parameters were calculated. One examiner performed all the

measurements made on Dolphin software, and randomly chosen 15 patients’ measurements

were repeated after 2 weeks by the same examiner (T.T.). To evaluate the intraexaminer

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agreements, the intraclass correlation coefficient was used and showed a high rate of

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consonance between measurements. The Wilcoxon signed-rank test was used to assess the

presence of significant differences between preoperative (T1) and postoperative (T2) periods.

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For analysis of correlations, the Spearmans rank correlation test was used. For the processing

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and analysis of the data, SPSS 20.0 for Windows (SPSS Inc, Chicago, IL) was used.
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This research was approved by the Ethics Board of Atatürk University Faculty of

Dentistry (with decision dated July 10, 2015 and numbered 35).
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RESULTS
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The mean body mass index (BMI) values of the whole patient group at T1 and T2
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were 21.7 kg/ m2 and 21.8 kg/m2 , and there was no significant differences between the BMIs

(p=0,286).
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The means and standart deviations of ∆Ts of the patients’ surgical skeletal changes for
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maxillary advancement (A-H) was 3,22 ± 0,77 mm; for mandibular setback (Pg-H), it was

−3,39 ± 0,78 mm; for anterior maxillary impaction (A-V), it was −1,46 ± 1,06 mm; for

posterior maxilllary impaction (PNS-V), it was −1,11 ± 0,85 mm; and for upper positioning of

mandibular symphysis (Pg-V), it was −3,09 ± 1,73 mm, according to FHP and VRP shown in

Table 1.
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Dimensional PAS changes are summarized in Table 2. The hyoid bone statistically

significantly moved backward (p<0,05) and downward (p<0,05). Only the V-ORO parameter

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was significantly decreased (p<0,05), and there was no statistically significant change in the

rest of the volumetric parameters (p>0,05). All of the minimum axial area parameters showed

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significant decrease in PAS (p<0,01).

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There was no significant difference between AHI scores before and after the surgery

(p>0,05). AHI scores was increased in 8 of 21 patients and decreased in 10. In 3 patients,

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there was no change in AHI scores. Other polysomnographic parameters; SupAHI and RDI
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also did not show any significant changes after the surgery (p>0,05) (Table 3).
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In the analysis of correlation between surgical skeletal changes and PAS dimension

parameters including hyoid position changes, it was show that the amount of backward
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movement at the pogonion was significantly correlated with posterior movement of hyoid
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bone (p<0,01). The amount of upper positioning of anterior maxilla was significantly

correlated with anterior movement of hyoid bone (p<0,05). The amount of upper movement at
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the pogonion was significantly correlated with anterior movement of hyoid bone (p<0,05)
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(Table 4).
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In the examination of the correlation between hyoid bone movements and PAS

dimension parameters, the analysis showed that only the amount of backward movement of

hyoid bone was significantly correlated with reduction in V-RLA parameter (p<0,01) (Table

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There was no significant correlation between the PSG paramaters and volumetric, area

or hyoid position parameters (p>0,05) (Table 5).

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DISCUSSION

Constriction of PAS after orthognatic surgery performed for treating class III skeletal

malocclusion has drawn substantial attention in recent decades due to concern that it may lead

to the development of OSAS. Since pharyngeal airway dimensions are among the most

crucial factors that cause OSAS, it is important to examine the PAS dimensions. In this study,

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Dolphin 3D software was used to examine the DICOM data. This software has been shown to

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have high reliability for pharyngeal airway volume measurement (El et al., 2010;

Weissheimer et al., 2012). The limits that we used for PAS volume segmentations are the

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slightly modified versions of those used by Li et al. and Hatab et al. (Li et al., 2014; Hatab et

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al., 2015). It has been shown that the pharyngeal regions that are the most responsible for the
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collapse in OSAS patients are the posterior regions of the soft palate and tongue (Katsantonis

et al., 1993; Boudewyns et al., 1997). We used reference points on soft tissue instead of
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vertebral reference points when separating air segments. When vertebral points are used for

reference, the retropalatal and retrolingual regions, which are the most responsible for OSAS,
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are not exactly matched to their boundaries. Moreover, vertebral lengths, locations and upper
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or lower limits do not correspond to the same region in each patient, and, as a result, different

and irrelevant regions are compared. Therefore, it is more rational to measure retropalatal and
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retrolingual regions using points determined from the anatomical structures that make up or
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are adjacent to the borders of these very structures.

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There seem to be two main trends in the literature that report that after bimaxillary

orthognathic surgery is performed for treating class III skeletal deformity, the volume of total

pharyngeal airway is either narrowed (Hong et al., 2011; Kim et al., 2013; Brunetto et al.,

2014; Li et al., 2014; Shin et al., 2015) or remains unchanged (Jakobsone et al., 2010; Lee et

al., 2012; Park et al., 2012; Uesugi et al., 2014; Hart et al., 2015; Hatab et al., 2015), as in this

study. Gökçe et al. even reported an increase in the volume of total pharyngeal airway after
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bimaxillary surgery (Gokce et al., 2014). As there are differences in the segmentation of the

PAS between the studies, comparisons of subregions’ volumes are not as reliable as the total

volume comparisons. In the majority of studies, nasopharyngeal volume was reported to show

no significant change after bimaxillary orthognathic surgery despite a tendency to increase

(Park et al., 2012; Li et al., 2014; Uesugi et al., 2014; Hart et al., 2015). Thus our finding of

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V-NPA parameter is consistent with most of the literature but not with the findings of Lee et

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al., who reported an increase, and of Kim et al., who reported a decrease, in nasopharyngeal

volume after bimaxillary surgery (Lee et al., 2012; Kim et al., 2013). V-RPA finding, which

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did not show a significant change in our study, is consistent with the study of Hatab et al.

(Hatab et al., 2015). However, there are also researchers who reported significant constriction

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in retropalatal airway volume after the surgery (Park et al., 2012; Kim et al., 2013; Shin et al.,
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2015). While no change in the V-RLA parameter is consistent with some studies (Park et al.,
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2012; Hatab et al., 2015), there are also studies reporting a signifiant decrease (Kim et al.,

2013; Shin et al., 2015). A significant decrease was observed in the V-ORO parameter, which
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was obtained by combining V-RPA and V-RLA parameters, and this finding is consistent
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with some studies (Jakobsone et al., 2010; Lee et al., 2012; Li et al., 2014), but others (Uesugi

et al., 2014; Hart et al., 2015) reported no significant change. Such varying results in the
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literature can be attributed to the effects of factors such as differences in follow-up time (Shin

et al., 2015), maxillary advancement and mandibular setback amounts (Kim et al., 2016),
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pharyngeal airway segmentation limits (Brunetto et al., 2014; Kim et al., 2016), and

especially small samples. When the mean values of the changes in the volumetric parameters

of our study are examined, it is seen that while there has been an increase in the V-NPA, all

other volumetric parameters have decreased. However, the statistically significant change is

seen only in the V-ORO as a decrease. This region reflects the sum of the V-RLA and V-RPA

parameters, which are the most responsible zones for OSAS, and therefore one should not be
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overly optimistic about an unchanged V-TOT, as it is created by the involvement of the V-

NPA, which is hardly responsible for OSAS. So it seems that maxillary advancement has

been insufficient to compensate for the constrictive effects of mandibular setback surgery as it

is seen on the significantly decreased V-ORO parameter, but on the contrary, this has acted as

a balancer for the V-TOT parameter.

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When the pharyngeal airway is evaluated in terms of OSAS, it is considered that the

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narrowest area information of the airway is more important than the area information from a

predetermined fixed point. The reason for this is that the most important factor in resistance to

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air flow according to Poiseuille's law is the degree of contraction. For this reason, some

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investigators have emphasized that the change in minimum axial area may also be more
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important than the change in total volume (Haskell et al., 2009; Lenza et al., 2010). According

to Schendel et al., as the axial area narrows, the risk of apnea and OSAS tendency is also
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increasing (Schendel et al., 2014). Therefore, the minimum axial areas, which are the areas

where collapse and resistance are most likely to occur in the development of OSAS, were
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examined, and fixed reference points were not used. In patients who have undergone
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bimaxillary orthognathic surgery, the number of studies evaluating the minimum axial area of

the pharyngeal airway before and after treatment is very limited. Panou et al. and Hart et al.
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reported that minimal axial area of PAS did not undergo significant changes after bimaxillary
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orthognathic surgery (Panou et al., 2013; Hart et al., 2015). Kim et al., on the other hand,
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reported that the minimal axial area of PAS decreased significantly after treatment in patients

who had undergone bimaxillary surgery, and this result is consistent with our findings (Kim et

al., 2016). MA-RPA, MA-RLA and MA-ORO parameters all decreased significantly.

Significant reductions of the MA-RPA and MA-RLA without significant decreases in the

associated volume parameters are the evidence that the volume parameter may not provide

information in the same direction as the minimum axial area parameter and may not be
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interpreted in the same way. In a situation in which only the volume parameter is measured, it

may be missed from the point that the narrowest area of the airway is narrowed, and may

cause misinterpretation. If the regions that are most likely to collapse are thought to be

regions where the surfaces are closest to each other, the narrowest area is the region that

determines collapse, no matter how large the volume is, as in the form of an hourglass. When

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considered together with the significant decrease of the V-ORO parameter, which is actually

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the riskiest region for causing OSAS, significantly constricted axial area parameters should be

interpreted in support of the decrease in PAS size.

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In today's studies with 3D imaging techniques such as CT and CBCT, the hyoid
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location loses its importance, and the field of interest is shifting to volume and area

parameters. The importance of hyoid bone is that the position of the hyoid bone is affected by
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suprahyoid and infrahyoid muscle tone, tongue position and mandible position, and the
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thought that the movement of the hyoid bone would correlate with the narrowing of the PAS,
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especially the inferior and posterior movements. Most of the studies (Gu et al., 2000; Foltan et

al., 2009; Gokce et al., 2012) confirm this idea, but there are also studies reporting changes in
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the PAS without a significant change in the hyoid bone position (Turnbull et al., 2000) and

that reporting no change in the PAS while the hyoid position has significantly changed (Park
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et al., 2010; Goncales et al., 2014). In our study, it was seen that the hyoid bone was displaced
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infero-posteriorly, which is consistent with the findings of the most studies in the literature

(Kim et al., 2013; Li et al., 2014; Shin et al., 2015).

In addition to the AHI, which is a determinant parameter for the diagnosis of OSAS,

the RDI parameter developed for upper airway resistance syndrome (UARS), which, although

it has not yet been accepted as a distinct sleep-related breathing disorder with a broad

consensus (Sateia, 2014) and the AHI parameter is observed in the supine position (SupAHI),
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it has been included in the study. The SupAHI parameter was included in the study to

examine the most appropriate relationship between the pharyngeal airway morphology that

was scanned in the supine position and apnea events at the same position. In our study, no

statistically significant change was seen in any of the PSG parameters. Studies with PSG in

the laboratory environment in patients who underwent bimaxillary orthognathic surgery for

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treating class III skeletal deformity are very limited (Hasebe et al., 2011; Gokce et al., 2012;

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Gokce et al., 2014). It is known that sleep evaluations made with portable PSG devices are not

at the same confidence level as PSG data applied in the laboratory environment.(Kushida et

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al., 2005; Foltan et al., 2009). For this reason, our findings will be compared only with the

PSG studies made in the laboratory environment. In 2012, Gökçe et al. examined 21 male

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patients who underwent bimaxillary orthognathic surgery with full-channel PSG, and they
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reported that the AHI scores have not changed (Gokce et al., 2012). They also investigated
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linear antero-posterior PAS dimensions on lateral cephalograms and noted that upper

compartments of the PAS (velopharynx and nasopharynx) were widened whereas lower
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compartments (oropharynx and hypopharynx) were narrowed. The same researchers

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conducted a similar study in 2014, but this time using 3D airway volume analysis with CT in

25 male patients who underwent bimaxillary surgery. The authors reported that AHI scores
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decreased significantly and that an increase in the volumes of superior compartment of the

total airway and the total airway itself, but a decrease in the lower and middle compartments
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of the airway, were detected (Gokce et al., 2014). The authors noted that the increase in total

airway may be due to advancement of velopharyngeal tissues with Le Fort I osteotomy. This

may also have caused the PSG parameters to improve. Increased total airway volume and

improved PSG parameters can be interpreted as the superiority of the advancement effects of

the Le Fort I osteotomy over the negative effects of the BSSRO setback component, and these

findings are clearly in contradiction to our results. The reasons for this discrepancy may be
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the methodological differences, such as differences in volume segmentation limits and/or the

amount of skeletal surgery changes, which are also different from our study. Hasebe et al.

evaluated the patients who underwent one-jaw and two-jaw surgeries in terms of airway

dimensions in cephalometric radiography and sleep quality with PSG, and they reported no

statistically significant change in linear airway dimensions in any group except the group with

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hyoid bone displacement to the inferior in one-jaw surgery (Hasebe et al., 2011). They also

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reported that the AHI parameter did not show any significant change in any group, which is in

agreement with our results.

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Posterior mandibular movements at the Pg point showed a correlation with the

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backward movement of the hyoid bone. This is an expected result of the backward positioning
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of the mandibular bone. Maxillary superior movements at point A showed correlations with

the anterior movement of the hyoid bone. A similar relationship has also been observed in the
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upward positioning of the chin. Superior movements at the Pg point showed correlations with

the anterior movement of the hyoid bone. This can be interpreted as stretching of the muscles
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connecting the hyoid bone to the mandible due to the anticlockwise vector. This suggests that
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all of the anterior superior positioning of the maxilla and mandible affects the hyoid bone;

and, contrary to what is expected, the reason why the movement of the hyoid bone was not in
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the vertical plane but in the horizontal one may be the adaptive muscle tone changes.
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The correlation analysis between hyoid bone movements and PAS dimensions showed
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that only the posterior movements of the hyoid bone correlated with a decrease in the V-RLA.

However, since the tendency of the hyoid bone to return to its original position with

physiological adaptation may vary from person to person, our results are incompatible with

the studies that included correlation analysis and that are also very limited in number. Kim et

al. reported that at 2 months postoperatively, posterior movement of the hyoid bone was

correlated with the decrease in total airway volume; however, interestingly, inferior
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movement of the hyoid bone was correlated with an increase in the total, nasopharyngeal and

oropharyngeal (this region was defined within the boundaries that correspond to our V-RPA

parameter) airway volumes, which they explained with the compensatory rearrangements of

the pharyngeal complex (Kim et al., 2013). They found no correlation at all at 6 months

postoperatively. Shin et al. reported that vertical and horizontal positions of hyoid bone were

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not correlated with any volume changes at the sixth month, first and second years of controls

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in 15 patients who had bimaxillary orthognathic surgery (Shin et al., 2015).

No correlation was found between the PAS dimensions and PSG parameters. In the

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literature, the number of studies examining the correlation between the pharyngeal

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dimensional changes and the polysomnographic changes after bimaxillary surgery is limited.
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Gökçe et al. reported that after the bimaxillary surgery, increases in pharyngeal dimensions

such as volume and cross-sectional area parameters correlated with the decreases in AHI (
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Gökçe et al., 2014). Uesugi et al. performed isolated SSRO and bimaxillary surgeries in

patients who had mandibular prognathism, and they reported that neither the isolated SSRO
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surgery group nor the bimaxillary surgery group showed any correlations between the PAS
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dimensions and the AHI parameter (Uesugi et al., 2014).

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CONCLUSION
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In conclusion, despite the unchanged total pharyngeal volume, bimaxillary

orthognathic surgery for class III malocclusion significantly decreased oropharyngeal

volumetric and areal dimensions of PAS without causing any deterioration in respiratory

functions at sleep, and caused the hyoid bone to move inferoposteriorly. This suggests that the

bimaxillary surgery for treating class III skeletal relationship is a safe procedure in terms of

OSAS. The main shortcoming of this study is that the number of samples is low, and therefore
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it will be useful to conduct future studies over long-term periods and in larger groups of

patients with 3D imaging systems and to include standardized volumetric and minimum axial

area parameters.

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Conflict of interest

No authors have any financial and personal relationships with other persons or organisations

that could inappropriately influence (bias) their work. There are no conflicts of interests to

disclose.

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Table 1. Surgical skeletal changes (mm) ( n=21)

Parameter Mean ± Minimum Maximum

Standard

Deviation

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Pg-H(∆T) –3,39 ± 0,78 –5,80 –2,20

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A-H(∆T) 3,22 ± 0,77 2,10 4,70

A-V(∆T) –1,46 ± 1,06 –3,00 –0,20

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Pns-V(∆T) –1,11 ± 0,85 –2,70 –0,10

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Pg-V(∆T) –3,09 ± 1,73 –5,50 0,70
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H, horizontal perpendicular distance from the associated points to the

VRP; V, Vertical perpendicular distance from the associated points to

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the FHP; ∆T, Difference between the T2 and T1 (T2–T1). Negative

values indicate backward or upward movement, positive values indicate

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forward or downward movement.

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Table 2. Differences in PAS measurements (n=21).*

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Measurement Parameter T1 T2 ∆T p Value

Hyoid bone Hyo-H 40,74±5,96 39,61±6,08 –1,12±2,39 0,018

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movements Hyo-V 82,91±8,02 83,60±7,73 0,68±1,92 0,030

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Volumetric V-NPA 3573,97±1743,04 3685,85±1669,46 111,88±893,82 0,114

changes (mm3) V-RPA 8260,78±3390,02 7955,05±3839,19 –305,73±1479,03 0,305

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V-RLA 4072,55±2713,95 3589,38±2356,46 –483,18±1299,53 0,058

V-ORO 12333,33±5794,17 11544,43±5518,48 –788,90±1331,43 0,023

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V-TOT 15907,30±6415,59 15230,28±5811,72 –677,02±1842,87 0,122

Minimum axial MA-RPA 181,41±90,62 158,43±81,07 –22,98±38,47 0,005

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area changes MA-RLA 230,66±69,16 197,30±64,09 –33,36±32,96 0,000

(mm2) MA-ORO 175,60±83,94 151,55±73,17 –24,05±35,73 0,005

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Hyo-H, horizontal perpendicular distance from the Hyo point to the VRP; Hyo-V, vertical perpendicular

distance from the Hyo point to the FHP. For hyoid bone movements, negative values indicate backward

or upward movement, positive values indicate forward or downward movement. V, volume of the

associated airway segment; MA, minimum axial area of the associated airway segment; NPA, nasopalatal

airway segment; RPA, retropalatal airway segment; RLA, retrolingual airway segment; ORO,
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oropharyngeal airway segment; TOT, total airway segment; T1, 1 week preoperatively; T2, 6–12 months

postoperatively; ∆T, Difference between T2 and T1 (T2–T1).

*Values are given as the mean ± standard deviation.

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Table 3. Differences in PSG measurements (n=21).*

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Parameter T1 T2 ∆T p Value
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AHI changes 3,34 ± 2,85 4,23 ± 4,57 0,89 ± 2,74 0,286

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(events/h)

SupAHI changes 5,41 ± 7,12 5,43 ± 8,89 0,02 ± 7,12 0,385

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RDI changes 6,35 ± 3,99 5,34 ± 4,76 -1,01 ± 4,41 0,322

(events/h)

Wilcoxon signed-rank test was used.

AHI, apnea–hypopnea index; SupAHI, AHI in supine position at sleep; RDI, respiratory

disturbance index; T1, 1 week preoperatively; T2, 6–12 months postoperatively; ∆T,
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difference between T2 and T1 (T2–T1).

*Values are given as the mean ± standard deviation.

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Table 4. Analysis of correlation between the surgical skeletal changes and PAS dimension

parameters (n=21).

Parameter Pg- A- A-V(∆T) Pns- Pg- Hyo- Hyo-

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H(∆T) H(∆T) V(∆T) V(∆T) H(∆T) V(∆T)

Hyo-H(∆T) ρ 0,568** 0,263 –0,469* –0,404 –0,500* 1 0,092

Hyo-V(∆T) ρ 0,043 –0,061 0,147 0,146 –0,079 0,092 1

V-NPA(∆T) ρ 0,123 –0,206 0,140 0,199 0,270 –0,247 –0,370

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V-RPA(∆T) ρ 0,215 0,139 –0,210 –0,380 0,120 0,144 –0,223

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V-RLA(∆T) ρ 0,213 0,080 –0,042 –0,051 –0,341 0,559** 0,090

V-ORO(∆T) ρ 0,156 –0,079 –0,073 –0,232 0,177 0,281 –0,173

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V-TOT(∆T) ρ 0,155 –0,148 –0,041 –0,050 0,304 0,121 –0,282

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MA-RPA(∆T) ρ 0,147 0,060 0,128 –0,147 0,161 –0,031 –0,137
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MA-RLA(∆T) ρ 0,089 0,186 0,063 0,122 –0,144 0,279 0,140
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ρ 0,159 –0,032 0,146 –0,072 0,178 0,041 –0,189
ORO(∆T)
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ρ: Spearman's rank correlation coefficient

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* : p<0,05 / **: p<0,01

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Table 5. Analysis of correlation between the PAS dimensions and

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polysomnographic changes (n=21).

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Parameter AHI(∆T) SupAHI(∆T) RDI(∆T)

V-RLA(∆T) ρ –0,136 0,091 0,152

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V-RPA(∆T) ρ 0,328 0,001 0,392

V-ORO(∆T) ρ 0,013
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V-NPA(∆T) ρ –0,234 –0,133 –0,261
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V-TOT(∆T) ρ –0,081 0,021 0,096

MA- ρ –0,116 0,289 0,040

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RLA(∆T)
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MA- ρ 0,254 0,006 0,373

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RPA(∆T)

MA- ρ 0,156 0,080 0,290

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ORO(∆T)
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Hyo-H(∆T) ρ 0,033 0,067 0,224

Hyo-V(∆T) ρ 0,111 0,144 0,102

ρ: Spearman's rank correlation coefficient.

*p<0,05; **p<0,01.
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Figure 1. Measurements used in horizontal position analysis. In the midsagittal plane,

perpendicular distances of points A, Pg and Hyo to the vertical reference plane were measured

as A-H, Pg-H and Hyo-H consecutively. A = A-point, which is the most concave point of the

anterior maxilla; Pg = Pogonion, which is the most anterior point of the mandibular

symphysis; Hyo = Hyoidale, which is the most antero-superior point of the hyoid bone.

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Figure 2. Measurements used in vertical position analysis. In the midsagittal plane,

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perpendicular distances of points A, Pg, Hyo and PNS to the Frankfort horizontal plane were

measured as A-V, Pg-V, Hyo-V and PNS-V consecutively. A = A-point which is the most

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concave point of the anterior maxilla; Pg = Pogonion, which is the most anterior point of the
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mandibular symphysis; Hyo = hyoidale, which is the most antero-superior point of the hyoid

bone; PNS = posterior nasal spine.

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Figure 3. Image of the boundaries of 3 PAS segments. The nasopharyngeal airway volume
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(V-NPA) had the following limits: the line passing between PNS and ala of vomer is its

anterior border, the line passing through the most superior point of the PAS is its superior
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border and the line parallel to the FHP passing through the PNS point is the inferior border of
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the V-NPA . Retropalatal airway volume (V-RPA) had the following limits: the line
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perpendicular to the FHP passing through the PNS point is its anterior border, inferior border

of V-NPA is its superior border and the line parallel to the FHP passing through the tip of the

uvula is the inferior border of V-RPA. Retrolingual airway volume (V-RLA) has the same

anterior border with V-RPA parameter, inferior border of V-RPA is its superior border and

the line parallel to the FHP passing through the top of the epiglottis is its inferior border. The

total pharyngeal airway volume (V-TOT) was obtained by the sum of all three airway
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segments’ volumes. The oropharyngeal airway volume (V-ORO) was obtained by the sum of

V-RPA and V-RLA parameters. Note that 5 volumetric airway parameters were calculated

from 3 volumetric airway segments.

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Figure 4. Change in the V-NPA in one of the patients from the side view of PAS. (A)

Situation before the surgery (T1). (B) Situation after the surgery (T2). In this patient, V-NPA

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Figure 5. Same patient in Fig.4. Change in the V-RPA and MA-RPA from the side view of

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PAS. (A) Situation before the surgery (T1). (B) Situation after the surgery (T2). The line
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passing through the airway segment at the top of the image and the circle located in the 3-D
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segment of V-RPA at the bottom, show the position of the minimum axial area detected by

the software. In this patient, both V-RPA and MA-RPA were decreased.
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Figure 6. Same patient as in Figures 4 and 5. Change in the V-RLA and MA-RLA from the
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side view of PAS. (A) Situation before the surgery (T1). (B) Situation after the surgery (T2).

The line passing through the airway segment at the top of the image and the circle located in
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the 3-D segment of V-RPA at the bottom, show the position of the minimum axial area
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detected by the software. In this patient, both V-RLA and MA-RLA were decreased.
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