Received: 5 December 2018 | Accepted: 7 December 2018

DOI: 10.1111/ocr.12291

SUPPLEMENT ARTICLE

3D Airway changes using CBCT in patients following

mandibular setback surgery ± maxillary advancement

Andrew G. Havron1 | Sharon Aronovich2 | Anita V. Shelgikar3 | H. Ludia Kim4 |

R. Scott Conley5

1
Department of Orthodontics and Pediatric
Dentistry, University of Michigan, Ann Structured Abstract
Arbor, Michigan Introduction: The aim of this study was to determine the 3D airway changes that
2
Department of Oral and Maxillofacial
occur following mandibular setback surgery alone vs bimaxillary surgery in patients
Surgery, University of Michigan, Ann Arbor,
Michigan with similar skeletal start forms.
3
Department of Neurology, University of Setting and Sample Population: The University of Michigan School of Dentistry and
Michigan, Ann Arbor, Michigan
Medical Center. A total of 85 patients undergoing mandibular setback with or with-
4
Private Practice, Ann Arbor, Michigan
5
out simultaneous maxillary advancement.
Department of Orthodontics, University at
Buffalo, Buffalo, New York Materials and Methods: A retrospective evaluation of pre-­and post-­surgical CBCT
scans for patients undergoing mandibular setback surgery alone (14) vs bimaxillary
Correspondence
R. Scott Conley, University at Buffalo School surgery (71) was performed. Cross-­sectional evaluation at standardized locations,
of Dental Medicine, Buffalo, NY. minimum cross section and volumetric analysis were performed (Dolphin Imaging &
Email: [email protected]
Management Solutions).
Results: Patients who underwent mandibular setback surgery alone showed a statis-
tically significant average increase of 47.5 mm2 in minimum axial area. Patients who
underwent bimaxillary surgery showed a statistically significant increase in airway
volume, minimum axial area, location of minimum axial area, and axial area at the re-
tropalatal and retroglossal regions.
Conclusions: The results demonstrate that the mandible can be setback safely with-
out decreasing airway dimensions. In borderline OSA patients, bimaxillary surgery
remains the preferred approach due to the larger airway increases observed. Long-­
term follow-­up with polysomnography must be conducted to determine the full func-
tional implications of both procedures.

KEYWORDS
airway remodelling, cone beam computed tomography, orthognathic surgery

1 | I NTRO D U C TI O N dental and skeletal malocclusion is a combination of improper align-

ment/relationship of the teeth along with improper position of the
Patients who seek orthodontic care have either a dental malocclu- bony bases of the maxilla and/or mandible.
sion, skeletal malocclusion, or a combination of the two. Dental mal- Class III skeletal malocclusion is a condition frequently seen in
occlusions are best described as improper alignment or relationship orthodontic practice, but is less common than Class II malocclu-
of the teeth with properly positioned maxillary and mandibular skel- sion. According to data from the third National Health and Nutrition
etal bases. Skeletal malocclusion is best described as an improper Examination Survey (NHANES III), a fraction of one per cent of
position of the bony bases of the maxilla, the mandible, or both, with American adult patients present with Class III malocclusion.1 Despite
normal alignment of the teeth over the bony bases. A combined this relatively small figure, a high percentage of those patients seek

30 | © 2019 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/ocr Orthod Craniofac Res. 2019;22(Suppl. 1):30–35.
Published by John Wiley & Sons Ltd
HAVRON et al. | 31

treatment due to the resulting functional and aesthetic concerns. compared to bimaxillary surgery for the correction of Class III skel-
Recent data indicate that over half of the patients presenting with etal deformity. The hypothesis is that mandibular setback surgery
skeletal Class III malocclusion will require surgical intervention. 2 will result in airway reduction while bimaxillary surgery will result in
A Class III skeletal pattern involves a relative or absolute pro- airway increase.
trusion of the mandible compared to the maxilla. This can be due
to true mandibular prognathism, true maxillary retrognathism, or a
combination of the two.3 A large percentage of patients will have 2 | M ATE R I A L S A N D M E TH O DS
some degree of both mandibular prognathism and maxillary retrog-
nathism; yet a Class III malocclusion resulting from hyperplasia of the Institutional review board exemption (#HUM00083483) was
mandible alone, or hypoplasia of the maxilla alone, is relatively rare. granted for this retrospective study. Inclusion criteria included adult
While on the surface Class III patients appear to have a larger-­than-­ patients with pre-operative and post-operative CBCT scans who
normal mandible, it is estimated that approximately 75% of patients underwent either mandibular setback alone or mandibular setback
diagnosed with a skeletal Class III malocclusion have maxillary ret- with maxillary advancement for the correction of Class III skeletal
4
rognathism as a component of their diagnosis. Class III malocclu- malocclusion. To account for variability in head position, only pa-
sion is widely believed to have an important genetic component, and tients with consistent head posture (<5°) as assessed by measuring
studies have found multiple genetic loci associated with Class III mal- the craniocervical angle (N-­S-­Ba) were included. Chart review iden-
occlusion.5-7 The term “Hapsburg jaw” has been used in the past as a tified 124 Class III surgical patients; 85 patients met the inclusion
descriptor for Class III skeletal malocclusion, named after the family criteria. The final groups included 14 mandibular setback alone and
dynasty which had a strong predilection for prognathic mandibles.8 71 two-­jaw surgery patients. (Table 1).
Class III malocclusion can be treated by several different means All scans were obtained with an EWOO Master 3DS™ CBCT
depending on the diagnosis and age of the patient. During adoles- scanner (EWOO Technology USA Inc., Houston, TX). The scan pa-
cence, orthopaedic growth modification such as chin cup therapy 9 rameters were 90.0 kV, 3.3 mA, 20 × 19 cm field of view, 15-­seconds
and reverse-­pull facemask therapy10 can be considered as well as exposure time, normal quality mode, 0.2 mm slice thickness, and
a new technique involving bone-­
anchored maxillary protraction isotropic voxel size of 0.40 mm. All CBCT scans were de-­identified,
plates.11 labelled, and saved in DICOM format.
Dental Class III can commonly be treated with full fixed appli- Pre-­and post-­surgical cephalograms were extracted from the
ances and elastic wear12 with or without interproximal reduction.13 CBCT for every patient. The cephalograms were digitally traced and
Orthognathic surgery, while often thought of as a “last resort,” can analysed using the COGS Analysis (Dolphin Imaging & Management
in fact be the only reasonable option in a case with a severe skeletal Solutions, Oakdale, CA).
imbalance and compromised facial aesthetics.
Until the 1980s, mandibular setback using the bilateral sagittal
2.1 | Three-­dimensional analysis
split osteotomy (BSSO) or and intraoral vertical ramus osteotomy
(IVRO)14 was the standard form of surgical correction.15 More re- Prior to analysis, all scans were reoriented. In the coronal plane, the
cently, practice trends have shifted to maxillary advancement with right and left inferior orbital borders were levelled. Sagittaly, the
or without mandibular setback in part due to concern that mandib- best fit of the zygomatic arch was levelled. Axially, the lateral walls
ular setback surgery, while beneficial to the facial profile and occlu- of the orbits were aligned.
sion may have a negative impact on a patient's pharyngeal airway The airway volume (Figure 1) was bounded superiorly by the
16
space (PAS). Studies have used two dimensional (2D) lateral ceph- line extending from posterior nasal spine (PNS) to the posterior
alometric films pre-­and post-­operative radiographs of patients un- pharyngeal wall and inferiorly by a parallel line from the anterior-­
dergoing mandibular setback surgery to measure airway changes, inferior border of C3 to the base of the tongue. The posterior limit
and many reports suggest setback leads to a decreased PAS in the was the posterior pharyngeal wall, and the anterior boundary was
17-33
short term. created by the soft palate and base of the tongue. Three seed
While 2D lateral cephalograms are reproducible, the airway is
a dynamic three-­dimensional (3D) structure. Cone beam computed TA B L E 1 Surgical groupings

tomography (CBCT) is an imaging modality that is becoming more Type of surgical

widespread in orthodontic, and orthognathic surgery discipline be- Group procedure performed Pre-­ANOVA Post-­ANOVA
cause it provides an accurate 3D representation of the airway and 1 Jaw IVRO/BSSO 14 14
surrounding structures while also exposing the patient to signifi- 2 Jaw Lefort +BSSO/IVRO 71 41
cantly less radiation than would be experienced with conventional
85 total 55
medical computed tomography or a combination of other normal
The full group of patients who underwent the assigned procedures was
dental diagnostic imaging.34 More study is clearly needed in this
collected. Prior to subgroup analysis, ANOVA was performed to estab-
area. The goal of this study was to evaluate the amount and loca- lish similar start forms for the two groups yielding the final study
tion of airway changes resulting from mandibular setback surgery population.
32 | HAVRON et al.

F I G U R E 1 A representative CBCT
airway segmentation. Mid-­sagittal slice
from CBCT depicting the “seed” points
(yellow dots), airway region of interest
(yellow box) and airway volume (purple
area)

points were placed in the region of interest, and airway sensitivity

3.2 | Three-­dimensional results
was set to 73. Each scan was assessed for “bleed through” and
identified areas were removed by adjusting the sensitivity and Three-­dimensional measurements were taken to assess several pa-
seed points. rameters of the pre-­and post-­operative airway, including airway
Minimum axial airway was determined for entire airway as well as volume, minimum axial area, minimum axial area distance superior
the retropalatal (anterior-­inferior border of C1), retroglossal (anterior-­ to inferior border, axial area at inferior border of C1 (retropalatal)
inferior of C2) and retropharyngeal (anterior-­inferior C3) regions. and axial area at inferior border of C2 (retroglossal). Measurement
of the craniocervical angle was also recorded. The results are shown
in Table 3. Mandibular setback alone patients experienced a statis-
2.2 | Statistical analysis
tically significant increase in minimum axial area. All of the other
Paired t tests were performed for 2D and 3D comparison of pre-oper- airway measures were unchanged and no airway reductions were
ative to post-operative changes within groups. Welch's unpaired t test observed. Two-­jaw patients experienced statistically significant in-
was used to compare the changes pre and post surgically between the creases in airway volume, minimum axial area, vertical location of
mandibular setback alone and the two-­jaw surgery groups. the minimum axial area, and the axial areas at both C1 (retropalatal
For intra-­and inter-­examiner reliability, a random number gener- region) and C2 (retroglossal region). The only statistically significant
ator was used to select 10 subjects from both groups. The measure- difference between groups was a change in axial area at the inferior
ments were repeated 2 months after the initial measurements. Both border of C1 (or retropalatal region) only.
intra-­and inter-­examiner reliability tests exhibited high correlation
ranging from 0.99 to 0.987 for all measures.
4 | D I S CU S S I O N

4.1 | Cephalometric evaluation

3 | R E S U LT S
Because all patients underwent orthognathic surgery, it was ex-
The initial sample yielded 14 mandibular setback and 71 two-­jaw sur- pected that several skeletal cephalometric measurements would
gery patients. The sample was refined to establish groups with identical show statistically significant changes consistent with the surgery
start forms and confirmed using ANOVA. The final sample included 14 performed. Patients who underwent a 1-­
jaw surgical procedure
mandibular setback and 41 two-­jaw surgery patients. (Table 2). showed statistically significant sagittal reductions in measurements
mandibular landmarks, such as B-­point, pogonion and gonion. The
measurements involving maxillary structures, such as Nasion to
A-­point, remained unchanged. The average amount of mandibular
3.1 | Cephalometric results
setback, based on cephalometric change, was 6.2 mm for the 1-­jaw
The mandible was setback 6.2 mm in the mandibular setback alone group.
group. Within the two-­jaw surgery group, the mandible was setback Patients undergoing 2-­jaw surgery showed statistically signifi-
a similar amount (5.6 mm) and the maxilla was advanced 4.5 mm cant changes in measurements that involved both the maxilla and
(Table 2). mandible. The average amount of mandibular setback, for the 2-­jaw
HAVRON et al. | 33

TA B L E 2 Cephalometric pre-­operative
Comparison of 1-­Jaw vs 2-­Jaw cephalometric subgroups
mean start forms for both 1-­jaw and 2-­jaw
patients after subgroup creation 1-­Jaw (n = 14) Pre-­Op 2-­Jaw (n = 41) Pre-­Op
Mean ± SD Mean ± SD P-­value

Ar-­PTM (HP) (mm) 32.09 ± 2.64 31.52 ± 3.31 0.6998

PTM-­N (HP) (mm) 55.94 ± 3.66 56.14 ± 3.99 0.7200
N-­A-­Pg (°) −1.11 ± 6.29 −7.40 ± 7.65 0.0835
N-­A (HP) (mm) −1.04 ± 3.23 −2.59 ± 4.39 0.3741
N-­B (HP) (mm) −1.49 ± 5.70 0.94 ± 9.50 0.5681
N-­Pg (HP) (mm) −1.16 ± 7.59 2.90 ± 11.39 0.4532
N-­ANS (perp HP) (mm) 56.27 ± 4.66 56.44 ± 4.05 0.6827
ANS-­Gn (perp HP) (mm) 72.19 ± 6.11 77.76 ± 8.40 0.1122
PNS-­N (perp HP) 54.85 ± 4.44 56.65 ± 4.39 0.8689
°
Mand Plane-­HP ( ) 31.87 ± 5.99 31.20 ± 6.67 0.7443
U1-­NF (perp NF) (mm) 29.55 ± 3.33 30.83 ± 4.63 0.8374
U6-­NF (perp NF) (mm) 25.05 ± 2.94 26.72 ± 3.25 0.4089
L6-­MP (perp MP) (mm) 29.53 ± 3.90 31.19 ± 3.85 0.4530
L1-­MP (perp MP) (mm) 39.96 ± 5.03 41.08 ± 3.73 0.7756
PNS-­ANS (HP) (mm) 54.47 ± 5.36 55.30 ± 4.60 0.6270
Ramus Height (Ar-­Go) 54.24 ± 5.98 58.99 ± 9.59 0.3394
(mm)
Go-­Pg (mm) 75.46 ± 7.56 76.39 ± 10.16 0.8380
B-­Pg (MP) (mm) 8.65 ± 2.28 10.62 ± 2.67 0.2716
°
Ar-­Go-­Gn ( ) 131.49 ± 4.62 131.85 ± 6.55 0.5367
OP-­HP (°) 9.36 ± 5.55 7.32 ± 6.29 0.3470
°
U1-­NF ( ) 118.59 ± 7.13 118.16 ± 8.11 0.6345
L1/Go-­Me (°)* 90.64 ± 5.81 84.46 ± 7.44 0.0157*
A-­B (//OP) (mm) 6.76 ± 2.37 9.69 ± 4.99 0.1817

*The lower incisor to mandibular plane measurement was disregarded as this is considered a dental
component.

TA B L E 3 Airway mean measurements after 2-­jaw patient exclusions

Comparison of similar 1-­Jaw and 2-­jaw patients undergoing different surgical procedures

1-­Jaw (n = 14) 2-­Jaw (n = 41)

Pre-­op Post-­op Chg Pre-­op Post-­op Chg P-­values

Airway volume 21.47 ± 7.36 22.60 ± 7.31 1.13 20.45 ± 7.89 24.73 ± 8.94 4.28 0.0672
(cm3)
Min. axial area 264.08 ± 111.97 311.61 ± 115.12 47.53 229.22 ± 117.39 272.32 ± 91.36 43.10 0.8649
(mm2)
Min. axial area 22.00 ± 12.52 22.25 ± 17.12 0.25 23.88 ± 14.41 16.66 ± 15.57 −7.22 0.2088
distance S-­I (mm)
Axial area at inf. 372.95 ± 118.26 397.17 ± 129.89 24.22 354.51 ± 145.64 427.86 ± 138.63 73.35 0.0472*
C1 (mm2)
Axial area at inf. 345.30 ± 129.67 384.91 ± 141.57 39.61 316.60 ± 180.06 369.33 ± 156.58 52.73 0.7428
C2 (mm2)
Craniocervical 107.18 ± 10.03 106.86 ± 8.21 −0.32 103.03 ± 8.09 102.57 ± 7.94 −0.46 0.9074
angle (°)

P-­values represent a comparison of how significant of a change occurred between pre-­and post-­operative measurements of 1-­jaw patients compared
to 2-­jaw patients.
*
P < 0.05.
34 | HAVRON et al.

group, was 5.6 mm. The average amount of maxillary advancement angulation can cause changes in airway form (eg head tilt chin lift
for the same group was 4.5 mm. manoeuvre in CPR). By controlling head position, the observed dif-
ferences reported can only be the result of surgery.
Based on the results of this study, fear of decreasing of patient's
4.2 | Three-­dimensional evaluation
PAS following mandibular setback surgery alone does not appear to
Previous studies have suggested that mandibular setback without be warranted. However, it is possible that long-­term follow-­up of these
maxillary advancement leads to a decreased pharyngeal airway patients could yield a different conclusion. The post-­operative scans
space (PAS).18 In the present investigation, the mandibular setback used in this study were taken, on average, 2 months post-­surgery. A
group showed a statistically significant increase in minimum axial study analyzing the same patients at 1 year, 5 years, and 10 years post-­
2
area post-­operatively of 47.54 mm . The difference between inves- operatively, for example, may yield a different result entirely.
tigations may result from the 2D vs 3D techniques employed. 2D The results of this study suggest that during treatment plan-
studies are unable to visualize airway shape changes fully. A change ning if a patient's facial appearance would benefit from a man-
from circular to elliptical especially if the long axis of the ellipse ex- dibular setback surgery alone there seems to be no harm in doing
tends mediolaterally would not be possible to view in 2D. It was un- so. If there are signs or symptoms of OSA, surgeons may elect
expected that setback surgery alone did not cause any statistically to perform bimaxillary surgery, or even maxillary advancement
significant change at the inferior border of C2, the retroglossal re- alone. A preferred approach would be to screened for OSA prior
gion, which is the region most anticipated to be negatively affected. to surgery and perform PSG. If OSA is diagnosed, revision of the
Patients undergoing 2-­jaw surgery demonstrated comprehen- surgical plan with the sleep team and the orthodontist should be
sive statistically significant airway increases between time points. considered.
The airway volume increased by 5.31 cm3, the minimum axial area Retrospective studies are unable to control all variables. The results
increased by 52.02 mm2, the minimum axial area distance superior reported may not be generalizable to other surgical centres if weight,
to inferior border moved inferiorly by 6.07 mm, the axial area at the magnitude of surgery, age or gender characteristics are different.
inferior border of C1 (retropalatal region) increased by 70.49 mm2,
and the axial area at the inferior border of C2 (retroglossal region)
increased by 65.35 mm2. The axial area in the retropalatal region 5 | CO N C LU S I O N S
increased significantly, which should be expected due to the sup-
porting structures being moved anteriorly. It was interesting that the Based on the results of this study, fear of decreasing of patient's PAS
minimum axial area increased, as well as the axial area in the retro- following mandibular setback surgery alone does not appear to be
glossal region. While we cannot explain exactly why this occurred, warranted. Specific conclusions include:
a plausible explanation could involve the anterior displacement of
the maxilla, which could lead to anterior displacement of the soft 1. Class III patients undergoing mandibular setback surgery alone
palate and thus the tongue due to its contact with the soft palate. showed a statistically significant increase minimum axial area
Anterior displacement of the musculature could easily cause, at least of the PAS after surgery.
in the short term, an increase in the entire PAS. However, future 2. Patients who undergo bimaxillary surgery showed a significantly
work would be needed in this area to determine exactly the cause increased retropalatal axial area after surgery compared to pa-
for such changes. tients undergoing mandibular setback alone.
All patients had a bite jig used for accurate positioning in the pre-­ 3. Patients who undergo bimaxillary surgery show no other signifi-
operative CBCT scans. This jig props the bite open a small amount, cant difference in airway volume, minimum axial area, minimum
so the results may have been affected slightly. However, all patients axial area location, or retroglossal axial area after surgery com-
had the bite jig present in the pre-­operative scans. In the 3D analysis, pared to patients undergoing mandibular setback alone.
the slight opening of the bite could have theoretically led to a more
compressed pre-­operative airway due to the downward and back-
ORCID
ward rotation of the mandible. A subsequent study demonstrated
2 mm of AP reduction and 2 mm increased vertical displacement of R. Scott Conley https://orcid.org/0000-0002-4888-4875
pogonion but no airway changes from the splint.35
Once the final groups were refined to statistically similar starting
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