CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY
Change in Inferior Sclera Exposure Following Le Fort I Osteotomy in Patients With Midfacial Retrognathia Sidika Sinem Soydan, DDS, PhD,* Burak Bayram, DDS, PhD,y Cagla Sar, DDS, PhD,z and Sina Uckan, DDS, PhDx Purpose:
For facial esthetic reasons, no sclera should be exposed above or below the irises when the head of a patient who has a normal skeletal pattern is in a neutral position and the eyelids are in a relaxed position. This study evaluated the decrease in sclera exposure after maxillary advancement or impaction in patients with midfacial hypoplasia.
Patients and Methods:
Forty-seven consecutive patients (24 male, 23 female) who underwent Le Fort I osteotomy were included. The patients were divided into 2 groups according to type of maxillary movement: group I underwent maxillary advancement (n = 23) and group II underwent maxillary advancement and impaction surgery (n = 24). Standardized preoperative and 6-month postoperative photographs of the frontal view of patients were evaluated using Adobe Photoshop CS5. The proportion of inferior sclera exposure to eye height was determined, and the proportional difference between the preoperative and postoperative orbital views was statistically analyzed.
Results:
The proportion of inferior sclera exposure to eye height decreased by a ratio of 0.07 (P = .001) in the right and left eyes of the 47 patients, with an average maxillary advancement of 6.1 mm. The proportion of inferior sclera exposure to eye height of the right and left eyes decreased from 0.1 to 0.02 and from 0.09 to 0.02, respectively, in group I (P = .001). The proportion of inferior sclera exposure to eye height decreased in group II by a ratio of 0.06 in the right and left eyes (P = .001).
Conclusion:
Inferior sclera exposure in patients with midfacial hypoplasia and retrognathia decreases significantly in accordance with the change in the lower eyelid position after maxillary advancement or impaction surgeries. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:166.e1-166.e5, 2014
The orbital region contributes substantially to the esthetics of the face. This region consists of the eyes, eyelids, eyelashes, and eyebrows. Each of these parts of the orbital region should be considered during an evaluation of facial esthetics. The visible part of the eye accounts for approximately one sixth of the entire eye globe and is made up of 3 vital constituents: the white sclera, the colored iris, and the black pupil. The white color of the sclera comes from the density of the fibrous tissue that forms
the outer covering of the eyeball. The contrast between the exposed sclera and the colored iris and pupil relieves the eye movement.1 The orbital cavity has a pyramid shape and contains the eye, extraocular muscles, eyelids, conjunctiva, lacrimal gland, optic nerve, and orbital fat. Eyelids are thin folds, which are covered with a flexible musculocutaneous lamella. The inner epithelium is continuous with the tarsus and sclera.2 The position of the moveable lower eyelids can change after maxillary
Received from the Faculty of Dentistry, Baskent University, Ankara,
tistry, Baskent University, Sokak no 26 Bahcelievler, Cankaya,
Turkey.
Ankara, Turkey; e-mail: [email protected]
*Fellow, Department of Oral and Maxillofacial Surgery.
Received August 17 2013
yAssistant Professor, Department of Oral and Maxillofacial
Accepted September 17 2013 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Surgery. zAssistant Professor, Department of Orthodontics.
0278-2391/13/01214-7$36.00/0
xProfessor, Department of Oral and Maxillofacial Surgery.
http://dx.doi.org/10.1016/j.joms.2013.09.025
Address correspondence and reprint requests to Dr Soydan: Department of Oral and Maxillofacial Surgery, Faculty of Den-
166.e1
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surgical movements and lead to a change in inferior sclera exposure.3 The upper eyelid margin is located 1 to 2 mm above the most superior point of the iris (superior limbus). No sclera should be exposed between the lowermost point of the iris (inferior limbus) and the lower lid margin in the orbital view when the head is in a neutral position and the forehead and the eyebrows are relaxed. The increase in the exposure of sclera below the iris is a clinical indication and a characteristic orbital feature of patients with midfacial hypoplasia or retrognathia.4 Orthognathic surgical procedures can affect the amount of visible sclera. However, this has not been analyzed. The aim of this study was to evaluate the change in inferior sclera exposition after maxillary advancement or impaction in patients with midfacial retrognathia.
Patients and Methods This study was approved by Baskent University (Ankara, Turkey) institutional review board and the ethics committee (Project D-KA 13/12). This study was conducted in accordance with the Declaration of Helsinki of 1975 as revised in 2000. Forty-seven consecutive patients with Class III skeletal deformity (24 male, 23 female; mean age, 23.6 1.84 yr) who were treated with Le Fort I osteotomy concomitant with bilateral sagittal split ramus osteotomy by the same surgical team were included in this study. The exclusion criteria were craniofacial syndrome, exophthalmos, previous facial trauma, and previous orbital surgery. The patients were divided into 2 groups according to the type of maxillary movement. Group I underwent maxillary advancement (n = 23) and group II underwent maxillary advancement and impaction (n = 24) surgeries. The mean ages of groups I and II were 23.2 1.88 and 24 1.66 years, respectively. The line of Le Fort I osteotomy of all included patients was a few millimeters higher than the deepest point of the lateral wall of the antrum; step osteotomy was not performed. Standardized preoperative and 6-month postoperative facial photographs were taken with an SLR digital camera (Canon EOS 450 D; Canon, Inc, Tokyo, Japan) mounted with a wide-angle lens. The camera was placed at a distance of 1.5 m from the patient. It was held in an upright position, and the level of the camera was adjusted so that the lens was focused on the patient’s eyes. The patients were instructed to look straight ahead at the lens of the camera, which was placed at eye level in front of them, to achieve a neutral head position. They were sitting and instructed to relax their forehead, nose, mouth, and eyebrows while the frontal photographs were being taken. The
FIGURE 1. Landmarks used for evaluation: a, upper eyelid margin; b, inferior limbus; c, lower eyelid margin. The proportional relation between the inferior sclera exposure (jbcj) and the eye height (jacj) was determined on standardized photographs. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
submandibular line of the patients was kept parallel to the floor. All photographs were evaluated using the following landmarks: inferior limbus, upper eyelid margin, and lower eyelid margin (Fig 1). The proportional relation between the inferior sclera exposure and eye height was determined in the preoperative and postoperative photographs (Fig 1). The proportions were measured by the same clinician using Adobe Photoshop CS5 (Adobe, San Jose, CA). STATISTICAL ANALYSIS
The proportional relations of the preoperative and postoperative facial photographs were measured twice, and statistical analysis of the average of the proportional measurements was performed. The pre- and postoperative proportional values were compared statistically by the Wilcoxon signed-rank test (level of significance, P < .05).
Results The mean maxillary advancement in the 47 patients was 6.1 1.8 mm. The mean maxillary advancement was 7.3 1.4 mm in group I. The mean maxillary advancement and mean impaction were 5 1.3 mm and 3 1.1 mm, respectively, in group II. Descriptive demographics and results of the statistical comparison of the preoperative and postoperative proportions of inferior sclera exposure to eye height in all 47 patients are presented in Table 1. The proportion of inferior sclera exposure to eye height decreased by a ratio of 0.07 in the right and left eyes,
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Table 1. DESCRIPTIVE DEMOGRAPHICS AND RESULTS OF STATISTICAL COMPARISON OF PREOPERATIVE AND POSTOPERATIVE PROPORTIONS IN ALL INCLUDED PATIENTS
Proportions
n
Mean
SD
Preoperative inferior sclera exposure of right eye vs right eye height Postoperative inferior sclera exposure of right eye vs right eye height Preoperative inferior sclera exposure of left eye vs left eye height Postoperative inferior sclera exposure of left eye vs left eye height
47 0.09
0.06
47 0.02
0.04
47 0.09
0.06
47 0.02
0.04
Sig (P Value)
.001*
.001*
Abbreviations: Sig, significance; SD, standard deviation. * P < .05. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
and the decrease in the exposure of the inferior sclera was statistically significant (P = .001). Statistical results of groups I and II are presented in Tables 2 and 3, respectively. The proportion of inferior sclera exposure to eye height in the right eye decreased from 0.1 to 0.02, and the proportion of inferior sclera exposure to eye height in the left eye decreased from 0.09 to 0.02 in group I. The decrease in inferior sclera exposure was statistically significant for the right and left eyes in group I (P = .001). The Table 2. DESCRIPTIVE DEMOGRAPHICS AND RESULTS OF STATISTICAL COMPARISON OF PREOPERATIVE AND POSTOPERATIVE PROPORTIONS IN GROUP I
Proportions
n
Mean
SD
Preoperative inferior sclera exposure of right eye vs right eye height Postoperative inferior sclera exposure of right eye vs right eye height Preoperative inferior sclera exposure of left eye vs left eye height Postoperative inferior sclera exposure of left eye vs left eye height
23 0.1
0.07
23 0.02
0.04
23 0.09
0.07
23 0.02
0.03
Sig (P Value)
.001*
.001*
Abbreviations: Sig, significance; SD, standard deviation. * P < .05. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
Table 3. DESCRIPTIVE DEMOGRAPHICS AND RESULTS OF STATISTICAL COMPARISON OF PREOPERATIVE AND POSTOPERATIVE PROPORTIONS IN GROUP II
Proportions
n
Mean
SD
Preoperative inferior sclera exposure of right eye vs right eye height Postoperative inferior sclera exposure of right eye vs right eye height Preoperative inferior sclera exposure of left eye vs left eye height Postoperative inferior sclera exposure of left eye vs left eye height
24
0.09
0.05
24
0.03
0.04
24
0.08
0.05
24
0.02
0.04
Sig (P Value)
.001*
.001*
Abbreviations: Sig, significance; SD, standard deviation. * P < .05. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
proportion of inferior sclera exposure to eye height decreased by a ratio of 0.06 in the right and left eyes in group II, and the decrease was statistically significant (P = .001). The difference in decrease of inferior sclera exposure between the 2 groups was not statistically significant for the right and left eyes (P > .05).
Discussion An evaluation of the orbital region should be included in the preoperative clinical examination of patients scheduled for orthognathic surgery. Facial analysis of the patient can be performed not only by clinical examination, but also by facial photographs or radiographs.5 (p14) Standardized facial photographs were used for the assessment in the present study. Millimetric measurements cannot be performed on photographs, however; proportional evaluations are more reliable than such measurements. Inferior sclera exposure may be a sign of exophthalmos, previous trauma, lower eyelid laxity, or dentofacial deformities related to maxillary hypoplasia.5 (p160) Patients who had exophthalmos or previous trauma were not included in the present study. Progressive laxity or elongation of canthal tendons and the tarsus during the aging process leads to inferior positioning of the lower eyelid and inferior sclera exposure.6 All patients included in the present study were young adults 18 to 25 years old. Various surgical methods have been reported for the correction of aging-related lower eyelid laxity.6-9 Exposure of the inferior sclera tends to give the face an elderly appearance and may cause cosmetic concerns. Inferior malposition of the lower eyelids
SOYDAN ET AL
FIGURE 2. Preoperative frontal view of a male patient with skeletal Class III deformity. This patient underwent 6-mm maxillary advancement and 3-mm maxillary impaction surgeries. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
also may give rise to ocular complaints, including tearing, foreign body sensation, chronic conjunctival inflammation, and blurring of vision owing to longstanding sclera exposure.10-13 The lower eyelids of patients with midfacial retrognathia are at an inferior position owing to insufficient support provided by the maxillary bone. This leads to increased inferior sclera exposure, even in younger individuals. The results of this study showed that maxillary advancement or impaction with Le Fort I osteotomy can improve the position of the lower eyelids in patients with midfacial retrusion. Although the proportional changes seem to be small, clinical observations of the results are remarkable (Figs 2 to 5). The present study is the first to evaluate the proportion of inferior sclera exposure in patients with midfacial retrognathia and changes after Le Fort I surgery. According to the overall results of this study, the amount of inferior sclera exposed decreased significantly when isolated maxillary advancement or combined advancement and impaction was performed. The proportion of inferior sclera exposure to eye height decreased by 7% after 6 to 7 mm of maxillary advancement and decreased by 6% after 5 mm of maxillary advancement and 3 mm of impaction. A total of 1 mm advancement of the maxilla provides approximately 1% decrease of inferior sclera exposition. Because the amount of the maxillary advancement was similar in the 2 groups, it can be concluded that maxillary impaction movement did not change the decrease of inferior scleral exposition in this study.
166.e4
FIGURE 4. Preoperative frontal view of a female patient with skeletal Class III deformity. This patient underwent 7-mm maxillary advancement surgery. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
However, a severe amount of isolated maxillary impaction (>3 mm) can have some effects on exposition of the inferior sclera. The level of the Le Fort I osteotomy line also can affect the amount of inferior sclera exposure and this was not evaluated in the present study. The clinician should be aware of lower eyelid tonicity during the preoperative assessment of a patient. There are 2 possible methods for the evaluation of lower eyelid tonicity: the lid distraction test and the lid retraction test. In the former, the clinician uses the thumb and index finger to gently pull the lower eyelid less than 7 mm away from the globe and observes the rate of its return to a normal position. In the latter, the lower eyelid is gently displaced inferiorly with the index finger, and its return to a resting position is observed.14 The decrease in the exposure of sclera will probably be less after maxillary advancement or impaction in patients who have increased lower eyelid laxity. Information on the proportions of the decrease in the exposure of the inferior sclera (7% after 6-mm maxillary advancement) may be useful in 3-dimensional surgical planning programs and may help the prediction of the change in scleral exposure in patients with midfacial retrognathia. Visible sclera is clinically undesirable and is common in patients with midfacial retrognathia. The
FIGURE 3. Postoperative frontal view of patient. A mild decrease in bilateral inferior sclera exposure was seen in this patient.
FIGURE 5. Postoperative frontal view of patient. A distinct decrease of bilateral inferior sclera exposure was seen in this patient.
Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
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amount of sclera shown is generally related to the severity of the deformity. The level of surgical maxillary movement affects the amount of correction of the lower eyelid position. The contribution of maxillary movement to the position of the lower eyelids should be evaluated carefully during preoperative surgical planning. In severe deformities, even a small decrease in the exposure of the sclera has a major esthetic impact on this conspicuous area.
References 1. Gunter JP, Antrobus SD: Aesthetic analysis of the eyebrows. Plast Reconstr Surg 99:1808, 1997 2. Rampazzo A, Gharb BB, Chen HC: Total lower eyelid reconstruction with free posterior auricular chondrocutaneous flap. J Plast Reconstr Aesthet Surg 63:e384, 2010 3. Flowers RS: The art of eyelid and orbital aesthetics: Multiracial surgical consideration. Clin Plast Surg 14:703, 1987 4. Naini FB: Facial Aesthetics, Concepts & Clinical Diagnosis. West Sussex, UK, Wiley-Blackwell, 2011, p 199
INFERIOR SCLERA EXPOSURE AFTER LE FORT-I 5. Meneghini F: Aesthetic Facial Surgery, Elements, Principles, Techniques. Padova, Italy, Springer, 2005 6. Goel R, Kamal S, Bodh SA, et al: Lower eyelid suspension using polypropylene suture for the correction of punctal ectropion. J Craniomaxillofac Surg 41:e111, 2013 7. Barrett RV, Meyer DR: The modified Bick Quick Strip procedure for surgical treatment of eyelid malposition. Ophthal Plast Reconstr Surg 28:294, 2012 8. Suh DH, Oh YJ, Lee SJ, et al: A intense-focused ultrasound tightening for the treatment of infraorbital laxity. J Cosmet Laser Ther 14:290, 2012 9. Arajy ZY: Open loop fascial sling for severe congenital blepharoptosis. J Craniomaxillofac Surg 40:129, 2012 10. Hintschich C: Correction of entropion and ectropion. Dev Ophthalmol 41:85, 2008 11. Kahana A, Lucarelli MJ: Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid ectropion repair. Ophthal Plast Reconstr Surg 25: 1, 2009 12. Leone CR Jr: Repair of ectropion using the Bick procedure. Am J Ophthalmol 70:233, 1970 13. Vallabhanath P, Carter SR: Ectropion and entropion. Curr Opin Ophthalmol 11:345, 2000 14. Tenzel RR: Complications of blepharoplasty: Orbital hematoma, ectropion and sclera show. Clin Plast Surg 8:797, 1981
Change in Inferior Sclera Exposure Following Le Fort I Osteotomy in Patients With Midfacial Retrognathia Sidika Sinem Soydan, DDS, PhD,* Burak Bayram, DDS, PhD,y Cagla Sar, DDS, PhD,z and Sina Uckan, DDS, PhDx Purpose:
For facial esthetic reasons, no sclera should be exposed above or below the irises when the head of a patient who has a normal skeletal pattern is in a neutral position and the eyelids are in a relaxed position. This study evaluated the decrease in sclera exposure after maxillary advancement or impaction in patients with midfacial hypoplasia.
Patients and Methods:
Forty-seven consecutive patients (24 male, 23 female) who underwent Le Fort I osteotomy were included. The patients were divided into 2 groups according to type of maxillary movement: group I underwent maxillary advancement (n = 23) and group II underwent maxillary advancement and impaction surgery (n = 24). Standardized preoperative and 6-month postoperative photographs of the frontal view of patients were evaluated using Adobe Photoshop CS5. The proportion of inferior sclera exposure to eye height was determined, and the proportional difference between the preoperative and postoperative orbital views was statistically analyzed.
Results:
The proportion of inferior sclera exposure to eye height decreased by a ratio of 0.07 (P = .001) in the right and left eyes of the 47 patients, with an average maxillary advancement of 6.1 mm. The proportion of inferior sclera exposure to eye height of the right and left eyes decreased from 0.1 to 0.02 and from 0.09 to 0.02, respectively, in group I (P = .001). The proportion of inferior sclera exposure to eye height decreased in group II by a ratio of 0.06 in the right and left eyes (P = .001).
Conclusion:
Inferior sclera exposure in patients with midfacial hypoplasia and retrognathia decreases significantly in accordance with the change in the lower eyelid position after maxillary advancement or impaction surgeries. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:166.e1-166.e5, 2014
The orbital region contributes substantially to the esthetics of the face. This region consists of the eyes, eyelids, eyelashes, and eyebrows. Each of these parts of the orbital region should be considered during an evaluation of facial esthetics. The visible part of the eye accounts for approximately one sixth of the entire eye globe and is made up of 3 vital constituents: the white sclera, the colored iris, and the black pupil. The white color of the sclera comes from the density of the fibrous tissue that forms
the outer covering of the eyeball. The contrast between the exposed sclera and the colored iris and pupil relieves the eye movement.1 The orbital cavity has a pyramid shape and contains the eye, extraocular muscles, eyelids, conjunctiva, lacrimal gland, optic nerve, and orbital fat. Eyelids are thin folds, which are covered with a flexible musculocutaneous lamella. The inner epithelium is continuous with the tarsus and sclera.2 The position of the moveable lower eyelids can change after maxillary
Received from the Faculty of Dentistry, Baskent University, Ankara,
tistry, Baskent University, Sokak no 26 Bahcelievler, Cankaya,
Turkey.
Ankara, Turkey; e-mail: [email protected]
*Fellow, Department of Oral and Maxillofacial Surgery.
Received August 17 2013
yAssistant Professor, Department of Oral and Maxillofacial
Accepted September 17 2013 Ó 2014 American Association of Oral and Maxillofacial Surgeons
Surgery. zAssistant Professor, Department of Orthodontics.
0278-2391/13/01214-7$36.00/0
xProfessor, Department of Oral and Maxillofacial Surgery.
http://dx.doi.org/10.1016/j.joms.2013.09.025
Address correspondence and reprint requests to Dr Soydan: Department of Oral and Maxillofacial Surgery, Faculty of Den-
166.e1
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surgical movements and lead to a change in inferior sclera exposure.3 The upper eyelid margin is located 1 to 2 mm above the most superior point of the iris (superior limbus). No sclera should be exposed between the lowermost point of the iris (inferior limbus) and the lower lid margin in the orbital view when the head is in a neutral position and the forehead and the eyebrows are relaxed. The increase in the exposure of sclera below the iris is a clinical indication and a characteristic orbital feature of patients with midfacial hypoplasia or retrognathia.4 Orthognathic surgical procedures can affect the amount of visible sclera. However, this has not been analyzed. The aim of this study was to evaluate the change in inferior sclera exposition after maxillary advancement or impaction in patients with midfacial retrognathia.
Patients and Methods This study was approved by Baskent University (Ankara, Turkey) institutional review board and the ethics committee (Project D-KA 13/12). This study was conducted in accordance with the Declaration of Helsinki of 1975 as revised in 2000. Forty-seven consecutive patients with Class III skeletal deformity (24 male, 23 female; mean age, 23.6 1.84 yr) who were treated with Le Fort I osteotomy concomitant with bilateral sagittal split ramus osteotomy by the same surgical team were included in this study. The exclusion criteria were craniofacial syndrome, exophthalmos, previous facial trauma, and previous orbital surgery. The patients were divided into 2 groups according to the type of maxillary movement. Group I underwent maxillary advancement (n = 23) and group II underwent maxillary advancement and impaction (n = 24) surgeries. The mean ages of groups I and II were 23.2 1.88 and 24 1.66 years, respectively. The line of Le Fort I osteotomy of all included patients was a few millimeters higher than the deepest point of the lateral wall of the antrum; step osteotomy was not performed. Standardized preoperative and 6-month postoperative facial photographs were taken with an SLR digital camera (Canon EOS 450 D; Canon, Inc, Tokyo, Japan) mounted with a wide-angle lens. The camera was placed at a distance of 1.5 m from the patient. It was held in an upright position, and the level of the camera was adjusted so that the lens was focused on the patient’s eyes. The patients were instructed to look straight ahead at the lens of the camera, which was placed at eye level in front of them, to achieve a neutral head position. They were sitting and instructed to relax their forehead, nose, mouth, and eyebrows while the frontal photographs were being taken. The
FIGURE 1. Landmarks used for evaluation: a, upper eyelid margin; b, inferior limbus; c, lower eyelid margin. The proportional relation between the inferior sclera exposure (jbcj) and the eye height (jacj) was determined on standardized photographs. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
submandibular line of the patients was kept parallel to the floor. All photographs were evaluated using the following landmarks: inferior limbus, upper eyelid margin, and lower eyelid margin (Fig 1). The proportional relation between the inferior sclera exposure and eye height was determined in the preoperative and postoperative photographs (Fig 1). The proportions were measured by the same clinician using Adobe Photoshop CS5 (Adobe, San Jose, CA). STATISTICAL ANALYSIS
The proportional relations of the preoperative and postoperative facial photographs were measured twice, and statistical analysis of the average of the proportional measurements was performed. The pre- and postoperative proportional values were compared statistically by the Wilcoxon signed-rank test (level of significance, P < .05).
Results The mean maxillary advancement in the 47 patients was 6.1 1.8 mm. The mean maxillary advancement was 7.3 1.4 mm in group I. The mean maxillary advancement and mean impaction were 5 1.3 mm and 3 1.1 mm, respectively, in group II. Descriptive demographics and results of the statistical comparison of the preoperative and postoperative proportions of inferior sclera exposure to eye height in all 47 patients are presented in Table 1. The proportion of inferior sclera exposure to eye height decreased by a ratio of 0.07 in the right and left eyes,
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INFERIOR SCLERA EXPOSURE AFTER LE FORT-I
Table 1. DESCRIPTIVE DEMOGRAPHICS AND RESULTS OF STATISTICAL COMPARISON OF PREOPERATIVE AND POSTOPERATIVE PROPORTIONS IN ALL INCLUDED PATIENTS
Proportions
n
Mean
SD
Preoperative inferior sclera exposure of right eye vs right eye height Postoperative inferior sclera exposure of right eye vs right eye height Preoperative inferior sclera exposure of left eye vs left eye height Postoperative inferior sclera exposure of left eye vs left eye height
47 0.09
0.06
47 0.02
0.04
47 0.09
0.06
47 0.02
0.04
Sig (P Value)
.001*
.001*
Abbreviations: Sig, significance; SD, standard deviation. * P < .05. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
and the decrease in the exposure of the inferior sclera was statistically significant (P = .001). Statistical results of groups I and II are presented in Tables 2 and 3, respectively. The proportion of inferior sclera exposure to eye height in the right eye decreased from 0.1 to 0.02, and the proportion of inferior sclera exposure to eye height in the left eye decreased from 0.09 to 0.02 in group I. The decrease in inferior sclera exposure was statistically significant for the right and left eyes in group I (P = .001). The Table 2. DESCRIPTIVE DEMOGRAPHICS AND RESULTS OF STATISTICAL COMPARISON OF PREOPERATIVE AND POSTOPERATIVE PROPORTIONS IN GROUP I
Proportions
n
Mean
SD
Preoperative inferior sclera exposure of right eye vs right eye height Postoperative inferior sclera exposure of right eye vs right eye height Preoperative inferior sclera exposure of left eye vs left eye height Postoperative inferior sclera exposure of left eye vs left eye height
23 0.1
0.07
23 0.02
0.04
23 0.09
0.07
23 0.02
0.03
Sig (P Value)
.001*
.001*
Abbreviations: Sig, significance; SD, standard deviation. * P < .05. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
Table 3. DESCRIPTIVE DEMOGRAPHICS AND RESULTS OF STATISTICAL COMPARISON OF PREOPERATIVE AND POSTOPERATIVE PROPORTIONS IN GROUP II
Proportions
n
Mean
SD
Preoperative inferior sclera exposure of right eye vs right eye height Postoperative inferior sclera exposure of right eye vs right eye height Preoperative inferior sclera exposure of left eye vs left eye height Postoperative inferior sclera exposure of left eye vs left eye height
24
0.09
0.05
24
0.03
0.04
24
0.08
0.05
24
0.02
0.04
Sig (P Value)
.001*
.001*
Abbreviations: Sig, significance; SD, standard deviation. * P < .05. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
proportion of inferior sclera exposure to eye height decreased by a ratio of 0.06 in the right and left eyes in group II, and the decrease was statistically significant (P = .001). The difference in decrease of inferior sclera exposure between the 2 groups was not statistically significant for the right and left eyes (P > .05).
Discussion An evaluation of the orbital region should be included in the preoperative clinical examination of patients scheduled for orthognathic surgery. Facial analysis of the patient can be performed not only by clinical examination, but also by facial photographs or radiographs.5 (p14) Standardized facial photographs were used for the assessment in the present study. Millimetric measurements cannot be performed on photographs, however; proportional evaluations are more reliable than such measurements. Inferior sclera exposure may be a sign of exophthalmos, previous trauma, lower eyelid laxity, or dentofacial deformities related to maxillary hypoplasia.5 (p160) Patients who had exophthalmos or previous trauma were not included in the present study. Progressive laxity or elongation of canthal tendons and the tarsus during the aging process leads to inferior positioning of the lower eyelid and inferior sclera exposure.6 All patients included in the present study were young adults 18 to 25 years old. Various surgical methods have been reported for the correction of aging-related lower eyelid laxity.6-9 Exposure of the inferior sclera tends to give the face an elderly appearance and may cause cosmetic concerns. Inferior malposition of the lower eyelids
SOYDAN ET AL
FIGURE 2. Preoperative frontal view of a male patient with skeletal Class III deformity. This patient underwent 6-mm maxillary advancement and 3-mm maxillary impaction surgeries. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
also may give rise to ocular complaints, including tearing, foreign body sensation, chronic conjunctival inflammation, and blurring of vision owing to longstanding sclera exposure.10-13 The lower eyelids of patients with midfacial retrognathia are at an inferior position owing to insufficient support provided by the maxillary bone. This leads to increased inferior sclera exposure, even in younger individuals. The results of this study showed that maxillary advancement or impaction with Le Fort I osteotomy can improve the position of the lower eyelids in patients with midfacial retrusion. Although the proportional changes seem to be small, clinical observations of the results are remarkable (Figs 2 to 5). The present study is the first to evaluate the proportion of inferior sclera exposure in patients with midfacial retrognathia and changes after Le Fort I surgery. According to the overall results of this study, the amount of inferior sclera exposed decreased significantly when isolated maxillary advancement or combined advancement and impaction was performed. The proportion of inferior sclera exposure to eye height decreased by 7% after 6 to 7 mm of maxillary advancement and decreased by 6% after 5 mm of maxillary advancement and 3 mm of impaction. A total of 1 mm advancement of the maxilla provides approximately 1% decrease of inferior sclera exposition. Because the amount of the maxillary advancement was similar in the 2 groups, it can be concluded that maxillary impaction movement did not change the decrease of inferior scleral exposition in this study.
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FIGURE 4. Preoperative frontal view of a female patient with skeletal Class III deformity. This patient underwent 7-mm maxillary advancement surgery. Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
However, a severe amount of isolated maxillary impaction (>3 mm) can have some effects on exposition of the inferior sclera. The level of the Le Fort I osteotomy line also can affect the amount of inferior sclera exposure and this was not evaluated in the present study. The clinician should be aware of lower eyelid tonicity during the preoperative assessment of a patient. There are 2 possible methods for the evaluation of lower eyelid tonicity: the lid distraction test and the lid retraction test. In the former, the clinician uses the thumb and index finger to gently pull the lower eyelid less than 7 mm away from the globe and observes the rate of its return to a normal position. In the latter, the lower eyelid is gently displaced inferiorly with the index finger, and its return to a resting position is observed.14 The decrease in the exposure of sclera will probably be less after maxillary advancement or impaction in patients who have increased lower eyelid laxity. Information on the proportions of the decrease in the exposure of the inferior sclera (7% after 6-mm maxillary advancement) may be useful in 3-dimensional surgical planning programs and may help the prediction of the change in scleral exposure in patients with midfacial retrognathia. Visible sclera is clinically undesirable and is common in patients with midfacial retrognathia. The
FIGURE 3. Postoperative frontal view of patient. A mild decrease in bilateral inferior sclera exposure was seen in this patient.
FIGURE 5. Postoperative frontal view of patient. A distinct decrease of bilateral inferior sclera exposure was seen in this patient.
Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxillofac Surg 2014.
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amount of sclera shown is generally related to the severity of the deformity. The level of surgical maxillary movement affects the amount of correction of the lower eyelid position. The contribution of maxillary movement to the position of the lower eyelids should be evaluated carefully during preoperative surgical planning. In severe deformities, even a small decrease in the exposure of the sclera has a major esthetic impact on this conspicuous area.
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INFERIOR SCLERA EXPOSURE AFTER LE FORT-I 5. Meneghini F: Aesthetic Facial Surgery, Elements, Principles, Techniques. Padova, Italy, Springer, 2005 6. Goel R, Kamal S, Bodh SA, et al: Lower eyelid suspension using polypropylene suture for the correction of punctal ectropion. J Craniomaxillofac Surg 41:e111, 2013 7. Barrett RV, Meyer DR: The modified Bick Quick Strip procedure for surgical treatment of eyelid malposition. Ophthal Plast Reconstr Surg 28:294, 2012 8. Suh DH, Oh YJ, Lee SJ, et al: A intense-focused ultrasound tightening for the treatment of infraorbital laxity. J Cosmet Laser Ther 14:290, 2012 9. Arajy ZY: Open loop fascial sling for severe congenital blepharoptosis. J Craniomaxillofac Surg 40:129, 2012 10. Hintschich C: Correction of entropion and ectropion. Dev Ophthalmol 41:85, 2008 11. Kahana A, Lucarelli MJ: Adjunctive transcanthotomy lateral suborbicularis fat lift and orbitomalar ligament resuspension in lower eyelid ectropion repair. Ophthal Plast Reconstr Surg 25: 1, 2009 12. Leone CR Jr: Repair of ectropion using the Bick procedure. Am J Ophthalmol 70:233, 1970 13. Vallabhanath P, Carter SR: Ectropion and entropion. Curr Opin Ophthalmol 11:345, 2000 14. Tenzel RR: Complications of blepharoplasty: Orbital hematoma, ectropion and sclera show. Clin Plast Surg 8:797, 1981
