CRANIOMAXILLOFACIAL DEFORMITIES/COSMETIC SURGERY

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Change in Inferior Sclera ExposureFollowing Le Fort I Osteotomy in Patients

With Midfacial Retrognathia

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Sidika Sinem Soydan, DDS, PhD,* Burak Bayram, DDS, PhD,y Cagla Sar, DDS, PhD,zand 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 inpatients with midfacial hypoplasia.

Patients andMethods: 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 move-ment: 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 ex-

posure to eye height was determined, and the proportional difference between the preoperative and post-

operative 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 pro-

portion 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 orimpaction surgeries.

� 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 es-

thetics of the face. This region consists of the eyes, eye-

lids, eyelashes, and eyebrows. Each of these parts of

the orbital region should be considered during an eval-

uation of facial esthetics.

The visible part of the eye accounts for approxi-mately 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

rom the Faculty of Dentistry, Baskent University, Ankara,

, Department of Oral and Maxillofacial Surgery.

nt Professor, Department of Oral and Maxillofacial

nt Professor, Department of Orthodontics.

sor, Department of Oral and Maxillofacial Surgery.

s correspondence and reprint requests to Dr Soydan:

nt of Oral and Maxillofacial Surgery, Faculty of Den-

166.e

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. Eyelidsare thin folds, which are covered with a flexible mus-

culocutaneous lamella. The inner epithelium is contin-

uous with the tarsus and sclera.2 The position of the

moveable lower eyelids can change after maxillary

tistry, Baskent University, Sokak no 26 Bahcelievler, Cankaya,

Ankara, Turkey; e-mail: sdksoydan@yahoo.com

Received August 17 2013

Accepted September 17 2013

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/13/01214-7$36.00/0

http://dx.doi.org/10.1016/j.joms.2013.09.025

1

FIGURE 1. Landmarks used for evaluation: a, upper eyelid mar-gin; b, inferior limbus; c, lower eyelid margin. The proportional re-lation between the inferior sclera exposure (jbcj) and the eye height

SOYDAN ET AL 166.e2

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 mar-

gin in the orbital viewwhen the head is in a neutral po-

sition 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 ad-

vancement or impaction in patients with midfacialretrognathia.

(jacj) was determined on standardized photographs.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

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 skel-

etal deformity (24 male, 23 female; mean age, 23.6 �1.84 yr) who were treated with Le Fort I osteotomyconcomitant with bilateral sagittal split ramus osteot-

omy by the same surgical team were included in this

study. The exclusion criteria were craniofacial syn-

drome, exophthalmos, previous facial trauma, and pre-

vious orbital surgery.

The patients were divided into 2 groups according

to the type of maxillary movement. Group I under-

went maxillary advancement (n = 23) and group II un-derwent 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 postopera-tive 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 pa-

tient’s eyes. The patients were instructed to look

straight ahead at the lens of the camera, which wasplaced at eye level in front of them, to achieve a neutral

head position. They were sitting and instructed to re-

lax their forehead, nose, mouth, and eyebrows while

the frontal photographs were being taken. The

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 pro-portional measurements was performed. The pre- and

postoperative proportional values were compared sta-

tistically by the Wilcoxon signed-rank test (level of sig-

nificance, 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 ad-

vancement and mean impaction were 5� 1.3 mm and

3 � 1.1 mm, respectively, in group II.

Descriptive demographics and results of the statisti-

cal comparison of the preoperative and postoperativeproportions of inferior sclera exposure to eye height in

all 47 patients are presented in Table 1. The propor-

tion of inferior sclera exposure to eye height de-

creased by a ratio of 0.07 in the right and left eyes,

Table 1. DESCRIPTIVE DEMOGRAPHICS AND RESULTSOF STATISTICAL COMPARISON OF PREOPERATIVEAND POSTOPERATIVE PROPORTIONS IN ALLINCLUDED PATIENTS

Proportions n Mean SD

Sig

(P Value)

Preoperative inferior sclera

exposure of right eye vs

right eye height

47 0.09 0.06

Postoperative inferior sclera

exposure of right eye vs

right eye height

47 0.02 0.04 .001*

Preoperative inferior sclera

exposure of left eye vs left

eye height

47 0.09 0.06

Postoperative inferior sclera

exposure of left eye vs left

eye height

47 0.02 0.04 .001*

Abbreviations: Sig, significance; SD, standard deviation.* P < .05.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

Table 3. DESCRIPTIVE DEMOGRAPHICS AND RESULTSOF STATISTICAL COMPARISON OF PREOPERATIVEAND POSTOPERATIVE PROPORTIONS IN GROUP II

Proportions n Mean SD

Sig

(P Value)

Preoperative inferior sclera

exposure of right eye vs

right eye height

24 0.09 0.05

Postoperative inferior sclera

exposure of right eye vs

right eye height

24 0.03 0.04 .001*

Preoperative inferior sclera

exposure of left eye vs left

eye height

24 0.08 0.05

Postoperative inferior sclera

exposure of left eye vs left

eye height

24 0.02 0.04 .001*

Abbreviations: Sig, significance; SD, standard deviation.* P < .05.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

166.e3 INFERIOR SCLERA EXPOSURE AFTER LE FORT-I

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 de-creased from 0.1 to 0.02, and the proportion of infe-

rior 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 RESULTSOF STATISTICAL COMPARISON OF PREOPERATIVEAND POSTOPERATIVE PROPORTIONS IN GROUP I

Proportions n Mean SD

Sig

(P Value)

Preoperative inferior sclera

exposure of right eye vs

right eye height

23 0.1 0.07

Postoperative inferior sclera

exposure of right eye vs

right eye height

23 0.02 0.04 .001*

Preoperative inferior sclera

exposure of left eye vs left

eye height

23 0.09 0.07

Postoperative inferior sclera

exposure of left eye vs left

eye height

23 0.02 0.03 .001*

Abbreviations: Sig, significance; SD, standard deviation.* P < .05.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac 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 signifi-cant (P = .001). The difference in decrease of inferior

sclera exposure between the 2 groups was not statisti-

cally significant for the right and left eyes (P > .05).

Discussion

An evaluation of the orbital region should be in-

cluded in the preoperative clinical examination of pa-

tients scheduled for orthognathic surgery. Facial

analysis of the patient can be performed not only by

clinical examination, but also by facial photographsor 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 exophthal-

mos, previous trauma, lower eyelid laxity, or dentofa-

cial 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 thecorrection 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

FIGURE2. Preoperative frontal view of a male patient with skeletalClass III deformity. This patient underwent 6-mm maxillaryadvancement and 3-mm maxillary impaction surgeries.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

FIGURE 4. Preoperative frontal view of a female patient with skel-etal Class III deformity. This patient underwent 7-mm maxillary ad-vancement surgery.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

SOYDAN ET AL 166.e4

also may give rise to ocular complaints, including

tearing, foreign body sensation, chronic conjunctival

inflammation, and blurring of vision owing to long-

standing 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 ad-

vancement or impaction with Le Fort I osteotomy

can improve the position of the lower eyelids in pa-

tients with midfacial retrusion. Although the propor-

tional 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 propor-

tion of inferior sclera exposure in patients with midfa-cial retrognathia and changes after Le Fort I surgery.

According to the overall results of this study, the

amount of inferior sclera exposed decreased signifi-

cantly when isolated maxillary advancement or com-

bined 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 max-illary advancement and 3 mm of impaction. A total of 1

mm advancement of the maxilla provides approxi-

mately 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 de-

crease of inferior scleral exposition in this study.

FIGURE 3. Postoperative frontal view of patient. A mild decreasein bilateral inferior sclera exposure was seen in this patient.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

However, a severe amount of isolated maxillary impac-

tion (>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 expo-

sure and this was not evaluated in the present study.

The clinician should be aware of lower eyelid tonic-

ity 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 ob-

serves 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 posi-tion is observed.14 The decrease in the exposure of

sclera will probably be less after maxillary advance-

ment 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-mmmax-

illary advancement) may be useful in 3-dimensional

surgical planning programs and may help the predic-tion of the change in scleral exposure in patients

with midfacial retrognathia.

Visible sclera is clinically undesirable and is com-

mon in patients with midfacial retrognathia. The

FIGURE 5. Postoperative frontal view of patient. A distinct de-crease of bilateral inferior sclera exposure was seen in this patient.

Soydan et al. Inferior Sclera Exposure After Le Fort-I. J Oral Maxil-lofac Surg 2014.

166.e5 INFERIOR SCLERA EXPOSURE AFTER LE FORT-I

amount of sclera shown is generally related to the se-

verity 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 im-pact on this conspicuous area.

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