Postoperative sensitivity disorders of the anterior palate

DIPLOMA THESIS

Postoperative sensitivity disorders of the anterior palate after septo(rhino)plasty:

A retrospective analysis

submitted by:

Magdalena Bachlechner

with the intention of achieving the title:

Doctor of dentistry (Dr. med. dent.)

Institution: Medical University of Graz – Department of Otorhinolaryngology

in cooperation with:

Medical University of Graz – Department of Dental and Oral Health

guided and supported by:

Assoz. Prof. Priv.-Doz. Dr.med.univ. PhD. Peter Valentin Tomazic

and

Assoz. Prof. Priv.-Doz. Dr.med.univ. Dr.med.dent. et scient.med. Michael Payer

Graz, 10.06.2020

2

Affirmation

I solemnly vow, that this diploma thesis has been written and composed without

assistance independently and by myself only. It has neither been partly nor fully

submitted as graded academic work. I herewith assure, that all references and

sources – segments used directly or indirectly, exact wording as well as meaning –

are stated and labeled as such.

Graz, 10.06.2020 Magdalena Bachlechner eh.

3

Principle of equality

For readability reasons, it may be noted that only the masculine form is being used.

Unless otherwise stated, the principle of equality always refers to both sexes.

4

Preface

Septoplasty and Septorhinoplasty are very common surgical interventions in

otorhinolaryngology. Since the nasal septum is released and operated on anteriorly

at the beginning of the operation, unintended lesions of the incisive nerve, whose

course crosses that exact area, are possible and may be leading to postoperative

numbness of the anterior palate and teeth.

Postoperative numbness of the palate is a complication, that needs to be taken

seriously as it may cause a loss in quality of life. The rate of this finding may be

higher than expected thus far. Little to no data about that possible correlation exist

in literature.

5

Dedication

To my parents, the reason of what I have become today.

6

Acknowledgements

I would like to express my deep gratitude to Prof. Tomazic, my main supervisor, for

his patient guidance, enthusiastic encouragement and valuable input of this diploma

thesis. My great appreciation is also extended to Prof. Payer, my second supervisor,

for his willingness to give his time so generously.

For an outstanding quality of training, I would like to thank Prof. Jakse, the head of

the Clinical Department of Dental and Oral Health.

For technical support, I am particularly grateful to Dr. Wünsch for the acquisition of

data.

Finally, I wish to acknowledge my family for their support, encouragement and love

through all my life.

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Abstract

Background

Close surgical manipulation at the course of the nervus incisivus during the procedure

of a septoplasty, or septorhinoplasty, may lead to postoperative numbness of the

anterior palate, the area of sensitive innervation of the incisive nerve.

The aim of this study is to investigate postoperative sensitivity disorders of the

anterior palate after septo(rhino)plasty in form of a retrospective analysis.

Material and methods

1 000 patients’ charts are collected via the patient medical record system MeDocs,

reviewed and analyzed. Patients with incomplete records, insufficient documentation

or nonexistent follow-up are excluded from this study. The statistical evaluation is

performed with Microsoft Excel. For data evaluation, descriptive statistics are used.

Patients’ data handling is anonymized.

Results

Out of 1 000 patients, 62.5% male and 37.5% female, 86% showed no complications

during the follow-up period. In 0.02% (2 out of 1 000) a sensitivity disorder of the

anterior palate occurred.

Conclusion

To our knowledge this is the largest study investigating postoperative numbness of

the anterior palate following septoplasty or septorhinoplasty. The current techniques

for those operations are safe for the incisive nerve despite close surgical manipulation

to the nerveʼs course. Still, patients should be informed about the possibility of an

occurring sensitivity disorder regarding the anterior palate during informed consent.

8

Zusammenfassung

Thema und Zielsetzung

Beim chirurgischen Prozedere einer (Nasen-)Septum Operation kommt es

unweigerlich zu einer Interaktion mit dem Verlauf des Nervus incisivus. Der Bereich

des vorderen harten Gaumens wird vom Nervus incisivus sensibel innerviert.

Das Ziel dieser Studie ist es zu untersuchen, ob es nach (Nasen-)Septumplastik

zu potentiellen postoperativen Sensibilitätsstörungen im Bereich des vorderen

Palatums kommt.

Material und Methoden

Mit Hilfe von MeDocs®, ein Programm für elektronische Patientenakten, werden

1 000 Patientenakten erhoben und analysiert. Patientinnen und Patienten deren

Daten unvollständig sind, oder die keine Nachbehandlungsphase aufweisen

können, werden von dieser Studie exkludiert. Die statistische Auswertung erfolgt

über Microsoft Excel®. Für die Datenauswertung werden deskriptive Statistiken

verwendet. Der Umgang mit Patientendaten ist anonymisiert.

Ergebnisse

Von 1 000 Patientinnen und Patienten, 62,5 % dem männlichen und 37,5 % dem

weiblichen Geschlecht angehörend, zeigten 86 % keine Komplikationen wärend der

Nachbehandlungsphase.

In 0,02 % (zwei aus 1 000 Patientinnen und Patienten) trat spezifisch eine Sensibili-

tätsstörung des vorderen Gaumens auf.

Fazit

Unseres Wissens nach ist dies die größte Studie, die sich mit postoperativen

9

Sensibilitätsstörungen am Palatum nach (Nasen-)Septumplastik beschäftigt. Trotz

des sich überschneidenden Areals von chirurgischem Ablauf und Verlauf des

Nervs, stellen die momentan üblichen state-of-the-art chirurgischen Praktiken keine

wesentliche Gefahr für den Nervus incisivus dar. Ungeachtet dessen sollte in einem

präoperativen Aufklärungsgespräch über eine eventuell mögliche postoperative

Sensibilitätsstörung informiert werden.

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Table of Contents

Affirmation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Principle of equality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Material and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Zusammenfassung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Thema und Zielsetzung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Material und Methoden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Ergebnisse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Fazit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Problem statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

11

Overall aim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Material and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Basic aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Embryonic development of the nose and incisive canal . . . . . . . . . . . . . . 17

The maxillary nerve – origin of the nasopalatine nerve . . . . . . . . . . . . . . . 19

The maxillary artery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The incisive canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

The nasopalatine duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Esthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Esthetic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Possible side-effects on front tooth esthetics after rhinoplasty . . . . . . . . . 25

Septoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Historical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Surgical technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Septorhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Historical background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

12

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Surgical techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

The open technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

The closed technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Advantages and disadvantages of the different approaches . . . . . . . . . 31

Standard instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Additional instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Sensitivity disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

The frequency of occurrence in sensitivity disorders of

the anterior palate after septo(rhino)plasty . . . . . . . . . . . . . . . . . . . . . . . . 38

The correlation between an occurring sensitivity disorder and

other cooperating factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

The comparison between theory and empiricism . . . . . . . . . . . . . . . . . . . 39

13

Lesions of the incisive nerve in oral and maxillofacial surgery . . . . . . . . . 40

Implication of the outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Legend of figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

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Introduction

Problem statement

Septoplasty and septorhinoplasty are exceedingly common surgical interventions in

otorhinolaryngology. The surgical access and operating field extend to the incisive

nerve. Unintended lesions of exactly this nerve may potentially lead to postoperative

numbness of the anterior palate and teeth.

This complication has not been well discussed in literature so far. MacDougall et al.

were one of the first to state that a possible problem with the incisive nerve may be

related to intranasal surgery. They postulated that a hemitransfixion incision may

preserve full function of the nerve, whilst the so called Killian incision may do the

contrary. (MacDougall et al. 1993: p. 1011-1013) One year later, Guyuron et al.

claimed the highest risk of nerve damage to be occurring in two situations during

the surgery: 1) when removing parts of the vomer and 2) the vertical plate of the

ethmoid. (Guyuron et al. 1994: p. 454-456) Chandra et al. claimed that chiseling, as

well as monopolar cautery in the area of the foramen incisivum pose a significant

risk, the latter due to thermic and electric forces. (Chandra et al. 2008: p. 86-88)

Overall aim

The aim of this diploma thesis is to retrospectively analyze all septoplasties

and septorhinoplasties performed during the last 3 years at the department of

otorhinolaryngology of the Medical University of Graz and interpret patients’ reported

postoperative numbness in the addressed region in the follow-up period.

15

Material and methods

In total 1 000 patients’ charts, between June 2016 and January 2019, were reviewed.

Surgical reports, out- and in-patient documentation, as well as doctors letters were

analyzed in order to obtain following data:

• specific type of surgery

• technique

• complications

• sex

• birth date (age)

• follow up period

• sensitivity disorders

Patients with incomplete charts or insufficient documentation and / or follow-up were

excluded from our analysis.

Between June 2016 and March 2019 1 254 surgeries (septorhinoplasties and

septoplasties), were performed at the Department of Otorhinolaryngology at

the Medical University of Graz. Considering a sufficient follow up-period and

documentation 1 000 patients were finally included in the analysis.

Patients’ charts were analyzed retrospectively via the patient medical record system

MeDocs after obtaining approval from the institutional review board of the Medical

University of Graz. (approval number: 30-472 ex 17/18)

Septoplasty was differentiated from septorhinoplasty, both of them were further

subdivided into surgeries with or without additional FESS (functional endoscopic

sinus surgery). Additionally data about whether splints had been used or not were

collected.

16

Following other complications – apart from sensitivity disorders – were analyzed:

• abscess

• asymmetry

• asymmetry in combination with hyperostosis

• epistaxis or hemorrhage in general

• fever

• atresia of the auditory canal

• sense of taste

• hyperostosis

• infection

• monocular hematoma

• nasal valve stenosis

• revision surgery

• revision surgery in combination with abscess

• revision surgery in combination with granuloma

• revision surgery in combination with hyperostosis

• revision surgery in combination with droop flap stenosis

• perforation of the septum

• tinnitus

Men and women from all age groups were included in this study.

The statistical evaluation was performed with Microsoft Excel. For data evaluation,

descriptive statistics were used. When dealing with numerical classifications,

measures of central tendency as well as standard deviations were incorporated.

Patientsʼ data handling was anonymized. Data was coded with a system of

consecutive numbers. Only authorized staff had access to the file that contains the

link between numbers and patientsʼ personal information.

17

Basic aspects

Anatomy

Embryonic development of the nose and incisive canal

At the third week of pregnancy and a crown-rump-length (short: CRL) of 15mm

the development of the nose slowly starts to take its course. The primary nasal

cavity begins to form. At no earlier than the ninth week of pregnancy, the fetus

measures a CRL of 26mm, external facial features begin to manifest. The formation

process of the definite nasal cavity takes its course. The median nasal septum is

growing downwards, so are the lateral palatal shelves (processi palatini). Until now,

the tongue had been in between the appendices of the palate, while we can now

spectate a lowering of this muscle. As a next step, the processi palatini (labeled

as “2” in Fig. 1) feature a change in growing direction and now thrive to medial.

(Anderhuber et al. 2012: p. 831)

Consequential, the incisive canal embryologically belongs to the primary palate.

(Vollmer et al. 2018: p. 15)

Fig. 1: Schematic illustration of the development of the palate

1... Primary palate and nasopalatine nerves2... Maxillary, lateral palatal shelves3... Nasal septum

(Laumann 2013: p. 8)

Fig. 2: Schematic illustration of the palate once the roof has been formed


Fig. 3: Detailed illustration of Fig. 2 showing the incisive canal (12th week of pregnancy)

1... Nasopalatine duct2... Nerve3... Artery


18

Following, the median nasal septum (labeled as “1” in Fig. 1) conjoins with the

processi palatini as well as the primary palate with the result of forming the secondary

palate. At the transition from primary to secondary palate, an epithelial cord remains,

already representing the later incisive canal (Fig. 3). (Anderhuber et al. 2012: p. 831)

Fig. 4: Human embryo at a CRL of 25mm (7th-8th week), horizontal cut, level of later roof of palateonc... Oral and nasal cavityt... Tongueppp... Primary palatal processps... Palatal shelfnpn... Nasopalatine nerves

Fig. 5: Enlarged section of Fig. 4

(Radlansky et al. 2004: p. 267)

Fig. 6: Human fetus at a CRL of 53mm (9th week), horizontal cut, level of later roof of the palateic... Region of development of the incisive canal with nasopalatine nerv, artery and ductpp... Primary palatesp... Secondary palatedc... Primordium of left maxillary milk tooth canineph... Pharynx*... Border between primary and secondary palate



Fig. 4 Fig. 5

Fig. 6 Fig. 7

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The maxillary nerve – origin of the nasopalatine nerve

The trigeminal nerve (V), being the fifth of the twelve cerebral nerves, is high in

complexity. It features three main branches:

V1: ophthalmic nerve

V2: maxillary nerve

V3: mandibular nerve

(Anderhuber et al. 2012: p. 70)

For this study the most important nerve is the maxillary nerve (V2), a sensitive

nerve, which divides into numerous branches.

Fig. 8: Human fetus at a CRL of 100mm (13th week), horizontal cut, level of the later roof of the palatenpn... Nasopalatine nervesnpd... Nasopalatine ductsic... Incisive canalpp... Primary palatesp... Secondary palate*... Border between primary and secondary palate



Fig. 8 Fig. 9

20

Leaving the cranial cavity through the foramen rotundum, the maxillary nerve

enters the fossa pterygopalatina. Shortly after, the rami ganglionares ad ganglion

pterygopalatinum form their own branch and further divide into a bundle of nerve

fibers, the rami nasales posteriores superiores mediales. They run to the back of the

nasal septum, apart from one fiber, the nervus nasopalatinus. It runs along the nasal

septum to the incisive canal and innervates the mucosa of the anterior palate area.

The posterior palate, or hard palate, is being supplied by the nervus palatinus major.

The nervi palatini minores run through the canales palatini to the palatine tonsil and

also to the gingiva of the soft palate.

The rami alveolares superiores posteriores, alveolares superiores anteriores

and the ramus alveolaris superior medius (the last two emerging from the

nervus infraorbitalis) compose the plexus dentalis superior. It innervates molars,

premolars, canines and incisives with surrounding gingiva. In the vestibule area,

the rami labiales superiores run to skin and mucosa of the upper lip, as well as

adjoining gingiva. In contrast, the buccal gingiva by the molars is innervated by

the nervus buccalis, a branch of the nervus mandibularis. (Anderhuber et al.

2012: p. 778f)

Fig. 10: Maxillary nerve and its branches (Prometheus 2009)

21

The maxillary artery

The maxillary artery, being one of the terminal branches of the external carotid

artery, roughly divides into three segments: (Gofur et al. 2019) the mandibular

part, the pterygoid part (White et al. 2019) and the pterygopalatine part, where the

sphenopalatine artery emerges. (Alvernia et al. 2017: p. 655-664)

The nasopalatine artery represents a branch of the sphenopalatine artery. (Vollmer

et al. 2018: p. 16) The sphenopalatine artery itself provides major blood supply

for the mucosa of the nasal cavity. More specifically it supplies, the nasal concha,

the lateral wall as well as the septum. It enters the nasal cavity through the

sphenopalatine foramen. (Eordogh et al. 2018: p. 82-88) Before leaving the foramen,

the sphenopalatine artery divides into two main vessels, the septal artery and the

posterior lateral nasal artery. (El-Shaarawy et al. 2018: p. 345-355) However there

can potentially be up to ten or more branches. (Simmen et al. 2006: p. 502-505) The

septal artery supplies the septum, the posterior lateral nasal artery the lateral wall.

(Anderhuber et al. 2012: p. 838) One branch merges with the descending palatine

artery and runs through the incisive canal, then enters the nasopalatine canal with

the nasopalatine nerve. (Fitzpatrick et al. 2019)

Fig. 11: Sensitive innervation areas (Prometheus 2009)

22

The incisive canal

With a length of approximately 10mm and a diameter of about 6mm the incisive

canal, also referred to as nasopalatinal canal, constitutes a bony conduit which

connects the nasal cavity to the oral cavity. On the superior end it ends as the

foramina nasalia (also called “Stenson Foramina”). On the

oral end, it segues into the foramen incisivum. (Lake et al.

2018) Consequential, a y-shaped form can be observed.

The foramen incisivum represents the incisive canals’ bony,

palatinal confluence. (Vollmer et al. 2018: p. 14)

The incisive canal contains the nervus nasoplatinus as

well as the arteria palatina. (Lake et al. 2018) Furthermore,

accompanying venous vessels run with the nerve and artery

and in some cases the connective tissue can even include

sero-mucous glandular tissue. (Vollmer et al. 2018: p. 15)

The foramen incisivum is to be found right behind the central incisors, beneath the

incisive papilla, which represents the approximate injection site for the nasopalatine

nerve block.

Fig. 12: Branches of the maxillary artery (Gray 1918)

Fig. 13: Y-shaped design of the incisive canals (Vollmer et al. 2018: p. 15)

23

The nervus nasopalatinus is a sensory nerve. It innervates the nasal septum, as

well as the anterior part of the hard palateʼs mucosa and gingiva, it then overlaps

with branches of the great nervi palatini. (Lake et al. 2018) Sicher et al. were the

first to describe a potential innervation of the central incisor by branches of the

nasopalatine nerve. (Sicher et al. 1928)

The incisors are mainly innervated by the rami alveolares superiores anteriores.

(Lake et al. 2018) As stated above, a potential innervation might also come from the

nasopalatine nerve. (Sicher et al. 1928)

The anesthetic blockage of the nervus nasopalatinus can be used for front teeth

extractions, or other minor surgical intervention. (Lake et al. 2018)

In addition, the incisive foramen plays a decisive role in tooth arrangement in

prosthetics. The foramen incisivum must always be behind and centrally located in

relation to the upper incisors. Thus, it is used by dental technicians as a reference

point when making a total prosthesis. Little to no data regarding a more precise

location exist in literature, possibly due to the anatomical variety in between patients.

(Cho et al. 2016: p. 571-576)

The nasopalatine duct

In literature, the nasopalatine duct and the incisive canal are often misleadingly

considered the same structure. The nasopalatine duct is an anatomic structure

only existing during embryonic development, consisting of epithelial tissue.

(Eppley et al. 1988: p. 360-362)

When the primary palate (labeled as “1” in Fig. 1) and the lateral palatal shelves

(labeled as “2” in Fig. 1) merge, two nasopalatine ducts (labeled as “1” in Fig. 3) on

either side of the nasopalatine nerves (labeled as “2” in Fig. 3) form. (Radlansky et

al. 2004: p. 265-271)

24

Esthetics

Esthetic factors

Our upper incisors play a huge role in function and esthetics. (Matsumura et al. 2017)

The link between these two is the incisal edge and its location. (Levine 2016: p. 69)

For functional reasons the incisal edge of the central incisors is to be positioned at

the border between cornified to uncornified epithelium, meaning between dry to wet

lip transition. This can be verified by letting the patient vocalize words that contain

the letter “s”, like “Mississippi”, in order to check if the tongue has enough space,

and (regarding this question posing concerning the front central incisors even more

important to us) words containing the letter “f”, like “fluffy”, to test the accurate length,

as well as inclination of the incisors. (Mahnke 2018: p. 123)

Levine describes seven fee lines in his book. The first three of them deal with only

the front teeth position. Line number one (labeled as “1”) runs through the incisal

edge of the central incisors, and the canine tip on both sides. This line determines

inclination (sagittal axis), middle line (perpendicular), as well as length of the incisal

edge. It also defines symmetry and balance of not just the mouth region, but the

entire face. Also, how much tooth can be seen, at a state of relaxed soft tissue of

the lip. Levine later describes it to be exposed by 2-4mm aligned in view of age and

Fig. 14: The seven „FEE“ lines used to evaluate symmetry, balance and harmony. (Levine 2016: p. 72)

25

sex. The second line (labeled as “2”), is to be drawn through the highest apex of all

front teeth, the crossover from white to red. Line three (labeled as “3”) shows that,

when drawn at the highest point of the lateral central incisor, it is parallel but slightly

underneath a line drawn through the highest point of both canines. (Levine 2016:

p. 69, 75) Line 4, 5, 6 and 7 refer to the lower front esthetics and shall not further

concern us in this thesis.

Possible side-effects on front tooth esthetics after rhinoplasty

In females, a lip position where, when smiling to an absolute maximum, 1-2mm of

gingiva are shown, is considered optimal. In men, it is considered to be insignificantly

less. (Pi et al. 2017: p. 135-139) Everything above 4mm can be referred to as a

“gummy smile”. Anything under, may be called a “low lip”. (Deepthi et al. 2018: p.

231-233)

In their study Pi et al. showed, that out of 76 patients (15 males, 61 females), who

had undergone rhinoplasty surgery, 63% had less upper incisor exposure, than

before the operation. There was no sign of significant difference in sexes or between

open or closed procedure. (Pi et al. 2017: p. 135-139)

Fig. 15: A 25-year-old female with a follow-up period of 12 months: She had a 25% decrease in maxillary incisor show. (Pi et al. 2017: p. 137)

26

Septoplasty

Historical background

The first records were found in Eqypt, at that time still documented on papyrus. They

described that a broken nose is to be treated by stuffing the nasal orifices with linen

rolls and applying external splints for septum stabilization. (Fettman et al. 2009:

p. 241-251) In the 18th century, Quelmatz suggested a regularly applied, steady

pressure to straighten out a possible deviation. (Peacock 1981: p. 341-356) In the

1900s, Adams came up with a slightly altered version. He provoked a fracture and

splinted it, hoping to see it heal back in a straighter constellation. (Adams 1875: p.

421-422) In the late 19th century Ingals published the submucous resection. (Pirsig

1982: p. 547-551) Many followed like Krieg, Boenninghaus, Killian, Metzenbaum

or Hajek who all refined the technique in their own specific ways. In the middle of

the 20th century Fomon was convinced that the upper lateral cartilages presented

even more stability than the septum itself. (Aaronson et al. 2014: p. 931-936) Cottle

later on introduced his Maxilla-premaxilla approach. (Jammet et al. 1989: p. 38-41)

Roughly 40 years later, in 1991, Lanza and Stammberger described the state of the

art technique of endoscopic septoplasty. (Sautter et al. 2009: p. 253-260)

Indications

The medical indications for a septoplasty are varying. Constant or intermittent

blockage of airways such as oral respiration, snoring, Otitis media, or ventilation

disorder of the middle ear indicate surgery. (Arnold et al. 2011: p. 541) Also, in case

of sluder’s neuralgia, one sided tension headache of moderately severe pain inter

alia originating at the root or side of the nose (Oomen et al. 2010: p. 360-364) due to

contact of the middle turbinate with the septum, qualifies for an operation. A change

in shape of the external nose and/or the columella leading to septum deviation

speaks for a procedure as well. Compounded hemostasis in case of epistaxis and

finally, compromised access for microscopic as well as endoscopic procedures

indicate septoplasty.

27

Surgical technique

First, the thorough incision of the nasal mucous membrane is performed. Then the

surgeon makes a horizontal cut of 2-3mm in front of the muco-cutaneous junction.

As a next step, the anterior, inferior edge of the septum is mobilized out of the

columella. Following, a incision of the perichondrium is made and the subperiosteal

detachment of the mucosa is performed. Then the surgeon mobilizes the cartilage

by detaching it from the bony septum and the nasal floor. Now, the fracturing of

the severely deviated parts from the vomer and the lamina perpendicularis are

necessary to take out excessive bone material. The next step is a wedge-shaped

or oval excision of the cartilage in the deviated area. If necessary, a possible strain

relief can be performed. Following, previously taken cartilage and bone fragments

are being crushed and reapplied between the layers of mucous membranes. Finally,

sutures and possibly splinting with silicon splints are applied and a nasal tamponade

is placed when necessary. (Arnold et al. 2011: p. 541fff)

Fig. 16: Surgical instruments from ancient India (Sorta-Bilajac et al. 2007: p. 708)

Septorhinoplasty

Historical background

The birthplace and the very first roots of (septo-)rhinoplasty can be found in India in

the year 1000-800 BC. Around that time in India, immoral conduct such as adultery

28

were punished by mutilation of the ear, or even more common: the nose. Due to

that need, Sushruta, later on described as the “father of plastic surgery”, comes

up with the so called “Indian method”, that defines the basic steps of a rhinoplasty

procedure. (Sorta-Bilajac et al. 2007: p. 707-710)

This knowledge was passed on from India to Arabia, Persia and Egypt. Only in the

15th century Tagliacozzi next documented a similar procedure. (Ackerknecht 1982)

200 years later, Cruso and Findlay from Great Britain, learned from Indian surgeons

during the Mysore war, and by that brought the “Indian technique” to Europe.

(Castiglioni 1958)

To this day, the basics remain the same. Naturally, some alterations and modifications

have been made over the years. (Sorta-Bilajac et al. 2007: p. 707-710)

“The portion of the nose to be covered should be first measured with a leaf.

Then a piece of skin of the required size should be dissected from the living

skin of the cheek, and turned back to cover the nose, keeping a small pedicle

attached to the cheek. The part of the nose to which the skin is to be attached

should be made raw by cutting the nasal stump with a knife. The physician then

should place the skin on the nose and stitch the two parts swiftly, keeping the

skin properly elevated by inserting two tubes of eranda (the castor-oil plant) in

the position of the nostrils, so that the new nose gets proper shape. The skin

thus properly adjusted, it should then be sprinkled with a powder of liquorice,

red sandal-wood and barberry plant. Finally, it should be covered with cotton,

and clean sesame oil should be constantly applied. When the skin has united

and granulated, if the nose is too short or too long, the middle of the flap should

be divided, and an endeavor made to enlarge or shorten it.”

Fig. 17: The original work of Sushruta (translated to the english language) (Champaneria et al. 2016: p. 663)

29

Indications

It is obvious that, a septorhinoplasty is indicated in various deformities of the nose.

Possible indications may include a cleft nose, due to a congenital malformation, a

hump or a crooked nose on the basis of developmental interference, a crooked nose,

caused by trauma, a saddle nose after septoplasty, which is produced iatrogenic, or

a vestibular stenosis, which would cause a collapse of nostrils when inhaling.

Surgical techniques

Even though, the procedure of septorhinoplasty is indicated in deformities of the

nose, in most cases the surgery still starts with a septoplasty. Since there are hardly

any cases, where the septum is not deviated as well, this operation is a common

start. (Arnold et al. 2011: p. 541fff)

In general, the open procedure is to be distinguished from the closed procedure.

The open procedure provides direct view, and therefore allows more precision.

(Brushi et al. 2006: p. 155-158) It has the downsides of an increased operating time,

more, as well as longer swollen soft tissue, and more scaring (and therefore possible

asymmetries in healing). The sacrificing of nasal tip structure is to be considered

another downside, unless counteractive measures are taken.

The closed procedure offers less operating time, less recovery time, a better chance

of minimal scaring (for example no transcolumellar scar), and less subcutaneous

fibrosis. (Shah et al. 2006: p. 55-60) Still, many surgeons opt for an open procedure.

Only experienced ones can counterbalance the enhanced risk (mostly due to

compromised vision) with experience. (Cutting et al. 2007: p. 2021-2022)

30

The open technique

A columella incision is being performed, exposing the columella, the nasal tip and the

nasal bridge. (Theissing et al. 2006: p. 46.112) When making the cut, it is fundamental

to preserve medial crura, to minimize scar contraction during the healing process.

When dissecting, scissors are considerately being used in a tunneling technique.

With that technique, soft tissue is slowly being dissected from the cartilage and the

bony pyramid until the entire nasal framework is exposed. Now, with full vision on

the operating field, the septum can be reshaped in any form necessary. Usually

the incision is closed in two steps: first the subcutaneous layer and second the

cutaneous layer. (Marcal, 2011)

The closed technique

A two-sided mucosal cut of the nasal vestibulum between the alar cartilage and

the lateral cartilage is being made. Next, the surgeon prepares with a tunneling

technique, concerning the nasal soft tissue, staying strictly subperichondral in areas

of cartilage and subperiosteal in areas of bone. The next step is the resection of

the cartilaginous cusp with a scalpel, whilst a chisel is used for the bony structures.

For fine adjustment, a diamond drill or rasp can be used. The nasal bridge now

shows a wide and shallow form, so called open roof, which is corrected by the

mobilization of the ossa nasalia, processus frontales maxillae, spina nasalis ossis

frontalis by medial, lateral and transversal osteotomies. Next, a medial shift of the

side walls is being performed. The narrowing and lifting of the nasal tip by reduction

of connective tissue and excision of cartilage follows. If indicated, fine adjustment of

the nasal bridge in form of crushed cartilage fragments, that are placed underneath

the soft tissue, are accomplished. Next comes the sculpturing and forming of the

soft tissue. Finally, sutures are applied and a nasal tamponade and or a roof tile

dressing is placed. (Arnold et al. 2011: p. 541fff)

31

Advantages and disadvantages of the different approaches

Fig. 18: Advantages and disadvantages of the different approaches (Marcal, 2011)

In the interest of completeness, a semi-open (external marginal approach) or an

endoscopically guided septorhinoplasty is of course also an operating option, the

surgeon can choose from. (Seid et al. 2016: p. 39-44)

Standard instruments

These include surgical devices, that are being used at the standard procedure of a

septo(rhino-)plasty, as listed below.

A needle holder, in ideal circumstances containing plain surfaces. Because sutures

are usually very fine, these plain surfaces are necessary in order to properly retain

the material, without producing a predetermined breaking point. Forceps are needed,

most importantly with a fine tip for selective and safe handling. One in particular is

specifically used for the columella. One pair of each, pointed, curved and blunt

scissors are provided. A retractor, designed with only one hook, in order to not leave

any scaring, when perforating the skin is being used. Obviously a scalpel is part of the

equipment, as well as a bipolar coagulation forceps, for hemostasis. Furthermore,

a cottle elevator, a cottle knife (for the columella) and blakesly-grasping forceps are

being provided. (Theissing 1996: p. 11; 66)

32

Additional instruments

Additional instruments can be: a chisel, that contains an angled edge, which allows

the surgeon to chisel an inflected line. An osteotome, that is sharpened on both

sides of the blade and is therefore producing a straight line can be used. Surgical

pegs, as in a straightening retractor, that is used for lifting the skin of the bridge of

the nose may be part of the surgical equipment. Also wire pegs, for the exposition

of the side cartilage and dull-sharp pegs, used for the exposition of the left and right

alar cartilage can be provided. In addition, a special forceps responsible for the

repositioning of bone fragments may be needed. (Theissing 1996: p. 79)

Sensitivity disorders

Classification

Sensitivity disorders are subdivided into: Hypoesthesia, Hyperesthesia, Paresthesia,

Dysesthesia and Anesthesia.

Different patients may feel different kinds of sensitivity disorders after trauma to a

nerve. While hypoesthesia characterizes reduced sensation, hyperesthesia is the

opposite, where patients feel hypersensitive towards touch. Discomfort like tickling,

tingling, or sometimes also a burning feeling describes paresthesia. If discomfort

of any kind gets to a point, where patients clearly classify it as painful, it is called

dysesthesia. Anesthesia characterizes no feeling at all.

33

Treatment

When a patient struggles with sensory impairment it is important to not just start

treatment but also to classify and document.

Documentation must include the exact expansion, best outlined in form of a drawing.

Also the patient is to be asked what kind of impairment in which areas he can

distinguish. A pointed probe shall help with differentiation between sharp and blunt,

which we also keep exact record of. With that technique, a precise and significant

comparison can be made when the patient next comes in for a checkup.

Medication

The patient gets a prescription for medication, accompanied by a soft laser therapy.

Neurobion forte (1×1), the tablet needs to be taken one time a day and is a vitamin B

supplement. The second drug is Prednisolon 5mg (4×1; 2×1; 1×1; 1×1): a cortisone

preparation, in this case mostly used for reduction of swelling, in order to give the

nerve space to heal properly. It has to be taken four times on day one, two times on

day two, and one time a day on day three and four. The therapy is a low-level-laser

treatment (LLLT) to stimulate the compromised nerve, and by that accelerate the

healing process. (Gluhak et al.: p. 54)

34

Results

Epidemiology

In total N=1 000 patients were included who underwent a procedure of septoplasty

or septorhinoplasty between June 2016 and January 2019.

The majority of patients belonged to the age group 21 to 30 years with a percentage

of 37%. 23% of the patients were from 31 to 40 years of age. The next big group was

from 41 to 50 years old (16%), closely followed by group 51 to 60 years with 13%.

Age groups zero to 20 years, 61 to 70 years and 71 to 100 years of age brought up

the rear with 6%, 5% and 1% (Figure 1).

0% 5% 10% 15% 20% 25% 30% 35% 40%

0 to 20 years

21 to 30 years

31 to 40 years

41 to 50 years

51 to 60 years

61 to 70 years

71 to 100 years

age distribu�on

Figure 1 – age distribution

35

62.5% male and 37.5% female patients were included in this study (Figure 2).

gender distribu�on

male female

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

septoplasty septorhinoplasty septoplasty in combina�onwith FESS

septorhinoplasty incombina�on with FESS

surgery technique

Figure 2 – gender distribution

Figure 3 – surgery technique

36

A classic septoplasty was most commonly performed (47%, N=469). SRPs were

performed in 39% (N=394). The combination with a FESS (functional endoscopic

sinus surgery) procedure more likely appeared in septoplasties with 14%. A

septorhinoplasty surgery in combination with a FESS procedure represents a

negligible proportion (0.2%).

complica�ons

no complica�ons

revision surgery

other

Figure 4 – complications

No complications were detected in 86% of patients, followed by the complications

revision surgery (7%), bleeding (2%), fever (1%), asymmetry (1%), infection

(1%), perforation of the septum (1%) and other (1%). “Other” may entail abscess,

hyperostosis, atresia of the auditory canal, monocular hematoma, droop flap

stenosis, granuloma, or tinnitus (Figure 4).

37

In the majority of patients (66%), splints were applied. In 22%, splints were explicitly

not provided. 12% of the operation reports did not provide information whether

splints had been used or not (Figure 5).

0% 10% 20% 30% 40% 50% 60% 70%

splint

no splint

no informa�on provided

special technique regarding the usage of splints

Figure 5 – special technique regarding the usage of splints

In 998 of 1 000 (99.8%) of patients no sensitivity disorder was detected or documented

during the follow up period.

sensibility disorders

yes no

Figure 6 – sensibility disorders

38

Discussion

Septoplasty and septorhinoplasty are exceedingly common surgical procedures

in functional and aesthetic modern medicine. Worldwide 726 907 rhinoplasties (of

any kind) had been performed in 2018 according to the International Society of

Aesthetic Plastic Surgery. (International Society of Aesthetic Plastic Surgery: p. 9)

In Germany, 14 071 were counted the same year. (International Society of Aesthetic

Plastic Surgery: p. 18) In addition, the procedure rhinoplasty was ranked the most

common cosmetic one age group 18 years and younger. (International Society of

Aesthetic Plastic Surgery: p. 7)

The frequency of occurrence in sensitivity disorders of the anterior palate after septo(rhino)plasty

Out of 1 000 patients only two described sensitive impairment during the follow

up period. On a percentage basis, this constitutes 0.2% with a possible sensitivity

disorder of the nervus incisivus. 99.8%, 998 patients, did not specify on any sensitivity

disorders during the postoperative healing time or the follow up period.

The result of this study states, that after a procedure of septo(rhino)plasty no

consequences, concerning sensitive impairment of the anterior palate, are to be

expected. Consequently, no lesion to the incisive nerve is to be anticipated.

The correlation between an occurring sensitivity disorder and other cooperating factors

Out of the two occurring sensitive impairments, one developed after a septoplasty

procedure, the other one after a septorhinoplasty operation. Regarding suture

material was no information provided at the septoplasty. The septorhinoplasty was

closed with Vicryl Rapid, Biosyn and silk sutures. In both cases splints were applied

for the healing period. Complications did occur after both operations. A perforation

of the septum was detected after the septoplasty, while hyperostosis was observed

after the septorhinoplasty. Both patients were male, one aged between 41 and 50,

and one between 21 and 30 years. In case of the septoplasty, the follow up period

39

accounted for seven months and six days, the septorhinoplasty was being observed

for one month and three weeks after.

The following chart provides an overview of the comparison between the two cases.

Procedure Splints Complications Gender Age boxFollow up

time

Septoplasty YesPerforation of

the septumMale

41-50

years

7 months

6 days

Septorhinoplasty Yes Hyperostosis Male21-30

years

1 month

3 weeks

Figure 7 – comparison between the two cases with a documented sensitivity disorder of the anterior palate

Consequentially, a correlation between an occurring sensitivity disorder and other

cooperating factors is inconclusive and of limited informative value.

The comparison between theory and empiricism

In 1995, Rettinger et al. published the article “Palatal sensory impairment after

setoplasty” concentrating on 31 patients undergoing septal surgery within a

prospective study. Their findings were 32% of patients with sensory impairment one

week post-op. The four month check-up only showed 16% (five patients) with palatal

sensitive discomfort remaining. (Rettinger et al. 1995: p. 282-285)

Chandra et al. brought up the topic again in 2008, reviewing 107 patients over a

period of three years. After being operated on by the same surgeon, the results were

three patients with a palatal sensitivity disorder (2.8%). After the three month follow-

up, two of the three had regained all sensitive sensation. At the one year check-up

one remained persistent. (Chandra et al. 2008: p. 86-88)

Rettinger et al. opted for a prospective trial, while Chandra et al. chose a retrospective

40

study, which was also the used method in this thesis. In Rettinger’s article, 31 cases

were analyzed, while in 2008 Chandra et al. evaluated more than the triple amount,

107 patients. In this study 1000 cases were assessed. With a percentage of 32%,

Rettinger et al. had the highest incidence of sensitivity disorders post-op. After a four

month check-up, the number dropped down to 16%. Chandra et al. followed with 2.8%

post-op and concluded with 0.9% after a one year follow-up. In this study the focus

was lying on the polar question. Therefore no further specification was distinguished

between post-op numbness of the palate and remaining discomfort after a follow-

up period of a certain amount of time. The finding of this thesis states, that in 0.2%

a palatal sensitivity disorder occurred post-op. This result seems comparable to

the outcome of the publication of Chandra et al., in addition to the fact that both

were retrospective studies. Worthy of mention is one remarkable difference: While

Chandra et al. had all surgeries performed by the same surgeon, this thesis does

not draw distinction between varying surgeons.

Lesions of the incisive nerve in oral and maxillofacial surgery

The trigeminal nerve, and therefore also the incisive nerve, being a connective

element between otorhinolaryngology and dentistry, naturally also plays a significant

role in oral and maxillofacial surgery.

2016 Agbaje et al. reviewed 7 602 patients, who had undergone oral or maxillofacial

surgery. In 56 cases, branches of the n. trigeminus had been compromised. After a

one year check up, 37.5% patients remained with enduring damage.

Only 2 patients (representing 3.6%) exhibited damage to the maxillary nerve.

(Agbaje et al. 2016: p. 321-327)

Possible procedures that were connected to nerve damage of branches of the

trigeminal nerve include implant surgery, bone grafting, tumor, cystic lesions,

infection, tooth extraction, overfilling in endodontic treatment, apicoectomy, flap

elevation, nerve transposition, orthognatic as well as pre-prosthetic surgery and

malpractice of administering anesthesia. (Sivolella et al. 2014: p. 3088-3117)

41

Implication of the outcome

An occurrence of two patients reporting a sensitivity disorder of the anterior palate

out of 1 000, representing 0.2%, can draw a conclusion of it not being a common

complication of the procedure of a septoplasty or a septorhinoplasty. Still, patients

should be informed about the possibility in an explanatory pre-operation discussion.

In this thesis, data was collected by analyzing charts, surgical reports, ambulatory

and in-patient documentation, as well as doctors’ letters. This means that, because

of this retrospective approach, the occurrence of a sensitivity disorder of the anterior

palate can only rely on patients independently reported complaints. If as standard,

the first post-op check-up would include a direct question, or even a leading question

towards the sensitivity of the palate, the outcome may differ from these findings. The

possible impact or change in result is yet to be investigated.

Conclusion

This study differs from Rettinger et al. and Chandra et al. in particular in the amount

of patients’ records reviewed. Rettinger et al. reviewed 31 patients, Chandra et al.

107. In this study 1000 patients were included giving it a high power despite its

retrospective nature.

In summary, the majority, accounting for over one third of the patients, belonged to

age group 21 to 30 years. Almost two thirds are composed of patients 21 to 40 years

of age.

Regarding the surgical technique it is stated that almost half of the procedures were

a classical septoplasty, closely followed by a classical septorhinoplasty.

In most cases no serious or permanent complications were documented (excluding

side effects of the usual postoperative healing progress). The only notable

complication was the need of a revision surgery (still only at 7% of occurrence).

42

The usage of splints during the healing process was indicated in two thirds of the

patients, whilst it was contraindicated in 22 percent of the time. In 12%, patients’

charts did not provide any information whether splints had been used or not.

In 99.8% of patients no sensitivity disorder was documented. Only two out of the

1 000 reviewed cases showed symptoms of impaired sensitivity. Thus, the current

techniques for septoplasties and septorhinoplasties are safe for the incisive nerve

despite close surgical manipulation to the nerve’s course.

43

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Archive.

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on Upper Lip Position and Incisor Show”, Aesthetic Plastic Surgery, vol. 41, no. 1,

pp. 135-139.

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human incisive canal”, Anatomy and Embryology, vol. 208, no. 4, pp. 265-271.

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Sushruta’s legacy”, Otolaryngology-head and neck surgery: official journal of

American Academy of Otolaryngology-Head and Neck Surgery, vol. 137, no. 5, pp.

707-710.

50

Vollmer, R., Voller, M., Nimtschke, U., Götz, W. & Schwab, W. 2018, “Bedeutung des

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vol. 12, pp. 14-20.

Figure 1 – age distribution (Bachlechner, M.)

Figure 2 – gender distribution (Bachlechner, M.)

Figure 3 – surgery technique (Bachlechner, M.)

Figure 4 – complications (Bachlechner, M.)

Figure 5 – special technique regarding the usage of splints (Bachlechner, M.)

Figure 6 – sensitivity disorders (Bachlechner, M.)

Figure 7 – comparison between the two cases with a documented sensitivity disorder

of the anterior palate (Bachlechner, M.)

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Documents

Postoperative sensitivity disorders of the anterior palate