hard and soft tissue changes after orthognathic surgery

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BANGALORE

“CLINICAL AND RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES

AFTER ORTHOGNATHIC SURGERY”

By Dr. MOHAMMED HANEEF

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment of the requirements for the degree of

MASTER OF DENTAL SURGERY IN

ORAL AND MAXILLOFACIAL SURGERY

Under the guidance of Dr. NEELAKAMAL H HALLUR M.D.S.

Professor & HOD

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY AL-BADAR RURAL DENTAL COLLEGE AND HOSPITAL

GULBARGA - 585 103, KARNATAKA, INDIA. [2011-2014]

II

Rajiv Gandhi University of Health Sciences, Karnataka.

DECLARATION BY THE CANDIDATE

I, hereby declare that this dissertation/thesis entitled “CLINICAL AND

RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES

AFTER ORTHOGNATHIC SURGERY” is a bonafide and genuine research work carried

out by me under the guidance of Dr. NEELAKAMAL H HALLUR, PROFESSOR & HOD,

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY, AL-BADAR RURAL

DENTAL COLLEGE & HOSPITAL GULBARGA.

DATE: Signature of candidate PLACE: GULBARGA Dr. MOHAMMED HANEEF

III

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “CLINICAL AND


AFTER ORTHOGNATHIC SURGERY”

is a bonafide research work done by

Dr. MOHAMMED HANEEF in partial fulfilment of the requirement for the degree

of MASTER OF DENTAL SURGERY IN ORAL AND MAXILLOFACIAL

SURGERY.

Signature of the Guide

DATE: / / 2013 Dr. NEELAKAMAL H HALLUR MDS PLACE: GULBARGA Professor & HOD

Department of Oral and Maxillofacial Surgery, Al-Badar Rural Dental College &Hospital

Gulbarga- 585103.

IV

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT, PRINCIPAL /HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled “CLINICAL AND


AFTER ORTHOGNATHIC SURGERY” is a bonafide research work done by

Dr. MOHAMMED HANEEF, post graduate student under the guidance of

Dr. NEELAKAMAL H HALLUR MDS Professor & HOD, Department of Oral and

Maxillofacial Surgery, Al-Badar Rural Dental College & Hospital, Gulbarga.

Seal & Signature of the HOD

Dr. Neelakamal Hallur M.D.S

Professor and Head Department of Oral Maxillofacial Surgery,

Al-Badar Rural Dental College and Hospital GULBARGA

Seal & Signature of the Principal

Dr. Girish Katti M.D.S

Principal Al-Badar Rural Dental College and Hospital

GULBARGA

DATE: DATE:

PLACE: GULBARGA PLACE: GULBARGA

V

COPYRIGHT

DECLARATION BY THE CANDIDATE

I, hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this dissertation /

thesis titled “CLINICAL AND RADIOGRAPHIC EVALUATION OF HARD

AND SOFT TISSUE CHANGES AFTER ORTHOGNATHIC SURGERY” in

print or electronic format for academic / research purpose.

DATE: Signature of candidate

PLACE: GULBARGA Dr. MOHAMMED HANEEF © Rajiv Gandhi University of Health Sciences, Karnataka

VI

Acknowledgment

No endeavour can start, continue or be completed without the blessings of Almighty

ALLAH. I bow my head in gratitude to the Almighty for bestowing his blessings on me,

providing and infusing me with enough strength to carry out this work and being with me in

all my endeavours.

The printed pages of this dissertation hold far more than the culmination of years of

study. These pages also reflect the relationships with many generous and inspiring people I

have met since beginning of my Post graduate work. I owe my gratitude to all those people

who have made this work possible and because of whom my postgraduate experience has

been one that I will cherish forever.

I am deeply indebted to my teachers and no word can sufficiently acknowledge for the

support they have provided me throughout my postgraduate course.

It is with supreme sincerity and deep sense of appreciation I place on record my

profound gratitude to my teacher and guide Dr. Neelakamal H Hallur, Professor and Head

of the Department of Oral and Maxillofacial Surgery for his efficacious guidance, critical

evaluation, cooperation and support to keep me afloat during the rough tides. A mere word of

thanks is not sufficient to express his unflinching guidance, keen surveillance, inestimable aid

and constant encouragement during the study. It is to him I extend my heartfelt gratitude for

his efficacious guidance and altruistic co-operation and support throughout my post

graduation course.

It gives me immense pleasure to extend my sincere thanks to my teachers, Dr. Aaisha

SiddiquaMDS, Professor, Dr. Syed ZakaullahMDS, Associate Professor, Dr. Kiran RadderMDS, Reader, Dr. Ashwin ShahMDS, Reader, Dr. Shereen FatimaMDS, Assistant Professor,

Dr.Chaitanya KothariMDS, Assistant Professor, Dr. Meenakshi KothariMDS, Assistant

Professor, Dr. Juhi ShabnumMDS, Assistant Professor and Dr. Syed AzizuddinBDS, Lecturer.

Department of Oral and maxillofacial Surgery, Al-Badar Rural Dental College and Hospital,

Gulbarga, for their kindness, courtesy and tireless pursuit throughout my post graduate

course.

VII

On a personal note words fail to express the amount of support given by

Dr. Pavan, Dr. Shahid, Dr. Juhi, Dr. Jyothi, Dr. Syed Mohammed Ali, Dr. Adnan,

Dr. Zaki, Dr. Abhishek, Dr. Jayesh and my colleagues Dr. Kamran, Dr. Amir, Dr. Deepa,

Dr. Vaki, Dr. Donekal Gurucharan, Dr. Rajershi Basu, Dr. Summaya Patel, Dr. Pavan

Khichade and Dr. Shivaraj Patil and all the non-teaching staff of department who have

helped me in every way during my post graduation course.

I sincerely thank our Principal, Dr. Girish KattiMDS, Al-Badar Rural Dental College

and Hospital, Gulbarga for providing the opportunity to utilize the facilities made available

in this institution.

I take the privilege to acknowledge my sincere gratitude to Dr. AshokMDS Prof. &

HOD, Dr. ArshadMDS, Assistant Professor, Dr. UroojMDS, Assistant Professor, Department of

Orthodontics, Al-Badar Dental College & Hospital, Gulbarga. I also acknowledge Dr. Ali R

PatelMDS, Assistant Professor, Dental Dept. KBN Hospital, for their generous help, advise

and support, throughout the study.

I wish to acknowledge the invaluable help by Mr.Jagannath Maski, Librarian, Al-

Badar Rurual Dental College and Hospital, Gulbarga, Mrs Jyothi P, Bio-statistician, N V

College, Gulbarga for their service in carrying out the statistical analysis. I also thank Mr.

Mohammed Ilyas Ahmed of Super Computers, Gulbarga for his timely help.

I express my heartfelt thanks to all my patients who have cooperated with me as a

part of this study and without whom this project would have never been possible.

My life is indebted to the prayers of my mother, Ms.Farha Naaz, my brothers and my

In-laws who have supported me in every phase of life.

My career has been the dream of my beloved father, Late Mr. Mohammed Farooq

and my Late Grandmother to whom I dedicate this dissertation.

Lastly, I would like to thank my wife Dr. Summaya Fatima for her support,

encouragement, quiet patience and care which helped me overcome setbacks and stay

focused.

Date:

Place: Gulbarga Dr. MOHAMMED HANEEF

VIII

LIST OF ABBREVIATIONS

COGS Cephalometrics for Orthognathic Surgery

VAS Visual Analogue Scale

OPD Out Patient Department

PAS Profile Assessment Score

BSSO Bilateral Split Sagittal Osteotomy

OMFS Oral and Maxillofacial Surgeons

LP Laypersons

SP Surgical patient

SD Standard deviation

OPG Orthopantogram

Pt. Patient

T Throat Point

A-P Anteroposterior

PC Personal Computer

AMO Anterior Maxillary Osteotomy

MM Millimeter

IX

ABSTRACT

“CLINICAL AND RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE

CHANGES AFTER ORTHOGNATHIC SURGERY”

BACKGROUND: A significant number of patients with severe malocclusions and

Dentofacial deformities with a desire to improve facial aesthetics choose surgical-orthodontic

treatment. Such a treatment has significant impact on the treated individuals. Assessment of

an individual’s appearance as perceived by their peers and the possible improvement

with Orthognathic surgery are important considerations, as the perception of aesthetic

improvement might differ between people with different backgrounds.

AIMS AND OBJECTIVES: The present study was conducted to evaluate clinical and

radiological hard and soft tissue changes after Orthognathic surgery in patients having convex

profile in the Department of Oral and Maxillofacial Surgery, at Al-Badar Rural Dental

College and Hospital, Gulbarga from September 2010 to September 2013.

MATERIAL AND METHODS: Preoperative (T0) Lateral Cephalogram were taken a week

before surgery and Postoperative (T1) Lateral Cephalogram were taken at 3rd month for all the

10 patients included in this study. Preoperatively and postoperatively limited COGS analysis

and limited Legan’s Analysis was done. Silhouettes were created using traced soft tissue

profiles and standardized. A survey was conducted using the Silhouettes which included the

Surgical patient, 5 Oral and Maxillofacial Surgeons and 5 Laypersons s.

X

RESULTS: Significant difference was found between PAS of T1 and T0 in all the groups,

with the maximum difference being in the Laypersons group with a t-value = 18.55

(<P=0.05). Significant Intra-group differences were found in perception of attractiveness

between OMFS and the Laypersons group with a t-value = 3.05, P=0.05 and also between

Surgical patient and Laypersons with t-value=2.41, P=0.05.

CONCLUSION: This study concludes that all the patients were able to perceive the change

in profile and were also satisfied with the aesthetic outcome. It was also concluded that all the

evaluators were able to perceive the change in attractiveness.

KEY WORDS: Orthognathic Surgery; Clinical Evaluation; Radiographic Evaluation.

XI

TABLE OF CONTENTS

SL. NO. CONTENTS PAGE NO.

1 INTRODUCTION 01

2 AIMS AND OBJECTIVES 04

3 REVIEW OF LITERATURE 05

4 MATERIAL AND METHODS 34

5 RESULTS 53

6 DISCUSSION 65

7 SUMMARY & CONCLUSION 72

8 BIBLIOGRAPHY 74

9 ANNEXURES 81

XII

LIST OF TABLES

TABLE NO.

TITLE PAGE

NO.

1a Hard tissue Cephalometric Land Marks used in this study 38

1b Soft tissue CephalometricLand Marks used in this study 39

2 Limited Burstone’s and Legan’s Analysis for Hard & Soft tissue changes

40

3 Comparison of Mean PAS scores 42

4 Patient details 53

5a T1-T0 of Hard tissue parameters 54

5b Student’s paired “t” test values 55

5c Comparison of achieved hard tissue change with Burstonenorms using “t” test

55

6a T1-T0 Soft tissue parameters parameters 56

6b Student’s paired “t” test 57

6c Comparison of achieved Soft tissue change with Legan and Burstone norm using “t” test

57

7a PAS score of all groups and Inter and Intra group comparison 58

7b Intra-group comparison between PAS difference of OMFS, Laypersons and Surgical patient

59

XIII

LIST OF FIGURES

FIGURE NO.

TITLE PAGE

NO.

1. 100mm Visual Analogue Scale 41

2. Case 1 Silhouettes 44





LIST OF GRAPHS

GRAPH NO.

TITLE PAGE

NO.

1. Intra-group comparison of mean pre- and postoperative PAS 59

XIV

LIST OF PHOTOGRAPHS

SL. NO.

PHOTOGRAPHS PAGE

NO.

1. Case No. 1 43

2. Case No. 8 45

3. Case No. 2 47

4. Case No. 7 49

5. Case No. 6 51

Introduction

1

INTRODUCTION

Human face is a complex mosaic of lines, angles, planes, shapes, textures and

colours. The interplay between these elements produces an infinite variety of facial

forms, from perfect symmetry to extreme disproportions.1,2,3,4

Facial harmony and balance are determined by the facial skeleton and its soft

tissue drape.3 The architecture and topographic relationships of the facial skeleton

forms a "foundation" on which the aesthetics of the face is based. However, it is the

structure of the overlying soft tissues and their relative proportions that provide the

visual impact of the face.4

A significant number of patients with severe malocclusions and dentofacial

deformities with a desire to improve facial aesthetics choose surgical-orthodontic

treatment for the correction of facial deformities and occlusal disharmony. Such

treatment has significant impact on the treated individuals.5,6 Orthognathic surgery

aims to achieve a harmonious skeletal, dental, and soft tissue relationship to improve

both function, and facial aesthetics for patients with jaw discrepancies.

Orthognathic surgery causes changes in shape and position of the overlying

soft tissue, resulting in alteration of facial aesthetics.7 In recent times, aesthetic aspects

of surgery are as important as functional goals.5,7,8,9

Introduction

2

For the majority (41–89%) of patients with convex profile, aesthetics is the

chief complaint when seeking Orthognathic surgery and is thus of primary

importance.10 And Correction of profile has been a prime reason and motivation

especially in patients with convex profiles in comparison to patients with concave

profile.11,12

Cephalometric norms have been used for providing guidance to the clinician

during diagnosis and treatment planning. This is even more so in orthognathic-

surgical treatment where there are obvious needs to identify the skeletal dysgnathia

and soft-tissue facial disharmony by comparing with the normative values.13,14,15

Assessment of an individual’s appearance as perceived by their peers and

the possible improvement with Orthognathic surgery are important considerations

when planning the surgical treatment. Therefore, it is important to know the

opinion of both the professionals and the Laypersons opinion on the facial

appearance of patients before and after mandibular advancement surgery as the

perception of aesthetic improvement might differ between people with different

backgrounds.10

Hence, there is a need to evaluate hard and soft tissue changes post operatively

after Orthognathic surgery and also to evaluate the perception of attractiveness due to

change in profile after Orthognathic surgery.

Introduction

3

The present study was conducted to evaluate clinical and radiological hard and

soft tissue changes after Orthognathic surgery in patients having convex profile in the

Department of Oral and Maxillofacial Surgery, at Al-Badar Rural Dental College and

Hospital, Gulbarga from September 2010 to September 2013.

Aims & Objectives

4

AIMS AND OBJECTIVES





The objectives of this study are to:

1. To evaluate preoperative and postoperative hard and soft tissue changes after

Orthognathic surgery in patients having a convex profile.

2. To evaluate the perceived level of improvement in facial attractiveness by the

Surgical patient, Laypersons and Oral and Maxillofacial Surgeons

Review of Literature

5

REVIEW OF LITERATURE

Burstone CJ et al. (1978)15 analysed the importance of Cephalometric in

Orthognathic surgery and described various landmarks used in Cepahalometric

analysis. They considered only dental and skeletal measurements and its application

to Surgical patients. Hence, they concluded that Cepahalometric appraisal was only

one step in diagnosis and planning of treatment; and COGS analysis could be used in

diagnosing the nature of facial dysplasia and abnormalities in position of teeth.

Legan HL & Burstone CJ. (1980)20 described a simplified and relevant

Cephalometric soft tissue analysis that was designed for patients who had required

Orthognathic surgery to complement a previously reported Dentoskeletal analysis.

When used along with other diagnostic aids, this soft tissue evaluation would enable

the clinician to achieve good facial aesthetics. The soft tissue analysis evaluated both

vertical and horizontal aspects of the face, including lip length and posture. The

measurement of intralabial gap brought in a functional parameter in addition to

morphologic consideration. However, the author cautions that if prime objective of

Orthognathic surgery was facial improvement, than soft tissue analysis would be

paramount importance in treatment planning.

Sarver DM & Weismann SM. (1991)28 conducted a study to compare the

short and long term net response of soft tissues in 36 patients who underwent superior

repositioning of maxilla via Lefort I osteotomy short. Their study concluded that soft


6

tissue changes associated with maxillary impaction are minimal and that no

significant differences exist between twelve-month records and five-year records.

Ewing M & Ross RB. (1991)29 did a study to interpret the predictability of

soft tissue response to mandibular advancement and Genioplasty in 31 patients who

had undergone mandibular advancement surgery. Out of which, 17 patients had also

received additional advancement Genioplasty. This study concluded that a consistent

1:1 ratio of hard to soft tissue movements was achievable and predictions could be

accurate when BSSO advancement was done alone. And that, when Genioplasty was

added to advancement the prediction was inaccurate and variable response of soft

tissues were seen particularly in the lower lip.

Willmott JJ, Barber HD, Chou DG, Katherine W. L. (1993)12 conducted

this retrospective study to analyse the association of severity dentofacial deformity

with patient’s motivation for treatment. A total of 142 patients, aged 16 years or older

were included in this study. The patients were subgrouped on the basis ANB angle as

Class I, Class II and Class III and motivation for Orthognathic surgery was derived

from clinician administered forms scaled from 1-10. The study found that ANB was

significant for high/low motivation for Orthognathic surgery using student’s t test.

The study concluded that patients with severe Class II dentofacial deformities had a

higher motivation.


7

Ling SS & Kerr WJS. (1998)11 evaluated the correlation between hard and

soft tissue change in 17 Class III patients treated by Bimaxillary surgery. The study

concluded that there was strong correlation in the horizontal movement of selected

landmarks approaching 1:1 ratio and weak correlation in vertical movement to

corresponding soft tissue landmarks.

Troulis MJ, Kearns GJ, Perrott DH & Kaban LB. (2000)31 described an

extended Genioplasty technique and evaluated stability of position, form, surface,

surface area of the chin and the incidence of postoperative sensory deficit. At the end

of 6 months the authors concluded that the procedure was stable with predictable

results could be achieved without any permanent neurosensory dysfunction.

Shelly DA, Southard TE, Southard KA, Casko JS, Jakobsen JR, Fridrich

KL & Mergen JL. (2000)22 published an article that investigated the impact of

mandibular advancement surgery on profile aesthetics and attempted to define

guidelines that could be of value to the clinician in predicting profile aesthetic change.

The sample consisted of 34 patients who had been treated with a combination of

orthodontics and mandibular advancement surgery without Genioplasty. Initial (pre-

treatment) and final (post-treatment) Cephalometric radiographs of each patient were

used to produce silhouette images and to quantify skeletal changes that occurred with

surgery. The authors concluded by recommending pre-treatment ANB angle of at

least 6° for improved profile aesthetics after mandibular advancement surgery.


8

Jokic D. Jokic D, Uglesic V, Macan D & Knezevic P. (2000)17 conducted

this study to evaluate the relationship between soft tissue and hard tissue changes;

correlation between thickness of tissue before and after surgery in Class III patients

treated with Bimaxillary surgery and BSSO advancement. Total of 78 patients were

included, Lateral cepahlograms were taken preoperatively and postoperatively from 3

months to 1 year. Zagreb 82, Legan and Burstone analysis were used for comparison

of soft tissue points before and after surgery. On conclusion, it was assessed that soft

tissue points between Sn and A and upper lip showed statistically significant change

and also correlated with SNA angle. And significant correlation was found with soft

tissue thickness and changes after surgery.

Chang EW, Lam SM, Karen M & Donlevy JL. (2001)32 conducted this

study to evaluate the results of sliding Genioplasty and versatility of the procedure.

Total of 43 patients aged between 16-52 years underwent Genioplasty alone or with

concomitant Orthognathic surgery. On conclusive, note the authors opine that

Genioplasty is a simple effective technique that gives excellent aesthetic results with

minimal complications.

Mobarak KA, Espeland L, Krogstad O & Lyberg T. (2001)33 conducted

this study to compare skeletal stability and the time course of postoperative changes

in high-angle and low-angle Class II patients after mandibular advancement surgery.

A total of 40 patients with mandibular retrognathism who were treated by BSSO

advancement were included in this study and were divided according to the

preoperative mandibular plane angle as high angle and low angle group. Lateral


9

Cephalogram were taken on six occasions: immediately before surgery, immediately

after surgery, 2 and 6 months after surgery, and 1 and 3 years after surgery. Hence,

this study concluded that the high-angle group and low-angle group had different

pattern of surgical and postoperative changes. High-angle group patients were

associated with higher frequency and greater magnitude of relapse, 38% of which

occurring in the late follow up period. Low-angle group patients had lesser changes of

relapse with 95% of which occurring in the first 2 months post operatively.

Mobarak KA, Espeland L, Krogstad O & Lyberg T. (2001)19 conducted

this Cephalometric study to assess long term soft tissue changes in profile and the

relationship between soft and hard tissue movements in mandibular advancement

surgery. 61 patients, treated mandibular advancement surgery were included in this

study. Lateral Cephalogram were taken on six occasions: immediately before surgery,

immediately after surgery, 2 and 6 months after surgery, and 1 and 3 years after

surgery. This study found that postsurgical changes in the upper and lower lips and

the Mentolabial fold were more pronounced among low-angle cases compared with

high-angle cases and changes were generally in 1:1 ratio with hard tissue counterpart.

They had concluded that for a more reliable and realistic long term prediction soft and

hard tissue ratios that accounted for mean relapse should be used.

Talebzadeh N & Pogrel MA. (2001)34 did a retrospective study with a

sample size of 20 patients who underwent Genioplasty alone or in addition to BSSO

advancement over a period of 12 months. Lateral Cephalometric radiographs were

traced and immediate postoperative changes and 12 months postoperative changes


10

were defined and evaluated for relapse rate at Pogonion, soft tissue Pogonion and soft

tissue B point. The relapse rate between was compared for Genioplasty alone and

Genioplasty with BSSO advancement surgery. At 12 months postoperatively soft

tissue landmarks showed statistically insignificant relapse and no significant

difference in relapse in between the groups even with different amounts of

advancement. Hence, according to the authors, advancement Genioplasty is an

important and reliable technique and a stable procedure when used with rigid internal

fixation.

Hamada T, Motohashi N, Kawamoto T, Ono T, Kato Y & Kuroda T.

(2001)18 conducted this study with 14 retrognathic patients who underwent surgical

mandibular advancement surgery to evaluate changes in hard and soft tissues and to

test a preliminary method for predicting soft tissue profile. Paired “t” Test was done

to identify significant hard and soft tissue changes following surgery between

preoperative and postoperative Lateral Cephalograms. Significant changes in the hard

and soft tissue changes were found in the area inferior to the point Stomion in both

horizontal and vertical dimensions. Their study demonstrated a significant correlation

not only with the corresponding hard tissue, but also with the non-corresponding

anatomical points.

Teitelbaum V, Perin AB, Maertelaer VD, Daelamans P & Glineur R.

(2002)35 studied the impact of 2 dental points and 4 skeletal points on the facial

profile within the framework of Orthodontic and surgical treatments on 95 patients.

The authors concluded that average displacement ratios of the soft tissue in relation to


11

the displacement of the corresponding hard tissue can be used as a means to predict

soft tissue movements.

Becelli R, Renzi G, Carbony A, Cerculli G, Perugini M. (2002)30 discussed

the aesthetic needs observed in surgical planning of a Class III patients and to

compare the presurgical aesthetic parameters with those recorded after six months of

follow-up. To obtain the proper aesthetic result and to restore proper stomatognathic

functionality, surgical treatment planning required the integration and correction of

skeletal cephalometric planning. In 24 of the 40 patients, the skeletal and aesthetic

planning was in agreement with each other. In the remaining 16 patients, the

correction of skeletal planning with the aesthetic planning was necessary to obtain the

correct aesthetic and functional restoration. In all patients, aesthetic, radiographic, and

functional analysis at the sixth month of follow-up revealed the restoration of correct

facial aesthetics in the vertical, transverse, and sagittal planes; no temporomandibular

joint problems; and a high degree of personal satisfaction regarding the aesthetic and

functional result obtained, including improvements in social life and also in

masticatory function. Cephalometric indications should always be compared with

aesthetic clinical indications and, possibly, the skeletal planning must be corrected in

the view of aesthetic needs, so that aesthetic and functional success can be reached at

the same time.

Kim JR, Son WS, Lee SG. (2002)36 presented a retrospective review and

analysis of 20 Bimaxillary protrusion patients treated with Orthognathic surgery. Out

of 20 patients, 18 patients underwent Wunderer method of anterior maxillary


12

osteotomy and 2 patients underwent anterior subapical osteotomy. Augmentation

Genioplasty was combined in 3 patients and reduction Glossoplasty in 2 patients.

Orthodontic treatment was accompanied in 8 patients. Lateral Cephalograms were

taken preoperatively (T0), within 1 week after surgery (T1), and at least after 1 year

postoperatively (T2). Statistically significant differences were found between T1-T2

and between T0-T2. They suggested that anterior subapical osteotomies could be done

to improve soft tissue profile significantly in bimaxillary patients wanting for instant

aesthetic facial results.

Rosenberg A, Muradin MSM & Bilt AVD. (2002)37 had conducted this

study on 51 patients treated with V-Y closure after Lefort I osteotomy to evaluate

nasolabial aesthetics. Forward multiple regression analysis was calculated for each

bony landmark and equations formulated (P < .05). The equation with the bony point

with the highest r2 value was considered most important variable. Selected variables

were used to form 4 subgroups with identical vector movements: impaction,

advancement, impaction with advancement and dorsal impaction. In these subgroups

forward multiple regression analysis was used to select equations with highest r2 value

(P < .05). This study concluded that V-Y plasty sufficed only in advancement cases,

whereas additional procedures like alar cinch suture, reduction of anterior nasal spine

or grinding of paranasal area are necessary to prevent worsened facial aesthetics.

Eggensperger N, Smolka W, Rahal A & Iizuka T. (2004)38 carried out this

study to identify contributing factors to skeletal relapse by analysing Cephalometric

changes after BSSO. Total of 60 patients were included in this study; 30 with


13

mandibular advancement and 30 patients with mandibular setback surgery were

included in this study. The patients were divided into three groups according to the

mandibulo-nasal plane angle to analyse the influence of hyper- and hypodivergent

facial pattern on the surgical outcome. On conclusion the authors conferred that the

magnitude of the surgical movement correlated with skeletal relapse without any

linear correlation. Hyperdivergent class II facial pattern had a higher relapse rate of

about 30% and with hypodivergent facial patterns had less relapse in both

advancement and setback surgery. The study concluded that skeletal relapse is

affected by the magnitude of surgical movement and different facial patterns

according to the mandibulo-nasal plane angle; however, the influence of both factors

were different between mandibular advancement and setback surgery.

Knight H & Keith O. (2005)14 did an assessment to compare Orthognathic

treatment outcome against a standardized facial spectrum with a sample size of 30

male patients and 30 female patients. They also investigated the relationship between

ANB angle and ALFH percentages on facial attractiveness. A panel of six Clinicians

and Non-Clinicians ranked standardized photographs from 1-30 on basis of

attractiveness. The study found that Anterio-posterior (AP) discrepancy and ALFH

percentage showed minimal correlation with facial attractiveness. However face with

>5 ANB angle were considered less attractive and ALFH percentage being less was

considered more attractive in female patients and while in opposite trend are seen in

male patients.


14

Chew MT. (2005)39 conducted a retrospective Cephalometric study to assess

the results of Bimaxillary surgery on Chinese patients with class III malocclusions

and also to evaluate the correlation between soft and hard tissue change. A total of 34

patients were treated with BSSO and Lefort I advancement surgery. Soft and hard

tissue changes were recorded by computer-supported measurements of pre-surgical

and post-surgical Lateral Cephalograms. A linear correlation model was used to

interpret the degree of correlation in terms of soft and hard tissue changes between the

two Cephalograms. The study found that there was normalization of Cephlaometric

variables after surgery. And it also found that mandibular soft and hard tissue

movements showed a strong correlation in the horizontal direction and moderate

correlation in the vertical direction. Maxillary soft and hard tissue movements showed

a moderate to weak correlation in both the horizontal and vertical directions.

Semaan S & Goonewardene MS. (2005)40 conducted this retrospective study

to evaluate the accuracy of Lefort I maxillary osteotomy with respect to presurgical

prediction in 33 females and 9 males. ‘Quick Ceph’ cepahlometric software was used

to digitize and compare presurgical and immediate postsurgical Lateral

Cephalograms. Vertical and horizontal landmarks were used to assess the discrepancy

between predicted maxillary position and the actual postsurgical result. Statistically

significant difference was found between predicted and actual vertical postsurgical

molar position and significant differences were also found for the palatal plane

angular measurements. Similarly, there was no statistically significant difference

found when assessing the primary direction of movement of the maxilla. The authors


15

concluded that 66% of the results were within 2 mm of prediction and 26% were

within 1mm of prediction and reaffirmed that although Lefort I osteotomy is an

accurate procedure it has a wide range of discrepancy.

El-Hadidy AM. (2005)41 published this article comparing long term treatment

outcome of the premolar setback osteotomy through tunnelled and non-tunnelled

techniques in 16 patients. Out of the total 16 patients, 12 patients were subjected for

second molar setback osteotomy and 4 patients for first premolar setback osteotomy.

On a conclusive note the author opined that second premolar setback osteotomy

through tunnelled technique to be the better one.

Jones BM, Vesely MJJ. (2006)42 did a review of the senior author’s

experience of aesthetic Genioplasty over an 11-year period. 64 patients indicated for

Genioplasty for aesthetic reason were included in this study. Out of the 64 patients, a

total of 54 patients underwent osseous Genioplasty, 8 patients underwent alloplastic

Genioplasty and two underwent removal of chin prosthesis only. The authors

concluded that osseous Genioplasty is the preferred technique because of its

versatility and long term stability compared to alloplastic methods.

Chew MT, Sandham A, Soh J, Wong HB. (2007)13 carried out this study to

evaluate the outcome of Orthognathic surgery by objective Cephalometric

measurement of postoperative soft-tissue profile and by subjective evaluation of

profile aesthetics by Laypersons and Clinicians. The sample consisted of 30 Chinese

patients who had completed combined orthodontic and Orthognathic surgical


16

treatment. The postoperative Cephalograms of these patients were analysed with

respect to profile convexity, facial height, and lip contours and these were compared

to the previously established aesthetic norms. Line drawings of the soft-tissue profile

were displayed to a panel comprising six Laypersons and six Clinicians who scored

the aesthetics of each profile using a 7-point scale. The study found that there were

good correlations in the aesthetic scores between Laypersons and Clinicians, even

though Clinicians tend to rate the profiles more favourably. This study concluded that

Facial convexity and facial height did not significantly influence the subjective scores

of both the Laypersons and clinicians. Lower lip protrusion was the only

Cephalometric variable that significantly influenced clinicians’ assessment of profile

aesthetics (P <.01).

Montini RW, McGorray SP, Wheeler TT, Dolce C. (2007)21 carried out this

study to compare paired of Silhouettes generated from presurgical and 5-year

postsurgical Cephalometric radiographs to evaluate the perception of Orthodontists,

Oral Surgeons and Laypersons to mandibular advancement surgery. A survey-based

method of data collection was used to evaluate 15 pairs of Silhouettes. These

Silhouettes included 1 control pair and 14 surgically treated pairs representing

mandibular advancements ranging from 0.11mm to 10.13mm. Collected data was

analysed to determine whether the changes can be perceived or whether these changes

could aesthetically pleasing. The study found that largest mandibular advancement

was perceived to have a significant (P<.05) worsening in VAS score by the

Laypersons group. There were significant differences among the groups of evaluators.


17

Hence, the study concluded that Orthodontists, Oral Surgeons and Laypersons

perceived changes in profile differently.

Narayan V, Guhan S, Sreekumar K, Ramadorai A. (2008)8 conducted the

study to evaluate patient’s self perceptions of facial form, oral function and

psychosocial function before and after orthognathic surgery. Fifty patients who

underwent Orthognathic surgery, of which 21 were used as control. A set of 22

questions were asked with respect to patient’s Self perceptions of facial form, oral

function and psychosocial function before and after Orthognathic surgery. The study

concluded that the patients who undergo Orthognathic surgery readily accept the

changes in their postoperative appearance and are satisfied with the achieved results.

Park JU, Hwang YS. (2008)43 conducted this study to determine the

relationship between the changes of soft and hard tissues after modified anterior

segmental osteotomy on the maxilla and mandible and also to evaluate the unintended

facial changes using Cephalometric and photometric analysis. A total of 30 patients

(22-50 years) who were diagnosed with Bialveolar or Bimaxillary protrusion and who

underwent anterior segmental osteotomy on the maxilla and mandible were included

in this study. Analysis of Lateral Cephalograms with lateral and frontal photographs

was done preoperatively and postoperatively. The results showed a significant change

in all soft and hard tissue parameters except the Labiomental angle. The ratio of upper

lip to maxillary incisor retraction was 0.67:1 and the ratio of lower lip to mandibular

incisor retraction was 0.89:1. Anterior segmental osteotomy might be recommended


18

as the treatment modality of choice in patients with Bimaxillary and/or Dentoalveolar

protrusion. The authors concluded that technique is simple, predictable and has

minimal postoperative complications.

Ono Takashi, Kawamoto T, Okudalra M, Moriyoma Keiji. (2008)44

carried out this investigation to predict soft-tissue changes in the forehead, nose, lips

and chin in association with Anterior Maxillary Osteotomy. 20 patients who

underwent anterior maxillary osteotomy were included in this study. Both hard- and

soft- tissue changes were evaluated using a set of Lateral Cephalograms taken

immediately before and after 7 months after surgery. Pearson correlation test were

done to examine the relationship between hard- and soft-tissue changes. Hard-tissue

changes were only observed in the maxillary region. Soft-tissue changes included

backward displacement of the Subnasale and the upper and lower lips. On conclusion

it was informed that anterior maxillary osteotomy influences hard-and soft-tissue

changes in the upper lip region and that the response in the horizontal dimension in

association with surgery can be predicted.

Tufekci E, Jahangiri A, Lindauer SJ. (2008)26 conducted this study to

evaluate whether there are differences in self-awareness and perception of an

individual’s own profile among various groups. A survey was done with 75 people in

each group of Orthodontic patients, Ist year and IIIrd year dental students respectively.

The subjects had to choose from among various Silhouettes the one that most

resembled their own profile. Profile photos of participants were analysed by two


19

Orthodontists who matched the individual to the depicted Silhouettes. Agreement

between participants and experts were evaluated using the kappa statistic. Differences

among groups in identifying their own profiles were evaluated. The authors concluded

that overall agreement between the individual’s perception of their own profiles and

evaluation by Orthodontists was 53%. The groups differed in their ability to recognize

their own profile. IIIrd year Dental students were the most accurate as compared to

other groups. This study concluded by suggesting that about half of the population

cannot characterize their own profile and the persons who perceived their profile

being different from average were most unhappy with their facial appearance.

Fabre M, Mossaz C, P Christou, Killaridis S. (2009)24 conducted this study

to compare Laypersons, professionals perception of soft tissue profiles of Class III

adults, and to evaluate which Cephalometric variables are likely to influence the

profile assessment score. Lateral head films and coloured profile photographs of 18

Class III patients and 9 patients with dental Class I malocclusion were included in this

study. Head films were hand traced and digitized. Printed profile photograph was

evaluated aesthetically by 18 Laypersons and 18 Orthodontists using a 10-graded

visual analogue scale (VAS). Hence, this study concluded that the degree of facial

convexity together with the steepness of the mandibular plane were negatively

predictive factors for the PAS given by the Orthodontists.

Tsang S, McFadden LR, Wiltshire WA, Pershad N, Baker AB. (2009)27

carried out this study to evaluate the potential to improve facial aesthetics. The degree


20

of skeletal and soft tissue Class II disharmony necessary before a significant benefit

from mandibular advancement surgery was determined. 20 laypeople, 20

Orthodontists, and 20 Oral Surgeons rated the attractiveness of before and after

treatment profiles of 20 mandibular advancement patients using a 5-point Likert scale.

The spearman rank correlation tested for relationships between amount of profile

change and varying pre-treatment ANB and profile angles were than examined.

Inverse correlations between profile change and profile angle, and positive

correlations between profile change and ANB angles were found. Orthodontists, Oral

Surgeons, and Laypersons found that profiles consistently improved when profile

angles were more or equal to 1590. However, the relationship between profile change

and ANB angle were found to be statistically significant. This study concluded that

pre-treatment profile angles of <1600 and ANB angles of >60 are necessary for

profiles to be consistently perceived as improved after surgery and also to minimize

the incidence of the profile worsening after the treatment.

Papadopoulos MA, Lazaridou-Terzoudi T, Oland J, Athanasiou AE,

Melsen B, Thessaloniki et al. (2009)5 did a comparison of soft and hard tissue

profiles of Orthognathic surgery patients who were treated recently and 20 years

earlier. A total of 90 patients were included in this study divided into two groups of

35 patients and 56 patients. Comparison of pre-treatment soft and hard tissue profile

was done using Lateral Cephalogram. 4 Cephalometric variables were evaluated, and

both the groups were further subgrouped as Orthognathic, Retrognathic and

Prognathic. On conclusion it was assessed that the differences in profile between the


21

two groups indicated that orthodontic-Surgical patients treated more recently had

exhibited smaller deviations from the norm than those treated in the earlier period.

Mortazavi H, Tabrizi R, Mohajerani H, Ozkan T. (2009)45 evaluated the

stability of hard and soft tissue movements in 15 patients with Retrognathia, who

underwent advancement Genioplasty. Soft and hard tissue Pogonion preoperatively,

immediately postoperatively and 18 month postoperatively were measured using

Lateral Cehphalograms. 15 patients were divided into two groups with genial

advancement <7 and >7mm. The study found that in group with <7mm advancement

the mean relapse was 0.60 mm and in groups with >7mm advancement the mean

relapse was 1.5mm. The authors opined that, Genioplasty is a predictable operation

specially when using rigid fixation.

Gunaseelan R, Anantanarayanan P, Veuabahu M, Vikraman B, Sripal R.

(2009)46 conducted this retrospective study to evaluate the intraoperative and

perioperative complications associated with anterior maxillary osteotomy (AMO),

and assess its safety and predictability in Orthognathic surgery. 103 patients who

underwent anterior maxillary osteotomy as a single procedure over in combination

with other osteotomies were evaluated over a period of year with a mean follow up

time of 3 years. Twenty-seven (26.2%,) patients out of the 103 patients had

complications of varying severity: 43.3% of these were soft tissue-related, and

36.6% were attributable to dental causes. And all other complications accounted for

the remaining 20%. This study concluded that although the indications of Anterior


22

Maxillary Osteotomy are limited, it is a safe and reliable procedure in routine

Orthognahtic surgery.

Amanna DT, Roy ET, Shetty KS, Kumar K. (2010)2 conducted this

Cephalometric study to predict lower lip and chin response to mandibular

advancement surgery and vertical reduction Genioplasty in 15 patients. Student’s “t”

test was used to compare the results of postsurgical outcome with presurgical

prediction. The authors concluded that there was no considerable difference between

surgical prediction and the surgical outcome and hence, presurgical predictions can be

relied on to a great extent.

Varlik SK, Demibas E, Orhan M. (2010)6 conducted this study to test the

hypothesis that lower facial height has no influence on frontal facial attractiveness and

treatment need based on perception of attractiveness by Laypersons. Frontal facial

Silhouettes of a man and a woman with normal lower facial height values were

modified by increasing and decreasing their lower facial heights in steps of 1mm to

obtain images with different lower facial height alterations ranging from +6mm to -

6mm for each sex. A panel of 100 Laypersons scored each silhouette’s attractiveness

on a 100mm visual analogue scale and also indicated whether they would seek

treatment if the image represented their own. Wilcoxon signed rank test was used to

compare the VAS scores. The study found that unaltered Silhouettes got the highest

VAS score. At +/- 4mm, more than 75% of the evaluators elected to have treatment.

On conclusion of this study the authors rejected the hypothesis.


23

Rustemeyer J, Eke Z, Bremerich A (2010)47 published this article in which

factors were evaluated effecting patient satisfaction in 77 patients and also evaluated

if the patient expectations were fulfilled after Orthognathic surgery. Questionnaires

consisting of 14 questions were given 1 year after Bimaxillary osteotomy for class-III

correction to subjects. Six questions were answered using an 11-point rating scale

base on visual analogue scale; 0- poor to 10- excellent. Another 7 closed-form

questions were answered in yes/no. Sagittal and Vertical Cephalometric parameters

were determined on postoperative Cephalograms. The study found significant

correlation between the variables affecting patient satisfaction and Cephalometric

variables, with satisfaction levels decreasing with lower postoperative SNB angle. On

conclusion, the authors noted that most distinctive factors for patient satisfaction after

Orthognathic surgery were chewing function and facial aesthetics with respect to the

lower face.

Arunkumar KV, Reddy VV, Tauro DP. (2010)56 Studied Lateral

cephalometric standards of South Indians (Karnataka) adults having Class I occlusion

and acceptable facial profile using Burstone’s and Legan’s comprehensive

cephalometric analysis. A total 100 patients were included in this study, the mean

values of hard and soft tissue measurements were compared with those Caucasian

adults. The study concluded, statistically significant skeletal differences between men

and women of the South Indian originin comparison to Caucasian origin. Men had

decrease facial divergence, anterior maxillary dental height and proclined upper


24

incisors. Women had marginally increased cranial base, increased midfacial height

and proclined upper incisors.

Johnston C, Hunt O, Burden D, Stevenson M, Hepper P. (2010)25

conducted this study to test the hypothesis, that self-perception of dental and facial

attractiveness among patients requiring Orthognathic surgery is no different from that

of control patients. Happiness with dental and facial appearance was assessed using

questionnaires completed by 162 patients who required Orthognathic treatment and

157 control subjects. Visual Analogue Scale, binary and open response data were

collected. Analysis was carried out using a general linear model, logistic regression,

and chi-square tests. The study found that Orthognathic patients were less happy with

their dental appearance than the controls. Class II patients and women had lower

happiness with their dental appearance. Among Orthognathic patients, the “shape”

and “prominence” of their teeth were the most frequent causes of concern. The

authors in conclusion of this study rejected the hypothesis and indicated that women

and patients requiring Orthognathic surgery had lower level of happiness with their

Dentofacial appearance.

Jayaratne YSN, Zwahlen RA, Lo J, Cheung LK (2010)48 conducted this

review to evaluate soft tissue changes resulting from anterior segmental osteotomies.

The electronic databases PubMed, Scopus and ISI web of knowledge were searched

for potentially eligible studies using a set of predetermined keywords. Full texts

meeting the criteria were retrieved and their references were manually searched for


25

additional relevant articles. 11 studies met the inclusion criteria. Lateral Cephalometry

was used in all studies. A reduction of the labial prominence with an increase in the

Nasolabial angle was noted subsequent to anterior segmental osteotomies. The

magnitude of the reported soft tissue changes and their ratios corresponding to the

osseous movements varied among studies. It was concluded that, long-term,

prospective, methodologically sound clinical trials with larger samples and 3-D

quantification are required to provide sufficient information of predicting the soft

tissue response to anterior segmental osteotomies.

Joss CU, Joss-Vassalli MI, Killiaridis S, Kuijipers-Jagtman AM. (2010)49

conducted a systematic review to evaluate soft tissue/hard tissue ratio in Bilateral split

Sagittal osteotomy with rigid internal fixation or wire fixation. The data bases of

PubMed, Medline, CINAHL, Webscience, Cochrane and Google scholar Beta were

searched. From the original 711 articles identified, 12 were finally included. Only 3

were prospective and 9 were retrospective. The prospective follow-up ranged from 3

months to 12.7 years for RIF and 6 months to 5 years for WF. The study found that

short- and long-term ratios for the lower lip to lower incisor for BSSO with RIF or

WF were 50%. No difference between the short- and Long –term ratios for the

Mentolabial-fold to point B and soft tissue Pogonion to Pogonion could be observed.

It was 1:1 ratio. One exception was seen for the long-term results of the soft tissue

Pogonion to Pogonion in BSSO with RIF; they tended to be greater than 1:1 ratio. The

upper lip mainly showed retrusion but with high variability. Hence, it was concluded

that despite a large number of studies on the short-and long-term effects of


26

mandibular advancement by BSSO, the results of the present systemic review have

shown that evidence-based conclusions on soft tissue changes are still unknown. This

is mostly because of the inherent problems of retrospective studies, inferior study

design, and the lack of standardized outcome measures. Well-designed prospective

studies with sufficient sample sizes that have excluded patients undergoing additional

surgery were needed.

Naini FB, Donaldson ANA, Cobourne MT, McDonald F. (2011)23 did an

Objective and Quantative evaluation of mandibular prominence influences perceived

attractiveness. An idealized profile was chosen and altere in 2mm increments from -

16mm to 12mm, in order to represent retrusion and protrusion of mandible,

respectively. The images were rated on 7-point Likert scale by a preselected group of

pre-treatment Orthognathic patients, Clinicians and Laypeople. This study found that

mandibular retrusion upto -4mm or protrusion upto 2mm was essentially

unnoticeable. Surgery was desired from mandibular protrusions of greater than 3mm

(Orthognathic patients and Laypeople) and 5mm (Clinicians) and also retrusions

greater than -8mm. The study concluded that Orthognathic patients were found to be

more critical than laypeople.

Deshpande SN, Munoli AV. (2011)50 conducted a long-term case series study

to evaluate the results of Osseous Genioplasty in Indian patients with regard to patient

satisfaction, complications and long-term stability. 37 patients who underwent

Genioplasty either alone or in conjunction with other Orthognathic surgery with a


27

minimum follow-up of two years were included in this study. The procedures done

included 22 advancement, 9 setbacks, and 4 horizontal and 2 vertical reduction

Genioplasty procedures. The study found that 97.3% were extremely pleased with the

results, there were no significant complications. The Osteotomised segment was well

maintained in its new position with good bony union and minimal resorption. This

study concluded Genioplasty to be a safe and effective means of creating a beautiful

and balanced facial profile by producing alterations in the chin morphology with

minimal complication and stable long-term results.

Reddy PS, Kashyap B, Hallur N, Sikkerimath BC. (2011)16 carried out this

study to determine the stability, ratio of hard and soft tissues and changes in the lower

facial profile after advancement Genioplasty. Ten patients were included in this study,

preoperative and postoperative Lateral Cephalogram was taken to evaluate hard and

soft tissue changes. The study found that ratio of horizontal changes of osseous to soft

tissues was found to be 1:0.89. The mean resorption was 0.85mm. The vertical

changes were minimal and non-significant. There were significant changes in the soft

tissue profile such as decrease in the soft tissue thickness, facial convexity angle,

Lower Facial Submental angle and increase in Mentolabial sulcus depth. This study

concluded that soft tissue response is almost equal to the bony movement and there is

minimal bony resorption if a standard advancement Genioplasty procedure is done

with a broad musculo-periosteal pedicle.


28

Rustemeyer J, Martin A. (2011)51 conducted this study to compare the

standard methods of Cephalometry and 2-D Photogrammetry, to evaluate the

reliability and accuracy of both methods. 26 patient with Class II relationship and 23

patients with class III relationship who had undergone bilateral sagittal split ramus

osteotomy were selected, with as median follow-up of 8 months between pre- and

postsurgical evaluation. Pre- and postsurgical Cephalograms and lateral photograms

were traced and changes were recorded. The study concluded that Cephalometry and

2-D photogrammetry offer the possibility to complement one another.

Erbe C, Mulie RM, Ruf S. (2011)52 conducted this retrospective study to

evaluate the skeletal and soft tissue facial profile changes as well as the predictability

and the short-term stability of the soft-tissue response to advancement Genioplasty in

Class I dental arch relationship patients. This study included 14 adult patients who

presented a Class I dental arch but a Class II skeletal arch relationship and underwent

advancement Genioplasty exclusively. Lateral Cephalograms taken immediately

preoperatively (T1), immediately postoperatively (T2) and 1 year postoperatively (T3)

were analysed. The hard tissue Pogonion was sagittally advanced by an average of

7.9 mm (p < 0.001) (T1–T2). The soft tissue chin followed the sagittal skeletal chin

movement and exceeded chin advancement due to the initial soft tissue swelling. In

the vertical dimension, the skeletal chin moved 3.0 mm (p < 0.01) upwards whilst the

soft tissue chin moved only 2.1 mm upwards (p < 0.01). All profile convexity angles

increased significantly (p < 0.001), implying that the profile was straightened by the

advancement of the chin. In the short term, advancement Genioplasty was a


29

predictable and stable procedure for chin correction. On conclusion the author implies

that a ratio of 1:1 may be used to predict the sagittal soft tissue to bony movements

for the period from before to 1 year after surgery.

Shetty A, Patil A, Ganeshkar S. (2012)53 carried this prospective study with

a sample size of 45 individuals have Class II malocclusion on account of deficient

mandible. The sample was divided into three equal groups of 15 individuals each

according to mode of treatment; treated by camouflage, fixed functional devices and

Orthognathic surgery. Pre and post treatment Lateral Cephalograms were used to

assess the skeletal, dental and soft tissue changes. Pre and Post treatment photographs

were assessed on VAS by Orthodontists, Oral Surgeons and Laypeople. Each group

achieved a reduction in facial convexity, but the results obtained from the surgical

group were more pronounced than the camouflage and the fixed functional group. The

study concluded that most appropriate reduction in profile convexity to improve facial

aesthetics can be attained by combined orthodontic and surgical treatment of

malocclusion.

Hockley A, Weinstein M, Borislow AJ, Braitman LE. (2012)54 conducted

this study to determine whether the use of photos or Silhouettes is a more

appropriated method of evaluating African American profile aesthetics and whether

there are different profile aesthetic preferences among Clinicians when using photos

compared with Silhouettes. Pre-treatment records of 20 African-American patients

were selected and each patient’s photo was digitally altered to create 7 photos and 7

Silhouettes with lip positions at uniform distances relative to Rickett’s E-line


30

standard. 15 evaluators consisting of orthodontic faculty and residents were asked to

select the most aesthetically pleasing profile from each patient’s photo series and

Silhouettes series. The study found that 86% of evaluator preferences for the

Photographs were within the acceptable aesthetic range than were the preferences for

Silhouettes. Flatter profiles with less lip projection than the aesthetic norm were more

often preferred in the Silhouettes than in photos. This study concluded that evaluator

preferences in the Photographs were closer to the established aesthetic norm than

were their preferences in the Silhouettes.

Naini FB, Donaldson ANA, Mcdonald F, Cobourne MT. (2012)23 carried

out this study to investigate quantitatively the influence of completing the

Orthognathic treatment process on patient’s perception of attractiveness and their

desire for surgical correction. The mandibular prominence of an idealized profile

image was altered in 2mm increments from 16mm to 12mm, to represent protrusion

and retrusion of mandible. Likert scale was used to rate the images by 50 patients at

T1 (pre-treatment) and T2 (6 months after orthodontic appliance removal). The study

found that the relative desire for surgery reduced by 85% for those patients who had

undergone Bimaxillary surgery in relations to those with single jaw surgery. Images

with severe retrusion and protrusion were rated poorly. The authors concluded that

going through the process of Orthognathic treatment does not appear to have any

significant effect on the patient’s perceptions of facial profile attractiveness.


31

Doreen Ng, De Silva RK, Smit R, De Silva H, Farella M. (2012)55

conducted this study to determine the perceived level of improvement in facial

attractiveness as assessed by people with different backgrounds in skeletal Class II

patients treated by mandibular advancement surgery by BSSO. Frontal and lateral

Pre- and Post- operative Photographs of 10 Caucasian patients were selected. Changes

in profile attractiveness were assessed by 10 Orthodontists, 10 Art students and 10

Laypersons. The study was carried out in 3 surveys, in first two surveys all three

examined the photographs and ranked the attractiveness on VAS, the third survey was

given to Orthodontists alone with pre- and postoperative status disclosed. Overall,

attractiveness scores after BSSO improved by 11.5% on lateral photographs and 7.5%

on frontal photographs. Scores for attractiveness differed significantly between the

groups with Orthodontists being more generous with improvement ratings. The

ratings almost doubled when the pre- and postoperative status was disclosed to

evaluators indicating a bias towards a more favourable outcome.

Bans A, Nedim O, Gulnaz M. (2012)56 authors published this study in which

they determined the vertical and Antero-posterior alterations in soft, dental and

skeletal tissues associated with facial angle in 21 high angle patients who underwent

Lefort I maxillary impaction in conjunction with BSSO advancement. Pre- and post-

surgical lateral Cephalograms were taken and compared using Wilcoxon test. Pearson

correlation test was carried out to determine the relative changes in skeletal, dental

and the facial soft tissues. The study found insignificant decrease in the Nasolabial

angle was correlated with the significant decrease in the vertical position of the nose


32

due to the nasal protraction noticed after bimaxillary surgery. The retraction of both

the upper lip and the upper incisors was correlated with the insignificant decrease in

the Columella-lobular angle. The insignificant decrease in both the vertical height of

the mandibular B point and the lower incisors was correlated with the insignificant

decrease in vertical height of the soft tissue Pogonion, attributable to the resulting

superior movement of the soft tissues of the chin and the counter clockwise rotation of

the mandible after maxillary impaction and bilateral sagittal split osteotomy,

respectively. The authors concluded that Bimaxillary orthognathic surgery seems to

be an efficient method for obtaining satisfactory results in the appearance of the soft,

the dental and the skeletal tissues associated with the facial profile in patients with

high angle Class II skeletal deformity.

Yadav OA, Walia SC, Borle RM, Chaoji KH, Rajan R, Datarkar AN.

(2012)57 studied Lateral cephalometric standards of normal Central Indians adults

having Class I occlusion and acceptable facial profile using Burstone’s and Legan’s

comprehensive cephalometric analysis. A total of 76 patients were included in this

study, the mean values of hard and soft tissue measurements were compared with

those Caucasian adults. The Central Indian males demonstrated greater anterior

cranial base length, ramal length and reduced chin depth. The inclination of upper and

lower incisors was also greater. The females were found to have greater posterior

cranial base length, increased anterior and posterior facial heights, and increased

maxillary length. Both mandibular body and ramal lengths were increased and there

was greater mandibular protusion and a reduced chin depth. The study concluded that


33

some of the cephalometric parameters in the central indian population are

significantly different than that of the Caucasian population, especially in females.

Parikh A, Phulari B. (2013)4 conducted this study is to compare all

parameters of hard and soft tissue angular and linear measurements in Class III

malocclusion in male with Class III malocclusion in female aged between 17-

21 years. All the patients included in this study had not undergone orthodontic

treatment in the past. The study concluded that Lower lip is thin at vermilion border in

Class III female while it is thick in male. Upper lip thickness at point A is more in

male as compared to females. Lower facial height is less in females as compared to

males. A linear measurement made from ANS to Menton is less in females as

compared to males.

Materials and Methods

34

MATERIALS AND METHODS





Source of the data

OPD, Department of Oral & Maxillofacial Surgery at Al-Badar Rural Dental

College, Gulbarga.

OPD, Department of Orthodontics and Dentofacial Orthopedics at Al-Badar

Rural Dental College, Gulbarga.

Inclusion Criteria

Patients who have completed their growth within the age group of 20 -35

years.

Patients with Maxillomandibular discrepancy in convex profile patients that

require surgical correction.

Patients who have completed their pre surgical orthodontic treatment.

Exclusion Criteria

Young Patients where growth has not ceased to occur.

Patients having craniofacial syndromes and clefting.

Patients having any systemic disease where in surgery are contraindicated.


35

Armamentarium

15cm Ruler

180 degree Protractor

Set square 45 degree and 60 degree

HB pencil/0.3mm led pencil

OHP marker

0.3 mm Acetate sheet

Method of collection of data

Study Design

• The present study was conducted in the Department of Oral and Maxillofacial

Surgery, Al-Badar Rural Dental College & Hospital with a sample size of 10

patients with convex profile.

• Case history was recorded using a standard case history proforma.

• Preoperative diagnosis was done using COGS analysis by Burstone et al.15,16,17

Patients requiring Presurgical orthodontics were started with Orthodontic

treatment.

• Patients deemed to be ready for Orthognathic surgery where subject to

Routine pre-surgical investigations. Medical and anaesthetic written fitness

were obtained.

• Informed/written consent was taken from the subjects/caretaker.


36

• Preoperatively following patient records were obtained 1 week prior to the

date of surgery.17

– Lateral cephalogram (T0) were taken by using a cephalotstat with the teeth

in centric occlusion and lips in repose.15, 16,17

– OPG (T0).

– Profile photographs (T0) and Frontal photographs (T0).

– Face bow transfer was done, if required and dental cast models were made.

– If required, Mock surgery was performed on dental cast models.

– Surgical splint was fabricated, if required.

– Presurgical Cephalometric analysis of the Lateral Cephalogram.

• Postoperatively following patient records were taken at 3rd month post

operatively.18

– Lateral Cephalogram (T1) was taken by using a cephalotstat with the teeth

in centric occlusion and lips in repose.16,17,19

– OPG (T1).

– Profile Photographs (T1) and Frontal photographs (T1).

Operative Procedure

A total of 10 patients with in the age group of 20 - 35 years had completed

their growth were included in this study. All the cases were operated under general

anesthesia with Naso-endotracheal intubation following aseptic technique.


37

Out of which 5 patients underwent advancement Genioplasty procedure. 3

patients underwent advancement Genioplasty in conjunction with anterior maxillary

setback osteotomy and 2 patients underwent Lefort I superior impaction in

conjunction with advancement Genioplasty in one patient and BSSO advancement in

another patient.

Cepahlometric Study:

Preoperative Lateral Cephalogram (T0) and Postoperative Lateral

Cephalogram were taken at 3rd month postoperatively (T1) were hand traced over

0.3mm acetate sheets using a HB pencil.7,16 The landmarks were identified as given

by Burstone et al15 and selective Hard tissue analysis given by Burstone et al15 and

soft tissue analysis given by Legan and Burstone20 was done by the same operator to

reduce intraoperative variability.5,7


38

TABLE NO. 1a: Hard tissue Cephalometric Land Marks used in this study

Sl.No Landmark Meaning

1 Sella (S) The centre of the pituitary fossa.

2 Nasion (N) The most anterior point of the nasofrontal suture in the

midsagittal plane.

3 Subspinale (A)

The deepest point in the midsagittal plane between the

anterior nasal spine and prosthion, usually around the

level of and anterior to the apex of the maxillary central

incisors.

4 Pogonion (Pg) The most anterior point in the midsaggital plane of the

contour of chin.

5 Supramentale

(B)

The deepest point in the midsagittal plane between

infradentale and Pg, usually anterior to andSlightly

below the apices of the mandibular incisors.

6 Anterior nasal

spine (ANS)

The most anterior point of the nasal foor; the tip of

premaxillain the mid sagittal plane.

7 Menton (Me) The lowest point on the contour of the mandibular

symphysis.

8 Gnathion (Gn) The midpoint between Pg and Me, located by bisecting

the facial line N-Pg and the mandibular plane.

9 Posterior nasal

spine The most posterior point on the contour of the palate.

10 Mandibular

plane (MP)

A plane constructed from Me to the angle of the

mandible (Go).

11 Gonion (Go) Located by bisecting the posterior ramal plane and the

mandibular plane angle.


39

TABLE NO. 1b: Soft tissue CephalometricLand Marks used in this study

Sl.No Landmark Meaning

1 Glabella (G) The most prominent point in the midsagittal plane of the

forehead.

2 Columella Point

(Cm) The most anterior point on the columella of the nose.

3 Subnasale (Sn) The point at which the nasal septum merges with the

upper cutaneous lip in the midsagittal plane.

4 Labrale superius

(La)

A point indicating the mucocutaneous border of the

upper lip.

5 Stomion superius

(Stms) The lowermost point on the vermillion of the upper lip.

6 Stomion inferius

(Stmi)

The uppermost point on the vermillion border of the

lower lip.

6 Labial inferius

(Li)

A point indicating the mucocutaneous border of the

lower lip.

7 Mentolabial

Sulcus (Si)

The point of the greatest concavity in the midline

between the lower lip (Li) and chin (Pg’).

8 Soft tissue

Pogonion (Pg’) The most anterior point on soft tissue chin.

9 Soft tissue

Gnathion (Gn’)

The constructed midpoint between soft tissue pogonion

and soft tissue menton.

10 Soft tissue

menton (Me’)

Lowest point on the contour of the soft tissue chin;

found by dropping a perpendicular form horizontal

plane through menton.

11 Gonion (Go) Located by bisecting the posterior ramal plane and the

mandibular plane angle.


40

TABLE NO. 2: Limited Burstone’s and Legan’s Analysis for Hard & Soft tissue

changes

Parameter T0

(preoperative)

T1

( 3rd month postoperative)

T1-T0

Hard tissue

N-A-Pg

N – A

N – B

N –Pg

N – ANS

ANS – Gn

PNS-ANS

Go-Pg

B-Pg

Soft tissue

G-Sn-Pg

Cm-Sn-Ls

Li-Pg LINE

Vertical Lip

– Chin Ratio

Intralabial

Gap

Hard and soft tissue values for respective T1 value was compared to established

esthetic norm given by Burstone et al.15

Hard and soft tissue changes recorded for T0 and T1were compared for each

parameter.


41

Clinical Analysis

• Soft tissue profile of each patient was hand traced over acetate sheets from Lateral

Cephalogram (T0 and T1) and transferred to PC, set to standard size, so as to place

points G and T for each patient equally near the top and bottom of the profile and

converted into Silhouettes using Adobe Photoshop software.21,22,23

• All the profile Silhouettes were printed on 10 A4 size paper; a survey was done

for perception of attractiveness due to change in profile after surgery.

• 5 pages of the survey had Preoperative (T0) and Postoperative (T1) Silhouettes

were placed beside each other. And the remaining 5 pages of the survey had

Silhouettes from T0 on the left side and T1 on the right side.

• Silhouettes were paired according to the patient and were assessed by the

respective Surgical patient, 5 Laypersons and 5 Oral and Maxillofacial

Surgeons.10,21,22,23,24,25,26

• Profile Assessment Score (PAS) for the profile Silhouettes was given using a

100mm Visual analogue scale; 1-10 score was given with 1 representing the least

attractive and 10 the most attractive.21,22,23,24

Figure 1: 100mm Visual Analogue Scale


42

• PAS scores for the T0 profile Silhouettes were compare with PAS for the T1

profile Silhouettes for all the groups.

• Intra-group comparison was done using mean score calculated from Oral and

Maxillofacial Surgeons (OMFS) group and the Laypersons group (LP) for each

patient. Difference between T1 and T0 was calculated from Oral and Maxillofacial

Surgeons and the Laypersons; comparison of this score was done with score

difference between T1–T0 of all the Surgical patients.21,27

TABLE NO.3: Comparison of Mean PAS scores

Surgical patient

Laypersons (Mean score)

Oral and Maxillofacial Surgeons (Mean score)

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Patient 8

Patient 9

Patient 10


43


44

Fig. 2: Case 1

VISU

AL A

NALOGUE SCA

LE

T0 T1


45


46

Fig. 3: Case 8

VISU

AL A

NALOGUE SCA

LE

T0 T1


47


48

C

VISU

AL A

NALOGUE SCA

LE

Fig. 4: Case 2

T0 T1


49


50

VISU

AL A

NALOGUE SCA

LE

Fig. 5: Case 7 T1 T0


51


52

VISU

AL A

NALOGUE SCA

LE

Fig. 6: Case 6

T1 T0

Results

53

RESULTS





In our study all the patients were within the age group of 20 – 35 years with a

mean age of 24.9 years. [Table 4] And had convex profile with mean G-Sn-Pg angle

of 22.4 degrees. [Table 4] All the patients that underwent surgery were subjected to

standard surgical protocol.

TABLE NO. 4: Patient details

SL.NO AGE /SEX

ANGLE OF FACIAL CONVEXITY

G-Sn-Pg’ PROCEDURE

Patient 1 25/F 220 Advancement Genioplasty





Patient 6 22/F 170 Anterior Setback Maxillary Osteotomy and Advancement

Genioplasty Patient 7 20/F 220 Anterior Setback Maxillary

Osteotomy and Augmentation Genioplasty

Patient 8 31/F 250 Anterior Setback Maxillary Osteotomy and Advancement

Genioplasty Patient 9 24/F 230 Lefort I Superior Impaction and

Advancement Genioplasty Patient

10 25/F 250 Lefort I Superior Impaction and

BSSO Advancement

Results

54

TABLE NO. 5a: T1-T0 of Hard tissue parameters

Parameter 1 2 3 4 5 6 7 8 9 10 Sl. No. Hard

tissue T0 T1

T1-T0

T0 T1 T-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

1 N-A-Pg 18 8 10 23 19 4 14 4 10 12 8 4 12 2 10 1 7 6 8 2 6 12 2 10 17 15 2 17 6 11

2 N – A 5 5 - 2 2 - 5 5 - 1 1 - 5 5 - 6 10 4 7 5 2 5 9 4 0 6 6 5 5 -

3 N – B 22 18 4 26 24 2 20 20 - 10 16 6 18 17 1 15 15 - 20 20 - 18 17 1 18 16 2 18 13 5

4 N –Pg 22 10 12 28 20 8 26 16 10 11 19 8 20 15 5 11 08 3 23 12 11 20 16 4 20 12 8 20 15 5

5 N – ANS 47 47 - 48 48 - 43 43 - 50 50 - 52 52 - 4 1 3 44 43 1 52 52 - 59 55 4 54 48 6

6 ANS – Gn 52 58 6 60 67 7 54 58 4 73 75 2 60 63 3 44 49 5 58 64 6 60 63 3 72 75 3 69 72 3

7 PNS-ANS 46 46 - 46 46 - 44 44 - 62 62 - 47 47 - 41 38 3 44 41 3 47 47 - 58 58 - 60 60 -

8 Go-Pg 64 70 6 57 64 7 52 60 8 86 94 8 65 71 6 60 64 4 52 62 10 65 71 6 78 86 8 66 73 7

9 B-Pg 5 12 7 4 10 6 2 10 8 3 11 8 7 13 6 7 11 4 5 14 9 7 13 6 8 15 7 8 8 -

Results

55

TABLE NO. 5b: Student’s paired “t” test values

CONCLUSION: * Shows significant difference

TABLE NO. 5C: Comparison of achieved hard tissue change with Burstonenorms using “t” test

Sl. No. Attained Values Established Norm as per

Burstone 1 Mean 32.1 32.02

2 SD 25.99 30.33

3 SEM 8.66 10.72

4 N 9 8

Statistically not-significant t-value =0.005, p-value= 0.99

Genioplasty

N=5

AMO + Genioplasty

N=3

Lefort I + BSSO/ Genioplasty

N=2 Sl. No

Parameter Hard Tissue t-

value Mean

change t-value

Mean Change

t-value

Mean Change

1 N-A-Pg 5.17* 7.6 0.69 7.33 1.44 10.5

2 N – A 0 0 1.00 3.33 1.00 3

3 N – B 0.12 1.8 1.00 0.33 2.33 3.5

4 N –Pg 1.52 8.6 2.38 6 4.33 6.5

5 N – ANS 0 0 1.51 1.33 5.00 5

6 ANS – Gn 4.74* 4.4 5.29* 4.66 0 3

7 PNS-ANS 0 0 2.00 2 0 0

8 Go-Pg 15.65* 7 3.78* 6.66 15.00* 7

9 B-Pg 15.65* 5.8 4.36* 6.33 1.00 3.5

t value for P=0.05 2.132 2.920 6.314

Results

56

TABLE NO. 6a: T1-T0 Soft tissue parameters parameters

Sl. No.

Parameter 1 2 3 4 5 6 7 8 9 10

Soft tissue T0 T1

T1-T0

T0 T1 T-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

T0 T1 T1-T0

1 G-Sn-Pg 22 14 8 26 19 7 24 14 10 23 12 11 17 10 7 17 10 7 22 18 4 25 18 7 23 18 5 25 20 5

2 Cm-Sn-Ls 80 80 - 102 102 - 118 118 - 95 95 - 100 100 - 90 110 20 88 100 12 80 108 28 110 135 25 100 108 8

3 Li- Pg Line 3 5 2 3 5 2 1 6 5 5 8 3 5 8 3 5 7 2 0 3 3 4 6 2 5 9 4 8 5 3

4 Vertical lip chin

ratio .47 .5 .03 .55 .44 .11 .7 .5 .2 .39 .51 .12 .6 .5 .1 .45 .8 .35 .62 .48 .14 .5 .68 .18 .5 .65 .15 .47 .44 .03

5 Intralabial gap 6 4 2 2 2 - 2 2 - 12 4 8 3 2 1 5 2 3 20 12 8 7 5 2 10 2 8 16 2 14

Results

57

TABLE NO. 6b: Student’s paired “t” test

CONCLUSION: * Shows significant difference

TABLE NO. 6c: Comparison of achieved Soft tissue change with Legan and

Burstone norm using “t” test

Sl. No. Attained Values Established Norm as per

Legan & Burstone 1 Mean 32.1 32.02

2 SD 25.99 30.33

3 SEM 8.66 10.72

4 N 9 8

Statistically significant, t-value = 0.005, p=0.9280

Genioplasty

N=5

AMO + Genioplasty

N=3

Lefort I + BSSO/ Genioplasty

N=2 Sl. No

Parameter Soft

Tissue t-value

Mean Change

t-value Mean

change t-value

Mean change

G-Sn-Pg 7.68* 8.6 6.43* 6 0 5

Cm-Sn-Ls 0 0 4.33* 20 1.94 11.5

Li-Pg

Line 5.48* 3 7.00* 2.33 0.14 3.5

Vertical

lip chin

ratio

0.91 0.05 0.91 1.41 0.67 0.145

Intralabial

gap 1.47 2.2 2.33 4.33 3.67 11

t value for

P=0.05 2.132 2.920 6.314

Results

58

TABLE NO. 7a: PAS score of all groups and Inter and Intra group comparison

Surgical patient

Laypersons Oral and Maxillofacial Surgeon

SP SP SP LP1 LP2 LP3 LP4 LP5 Mean

LP LP OMFS 1

OMFS 2

OMFS 3

OMFS 4

OMFS 5

Mean OMFS

OMFS

T0 T1 T1-T0

T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T1-T0

T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T1-T0

Pt. 1 5 8 3 5 8.5 5 7 5 8 4 7 5 7 4.8 7.5 2.7 3.5 8 3 8 3 7.5 3 8 5 7 3.5 7.7 4.2

Pt. 2 5.5 8.5 3 5 9 4 6 3 8 4 7 5 8 4.2 7.6 3.4 2 7 3 6 4 7 2 7 4 6 3 6.6 3.6

Pt. 3 5 8.8 3.8 5.5 9 5 8 6 8 4 8 3 6 4.7 7.8 3.1 3 8 4 7 5 6 5 7 6 8 4.6 7.2 2.6

Pt. 4 4 9 5 2 8 4 7 5 5 3 9 4 6 3.6 7.0 3.4 1 8 3 7.5 3 7 1 6 4 8 2.4 7.3 4.9

Pt. 5 4 9.5 5.5 5 7.5 6 8 4.5 7 3 8 5.5 7 4.8 7.5 2.7 3 6 4 7 2 6 1.5 8 4 7.5 2.9 6.9 4.0

Pt. 6 6 9 3 7 8.5 5 9 4 7 5 7 5 7 5.2 7.7 2.5 4 9.5 5 8 6 7 4 7 5 7 4.8 7.7 2.9

Pt. 7 3 7 4 6 7 3 6 2 5 3 6 3 5 3.4 5.8 2.4 1 7 2 6 2 6 1 4 1 6 1.4 5.8 4.4

Pt. 8 6 8.5 3 6 8 4 8 3 7 4 7 4 7 4.2 7.4 3.2 2.5 8 4 8 4 7 2 6 4 7 3.3 7.2 3.9

Pt. 9 5 8.5 3.5 3 8 3 7 4 7 4 7 3 8.5 3.4 7.5 4.1 3 7 4 7 4 8 3 7 4 8 3.6 7.4 3.8

Pt. 10 4 8.5 4.5 4 7 2 6 3 7 5 6 5 7 3.8 6.6 2.8 1.5 8 2 7 4 7 2 6 3 6 2.5 6.8 4.3

F-VALUE

- T0(F- VALUE = 1.11), T1 (F- VALUE = 2.49) T0(F- VALUE = 3.64*), T1 (F- VALUE = 1.93)

MEAN 3.83 T value (<P=0.05) shows significant difference between T1 and

T0 3.03 T value (<P=0.05) shows significant difference between T1 and

T0 3.86

Results

59

GRAPH 1: Intra-group comparison of mean pre- and postoperative PAS

TABLE NO. 7b: Intra-group comparison between PAS difference of OMFS,

Laypersons and Surgical patient

Conclusion: * Shows significant difference (t-value is 1.734 for p=0.05)

Comparison of PAS difference between Mean t-value

OMFS and Laypersons 3.86 3.03 3.05*

OMFS and Surgical patient 3.86 3.83 0.08

Surgical patient and Laypersons 3..83 3.03 2.41*

Results

60

Out of the total 10 patients, 5 patients underwent advancement Genioplasty

alone. Out of the remaining 5 patients, 2 patients underwent anterior setback anterior

maxillary osteotomy with advancement Genioplasty, 1 patient underwent anterior

maxillary osteotomy with augmentation Genioplasty and 2 patients underwent Lefort

I osteotomy with superior impaction along with advancement Genioplasty in one

patient and BSSO advancement in another patient. [Table 4]

Patients were divided into three separate groups based on the surgery performed for

statistical analysis.

Only Advancement Genioplasty

Anterior Maxillary Osteotomy and Advancement Genioplasty

Lefort I impaction and Advancement Genioplasty/BSSO Advancement

T0 and T1 hard and soft tissue changes were compared using student’s “t” test

in patients who underwent Genioplasty alone, in patients who underwent

advancement Genioplasty with AMO with setback and in patients who underwent

Lefort I osteotomy with Genioplasty and BSSO mandibular advancement separately.

Statistically significant change was found patients who underwent only

Advancement Genioplasty with a t-value > 2.132, (P=0.05) with the following

parameters.[Table. 5a, 5b]

N-A-Pg angle with t-value =5.17,

ANS-Gn with t-value =4.74,

Go-Pg with t-value =15.65 and

B-Pg with t-value = 15.65.

Results

61

Statistically insignificant changes were found with the following parameters,

N-A with t-value = 0,

N-B with t-value = 0.12,

N-Pg with t-value = 1.52,

N-ANS with t-value = 0 and

PNS-ANS t-value = 0.

The values are indicative significant postoperative sagittal changes with

respect to lower facial height and hard tissue Pogonion advancement due to increase

in mandibular length.

Statistically significant change was found in patients who underwent

Genioplasty in conjunction with AMO setback osteotomy with a t-value > 2.920,

(P=0.05), [Table. 5a,5b]

ANS-Gn with t-value = 5.29.

B-pg with t-value = 4.36.

Go-Pg with t-value =3.78.

Statistically insignificant changes were found with the following parameters,

N-A-Pg t-value = 0.69.

N-A with t-value = 1.00.

N-B with t-value = 1.00.

N-Pg with t-value = 2.38.

Results

62

N-ANS with t-value = 1.51.

PNS-ANS with t-value = 2.0.

The values obtained are indicative of increase in lower facial height with

advancement of hard tissue Pogonion due to increase in mandibular length.

Statistically significant was seen only at Go-Pg with a t-value =15.00 who

underwent Lefort I advancement and superior impaction in conjunction with

advancement Genioplasty and BSSO advancement respectively. [Table 5a, 5b] All

other parameters in this group were statistically insignificant.

Mean hard tissue advancement of Pg was calculated to be 6.9 mm with mean

Go-Pg length of 71.5 +/- 10.83 and mean improvement in N-A-Pg was calculated to

be 7.3 degrees with mean postoperative N-A-Pg angle of 7.3 +/-5.7 degrees.

The parameters with respect to hard tissue changes were compared to

established norms given by Burstone et al15 using student’s “t” value test was found to

be insignificant with P=0.99, indicating normalization of parameter values post-

surgery.[Table 5c]

Comparison of soft tissue parameter was done using Student’s “t” test.

Statistically significant change was found who underwent Genioplasty alone, with a

t-value > 2.132 (P=0.005) [6a,6b]

G-Sn-Pg with t-value = 7.8.

Li-Pg line witht-value = 5.48.

Results

63

Statistically insignificant change was found with following parameters,

Cm-Sn-Ls with t-value = 0.

Vertical lip chin ratio with t-value = 0.91.

Intralabial gap with t-value = 1.47.

Statistically significant change was also found in a patients who underwent Anterior

setback maxillary osteotomy in conjunction with Genioplasty with a t-value =2.92,(P

= 0.05). [Table 6a,6b]

G-Sn-Pg with t-value = 6.43.

Cm-Sn-Ls with t-value = 4.33.

Li-Pg line with t-value = 7.00.

Statistically insignificant change were found with the following parameters,

Vertical lip Chin ratio with t-value = 0.91.

Intralabial gap with t-value = 2.33.

Statistically insignificant change was found with all the parameters in patients

who underwent Lefort I osteotomy in conjuction with BSSO advancement and

advancement Genioplasty.

For all the patients postsurgical mean change in G-Sn-Pg angle was observed

to be 7.1 degrees with mean postsurgical G-Sn-Pg angle measuring 15.3 +/-3.7 and

mean improvement in intralabial gap was calculated at 3.4mm with mean intralabial

gap postsurgery being 3.7 +/- 3.12.

Results

64

The parameters with respect to soft tissue changes were compared to

established norms given by Legan et al20 using student’s “t” value test was found to be

insignificant with P=0.9280, indicating normalization of parameter values post-

surgery. [Table 6c]

Preoperative and postoperative PAS obtained from OMFS and Laypersons

were subjected to One ANNOVA variance test to check intra group variance.

Significant Intra-group variance was found with T0 values obtained from OMFS

group (F-value = 3.64) while the variance for T1 scores was insignificant. Inter-group

variance with T0 and T1 PAS scores for the Laypersons group was found to be

statistically insignificant. [Table 7a] [Chart 1]

Significant differences were found between T1 and T0 PAS score in all groups

using Student’s “t” Test for <P=0.05. Significant difference was found in Laypersons

group with a t-value =18.55, followed by OMFS group with a t-value =17.69 and

lastly by the Surgical patient at t-value =13.27(<P=0.05). [Table 7a]

Intra-group comparison was done using mean T1-T0 PAS score between

Surgical patient, OMFS group and Laypersons group with a T-value of 1.734 for

P=0.05. [Table 7b]

Statistically significant difference was found between,

OMFS and Laypersons group with a t-value = 3.05 (P = 0.05)

Surgical patient and Laypersons group with a t-value of 2.41 (P=0.05).

Statistically insignificant difference was found between the OMFS group and Surgical

patient with a t-value = 0.08 (P = 0.05). [Table 7b]

Discussion

65

DISCUSSION

In recent decades, Orthognathic surgery has become widely accepted as the

preferred method of correcting moderate-to-severe skeletal deformities including

facial aesthetics.5,6,11,30

Orthognathic surgery has the potential to change facial aesthetics

dramatically.19 Patients seeking treatment are usually eager to receive precise

information about the facial changes that surgical intervention may bring about.19

Facial appearance is important for psychological well-being and social

acceptance, because the face, as the most distinguished body part, influences the

manner of perception by others, thereby modulating social interaction.52

People with an attractive facial appearance have been reported to have a

greater variety of positive social responses.11,14,21,52 An attractive face can have a

profound effect on self-esteem and social adjustment. Patients requesting

Orthognathic surgery often present with a dislike of one or more aspect of their facial

appearance. Inherent in their request for treatment is a wish to improve facial

appearance.14 The measurement of improvement rather than change in facial

appearance is not only difficult, but lacks accuracy and can often only be described in

terms of relative change or change in relation to another face or group of faces.14,52

The recognition of aesthetic factors and the prediction of the final facial

profile play an increasingly significant role in Orthognathic treatment planning, since

Discussion

66

the facial profile produced by Orthognathic treatment is of great significance for

patients.13,30,52

Previous studies have demonstrated that the motive ‘improving facial profile’

was less fulfilled (70.4 per cent) compared with others.21,30 It has been suggested that

Professionals and Laypersons were unaware of all facial changes following surgical

treatment, with Laypersons being more difficult to impress.11 Consequently, the

relationship between hard tissue surgery and the effect which it has on the overlying

soft tissue is extremely important in predicting facial changes.7A positive and

perceivable result depends on the soft issue effect and the stability of the surgical

correction, as well as achieving an amount of surgical correction great enough for

patients, Dental professionals, and Laypersons to recognize.21



Department of Oral and Maxillofacial Surgery at Al-Badar Rural Dental College and


All the patients in this study were assessed clinically and radiologically.

Presurgical and postsurgical, Lateral Cephalograms were taken for all the 10 patients.

Limited Burstone15 analysis and Legans20 analysis was used to compare preoperative

and postoperative changes after Orthognathic surgery.

Cephalometrics is a reliable and consistent diagnostic modality for

orthognathic surgery planning and by planning surgery within the range of normal

Discussion

67

cephalometric norms, one can achieve perfect dentofacial balance and harmony.57

Variability is a characteristic of different faces and facial types and does not represent

all. Established standard values of human facial measurement may be inadequate for

planning surgery in all ethnic groups. Cephalometrics for Orthogathic surgery given

by Burstone et al15in 1978 is based on Caucasian population.15 Various studies have

been done to establish esthetic norms for different ethnic group, Flynn established

ethnic norms for black American, Alcade established norms for Japanese adults, Lew

et al established norms for south Asian population, Yadav et al for North Indian

population and Arunkumar et al for South Indian population.57,58

In our study, the selected postsurgical hard and soft tissue Cephalometric

parameters showed normalization with the esthetic norms established by Burstone et

al.15 Student’s “t” was used to compare our results with the esthetics norms

established by Burstone et al15 for hard tissue and Legan et al20 for soft tissue, and a

statistically insignificant relationship was found. (P=0.99, P=0.9280) [Table 5c,6c]

The average hard tissue advancement of Pogonion (Go-Pg)was achieved at

7mm [Table 5a,5b] after advancement Genioplasty is in agreement with studies

conducted by Troulis et al31 where he reported an advancement of 8.9mm +/-3.6 (Pg

perpendicular to FH plane) and also with study conducted by Chang et al32 who

reported 8mm of advancement. Change in G-Sn-Pg angle by 8.40 due to advancement

of hard tissue pogonion is compatible with study conducted by Sridhar et al16, who

reported a decrease in G-Sn-Pg angle by 6.64 degrees with 7mm pogonion

Discussion

68

advancement with net gain of 1.4mm in mentolabial sulcus depth as compared to

3mm net gain. [Table 6a, 6b]

In our study, there was increase in Nasolabialangle with a mean postoperative

angle of 112.2° in patients treated with AMO setback and Lefort I superior impaction.

Similar results have been reported by Je U Pak et al43 who reported 109° +/- 9.03°

after anterior maxillary setback osteotomy. Kim JR et al36 reported statistically

significant postsurgical nasolabial angle of 104.8° +/- 7.8 compared to preoperative

nasolabial angle of 91.8 +/- 11.3. Similar postsurgical changes in nasolabial angle

were published in a systemic review to determine facial soft tissue response to

anterior maxillary osteotomy by Jayaratne YSN et al48 after Orthognathic surgery.

Although clinical assessment of Orthognathic surgery outcomes requires examination

in three dimensions, quantitative measurement of a Dentofacial deformity is still

predominantly carried out in the lateral view.10 Previous studies indicate that A-P

dimension to the most important factor in judging facial attractiveness.14,52

Previous studies on perception of facial attractiveness have reported the use of

photographs, Silhouettes and profile tracings for esthetic profile assessment.

Silhouettes have been advocated by some authors because they eliminate extraneous

esthetic variables that can influence the evaluator such as hair, complexion, and

makeup.23,54 However, Silhouettes, when based on a rating system for esthetic

preference, might be inadequate if viewing the entire face is necessary to judge

attractiveness.54 Silhouettes can be useful to quantify a linear or an angular change of

the profile but perhaps not to quantify an aesthetic change.54

Discussion

69

Hockley et al54 conducted a study to determine whether photos or Silhouettes

are more reliable for aesthetic evaluation. They reported that the esthetic ratings of

photos were nearer to the esthetic norm than the ratings of Silhouettes for the same

person. Flatter profiles with less lip projection were more often preferred by raters in

the Silhouettes than in the photos. Coleman et al suggested that Silhouettes provide

less distracting information than do photos and allow evaluators to better focus on the

lips to express their preferences. But Hockley et al reported in their study that only

66% of the Silhouettes preferred by the raters were within the acceptable esthetic

range compared with 86% of the photos. They also found a greater percentage of rater

preference for profiles flatter than the esthetic norms when viewing Silhouettes

compared with photos (31% in Silhouettes and 9% of photos). It has also been

reported that profile outline alone plays only a limited role in the evaluation of facial

esthetics, other features of face the influence the evaluators perception of

attractiveness.54 A common ranking procedure usually undertaken to determine facial

attractiveness is Visual analogue scale.6,21 Many other investigators have used visual

analogue scales (VAS), which have certain advantages.6

The use of the unmarked VAS proved to be a simple and rapid method for

assessing the perceptions of facial attractiveness.14 The VAS has several advantages

over other methods that have been used in previous panel assessments of facial

attractiveness. VAS is more sensitive to small changes than simple descriptive ordinal

scales. Additionally, ratings can be given quickly and the scores analyzed as

continuous measures. Recording the results as continuous variables in millimeters

Discussion

70

allows more freedom in the analysis of data and permits more powerful parametric

statistics to be used.6 The rating scores can detect differences in overall perception

of facial attractiveness between the groups and yet the use of mean evaluators scores

and the subsequent paired analysis decreases the variability observed among

judges and focuses the analysis on the change measures.14 The difference between the

pre-treatment and post-treatment mean scores indicates the direction of change as

well as the extent of change. In addition, the VAS can minimize biases towards

preferred values as found with numeric or equal-appearing interval scales.6,54

There are limitations when using the VAS to measure a subjective

phenomenon, such as facial attractiveness. It is thought to be difficult to ensure that

all the evaluators interpreted the anchor points of very unattractive and very attractive

in exactly the same way or that comparable positioning of marks on the scale implies

the same feeling by the same or different evaluators.6,14 Finally, it is uncertain how

many millimeters of difference in facial attractiveness are required to be clinically

relevant and/or meaningful.6, 14,24,55

Doreen Ng et al55 reported that when presurgical and postsurgical status of

patients are disclosed the ratings are significantly higher and favorable.

Paired blackened Silhouettes on white background were used for evaluating

facial profile esthetics. Significant difference between T0 and T1 mean scores was

found in all groups correlating with the study done Montini et al21 and Shelly et al22

indicating recognition of facial changes between the paired Silhouettes. Intra-group

comparison concluded statistically significant difference between the mean scores of

Discussion

71

OMFS group and the Laypersons group and between Surgical patient and the

Laypersons group correlating with findings of Montini et al21, Shelly et al22 and

Shetty et al53. (t-value=3.83 at P=0.05, t-value=3.03 at P=0.05 and t-value=3.86 at

P=0.05) [Table 7a,7b]

Previous studies report that dental professional are more accurate and critical

in analyzing of facial esthetic as compared to Laypersons s.21,24 It has also been

suggested that Laypersons are hard to impress and may concentrate on other features

of the face to rank a facial profile in particular the lip.13,24.

This study concludes that all the patients were able to perceive the change in

profile and were also satisfied with the aesthetic outcome. It was also concluded that

all the evaluators were able to perceive the change in attractiveness.

Summary & Conclusion

72

SUMMARY & CONCLUSION

Assessment of an individual’s appearance as perceived by their peers and

the possible improvement with Orthognathic surgery are important considerations

when planning the surgical treatment. Therefore, it is important to know the

opinion of both the professionals and the Laypersons opinion on the facial

appearance of patients before and after Orthognathic surgery as the perception

of aesthetic improvement might differ between people with different backgrounds.10



Department of Oral and Maxillofacial Surgery at Al-Badar Rural Dental College and


Lateral Cephalograms were used to evaluate difference between hard and soft

tissue changes and create Silhouettes to evaluate the perception of attractiveness due

to change in profile after surgery.

Statistically significant changes were found between the presurgical and

postsurgical parameters under consideration using Student’s “t” test at P=0.05.

Statistically insignificant changes were observed between the established aesthetic

norms by Burstone et al15 and the postsurgical Cephalometric variables with a t-value

=0.005 for hard tissue parameters, and t-value = 0.093 for soft tissue parameters.

Summary & Conclusion

73

Statistically significant difference was found between perceptive assessment

score given to the preoperative and postoperative Silhouettes in all the groups, with

the maximum difference being found in the Laypersons group with a t-value = 18.55

(<P=0.05) and with minimum difference being found with scores of the Surgical

patient with a t- value =13.27 (<P=0.05).

Significant Intra-group variations were found in perception of attractiveness

were found between OMFS and the Laypersons group with a t-value = 3.05, P=0.05

and also between Surgical patient and Laypersons with t-value=2.41, P=0.05.All the

evaluators could perceive changes in profile after the surgery. The final facial

convexity angle that could be achieved in all these patients with a variety of surgical

procedures was 15.3°+/- 3.33 which was acceptable to the all the patients and groups

evaluating the facial aesthetic changes due to change in profile.

This study concludes that all the patients were able to perceive the change in

profile and were also satisfied with the aesthetic outcome. It was also concluded that

all the evaluators were able to perceive the change in attractiveness.

Though with a relatively shorter duration of follow-up and small sample size,

variety of surgical procedures being performed the study embarks upon the

significance of perception of facial aesthetics due to profile change with respect to

hard and soft tissue changes taking place after Orthognathic surgery. The same needs

to be further evaluated with a larger sample size, single operative procedure, use of

Photographs and Silhouettes, aesthetic norms established for Indian population and

lastly with a longer duration of follow-up.

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74

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Annexures

81

ANNEXURES

ANNEXURE -1

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY,

AL-BADAR RURAL DENTAL COLLEGE & HOSPITAL, GULBARGA.

“CLINICAL AND RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES AFTER ORTHOGNATHIC SURGERY”

CASE HISTORY PROFORMA

Name: OPD No:

Age/sex: Occupation:

Phone No: DOA:

DOS: DOD:

Address:

Chief compliant:

History of present illness:

Past medical history:

Drug history:

Annexures

82

Personal history:

Appetite:

Diet:

Bowel:

Micturition:

Sleep:

Habits:

Respiration:

Deglutition:

Family history:

General physical examination:

Built:

Height:

Weight:

Anaemia/Jaundice:

Cyanosis:

Blood pressure- mm of Hg:

Pulse – beats/min, regular:

Temperature:

Annexures

83

Extra oral examination:

Face:

Facial form:

Facial profile:

Lip competance:

Lip line- at rest:

On smiling:

Interincisal gap- mm:

Inter labial gap –mm:

Mento labial sulcus-mm:

. Temparo mandibular joint-

Intra oral examination:

Frenal attachment

upper:

lower:

Gingiva:

Palate:

Tongue:

Dental status:

Restoration:

Occlusion:

Oral hygiene:

Stains:

. Overjet – mm:

. Overbite – mm:

Annexures

84

Provisional diagnosis:

Radiographs:

Radiographic interpretation:

HARD TISSUE ANALYSIS

Sl.no Parameter Unit Mean Presurgical

(T0)

Postsurgical 3rd month

(T1) HORIZONTAL SKELETAL PROFILE

1 N-A-Pg Deg Males : 3.9 +/- 0.4°, Females: 2.6 +/- 5.1 °

2 N – A

( II – HP ) mm

Males= 0.0 +/ 3.7mm,

Females = -2.0 +/- 3.7mm

3 N – B

( II – HP ) mm

Males=-5.3 +/-6.7mm;

Females=-6.9 +/- 4.3 mm

4 N –Pg

( II – HP ) mm

Males = -4.3 +/- 8.5mm;

Females=-6.5 +/- 5.1 mm

VERTICAL SKELETAL DYSPLASIA

1 N – ANS

( 1 to HP) mm

Males= 54.7+/- 3.2mm;

Females= 50 +/- 2.4mm

2 ANS – Gn

( 1 to HP) mm

Males= 54.7+/- 3.2mm;

Females= 50 +/- 2.4mm

MAXILLA AND MANDIBLE

1 PNS-ANS

( II-HP ) mm

Males =57.7 ± 2.5mm;

Females =52.6 ± 3.5mm

2 Go-Pg

( II-MP ) mm

Males = 83.7±4.6mm; Females=74.3±5.8mm

3 B-Pg

( II-MP ) mm

Males = 8.9 ± 1.7mm; Female = 7.2 ± 1.9mm

Annexures

85

Treatment plan:

Blood Investigations:

RBC Count Cells/cumm

Hb% Gm%

Blood group

Bleeding time

Clotting time

Random blood sugar tests

Urine routine Albumin

Sugar

HIV

HBsAG

ECG

Chest X-ray

SOFT TISSUE ANALYSIS Facial Form To Describe Overall Horizontal Soft Tissue Profile

Sl.no Parameter Unit Mean Presurgical

(T0) Postsurgical 3rd

month (T1)

1 Angle of facial

convexity (G-Sn-Pg)

Degree 12°+/-4

LIP POSTION AND FORM

1 Nasolabial angle

(Cm-Sn-Ls) Degrees

102°+/-8

2 Mentolabial Sulcus Depth (Li-Pg Line)

mm 4+/-2

3

Vertical Lip Chin Ratio

(Sn-Stm1:Stm2-Me)

Ratio 1:2

4 Intralabial Gap

(Stm1-Stm2) mm 2+/-2

Annexures

86

Treatment done:

Approximate blood loss-

Intraoperative fluids-

Sutures used-

Name of surgeon:

Anaesthetist:

Assistants:

Doctor’s orders:

Annexures

87

ANNEXURE – 2

CONSENT FORM

DEPT. ORAL AND MAXILLOFACIAL SURGERY AL BADAR RURAL DENTAL COLLEGE AND HOSPITAL,

GULBARGA.

I __________________________________________ , undersigned hereby give my

consent for undergoing orthognathic surgery, for the study “CLINICAL AND


AFTER ORTHOGNATHIC SURGERY” being conducted by Dr. Mohammed

Haneef under the guidance of Dr. Neelakamal H Hallur MDS, Professor & Head,

Department of Oral and Maxillofacial Surgery. And I also, hereby give my consent

toparticipate in this study.

Patient Signature

Date:

hard and soft tissue changes after orthognathic surgery

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