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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
RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES
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
RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES
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
3. Case 8 Silhouettes 46
4. Case 2 Silhouettes 48
5. Case 7 Silhouettes 50
6. Case 6 Silhouettes 52
LIST OF GRAPHS
GRAPH NO.
TITLE PAGE
NO.
1. Intra-group comparison of mean pre- and post- operative 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 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.
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
Review of Literature
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.
Review of Literature
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.
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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 hypo- divergent
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.
Review of Literature
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
Review of Literature
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
Review of Literature
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.
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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.
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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
Review of Literature
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.
Review of Literature
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
Review of Literature
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
Review of Literature
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.
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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 post- operative 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 post- operative 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
Review of Literature
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
Review of Literature
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
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.
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.
Materials and Methods
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.
Materials and Methods
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.
Materials and Methods
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
Materials and Methods
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.
Materials and Methods
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.
Materials and Methods
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.
Materials and Methods
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
Materials and Methods
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
Materials and Methods
43
Materials and Methods
44
Fig. 2: Case 1
VISU
AL A
NALOGUE SCA
LE
T0 T1
Materials and Methods
45
Materials and Methods
46
Fig. 3: Case 8
VISU
AL A
NALOGUE SCA
LE
T0 T1
Materials and Methods
47
Materials and Methods
48
C
VISU
AL A
NALOGUE SCA
LE
Fig. 4: Case 2
T0 T1
Materials and Methods
49
Materials and Methods
50
VISU
AL A
NALOGUE SCA
LE
Fig. 5: Case 7 T1 T0
Materials and Methods
51
Materials and Methods
52
VISU
AL A
NALOGUE SCA
LE
Fig. 6: Case 6
T1 T0
Results
53
RESULTS
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.
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 2 20/F 260 Advancement Genioplasty
Patient 3 35/F 240 Advancement Genioplasty
Patient 4 25/F 230 Advancement Genioplasty
Patient 5 22/F 170 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 post- operative 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
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.
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
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.
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
RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES
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: