A three dimensional analysis of soft and hard tissue changes following

bimaxillary orthognathic surgery in skeletal III patients

A. M. McCance. J. P. Moss. W. R. Fright, D. R. James. A. D. Linney

tiniwrsir). Collqy Ihtul Hospird. Mortinwr Murket, London

SUMMAH Y. The three dimensional changes in the bone and the ratio of soft tissue to bone movement were
investigated in a group of 16 Skeletal 111 patients following orthognathic surgery. Computerised tomogram scans
were taken for each patient pre-operatively and 1 year postoperatively. The scans were superimposed, radial
measurements calculated, and the changes illustrated by two separate colour scales. There was no constant pattern
of movement in the maxilla or mandible in these patients. However, following a Le Fort 1 osteotomy there was
commonly a 1 : 1 ratio in the midline which increased to 1.25: I at the alar bases and over the canine regions
bilaterally. There was also a 1.25 : 1 ratio or greater over the chin and mentalis regions following mandibular set
back.

IR’TRODLCTIOIV our et (II., 1983j., and the upper lip shortens by 20%
of the degree of impaction (Bell VI al.. 1980).
An increasing amount of surgery is being performed The purpose of the study was to investigate the
to correct the underlying skeletal problem in the three dimensional changes in the bone and the ratio
treatment of adult malocclusion and facial deformity. of movements of the overlying soft tissues across the
However the ability to measure and predict the whole of the facial complex following orthognathic
changes as the result of surgery is usually limited to surgery.
two dimensional assessment of lateral skull radio-
graphs. Traditionally, attempts at comparing profiles
with a view to quantifying changes due to growth or
surgery have involved an operator identifying and METHOD
locating landmarks (Walker & Kowalski, 197 I : Dcnis
& Speidel, 1987). The landmarks are often sparse. The patient sample comprised 16 adult patients with
and objections have been voiced on their use. The a class III skeletal I11 malocclusion (9 male and 7
main objections have been that individual analysis female) who required a combination of orthodontics
may bc dependent on profile orientation and that the and surgery to correct their malocclusion. All the
landmarks provide no information on shape or patients in the group were aged I7 years and over.
change in shape in the segments joining them. The Computeriscd tomogram (CT) scans wcrc taken
determination of landmarks also relies on expert of each patient pre-opcrativcly and I year postopera-
opinion to create homologous points (Mardia. 1989). tively. A typical prc-operative scan consisted of 30
Also many of the bony landmarks commonly used 60 I.5 mm thick slices separated by a gap of 3 mm
to evaluate change are destroyed during the surgery throughout the area of surgical interest. The slice
itself (Houston et ~11.. 1987). spacing was increased over the immediate neighbour-
There have been varying values published for the ing areas such as the eyes. The postoperative scans
ratios of soft tissue to bone movement in the midsagit- were restricted to 6 mm slice spacings and the patients
tal plant. In mandibular setbacks the most consistent were scanned only from the supraorbital ridges to
findings arc a 1 : I ratio over the chin (Lines & just below the mandible. This increase in slice spacing
Steinhauser, 1974; Worms et ul., 1976: Moshiri rt al., was to minimize the amount of radiation to the
1982). The ratio of movement then reduces to 0.9: I patient. However. it was important to have sufficient
over B point and 0.8 : I over the lower lip in relation arca scanned to permit superimposition of the scans
to the lower incisor. In maxillary advancements the over a stable and unchanged area of the face. The
thickness of the upper lip is reduced by a ratio of CT data invariably required modification to exclude
I : 2 (Lines & Steinhauser, 1974; Dann er (II.. 1976: the presence of streak artifacts caused by amalgam
Freihofcr, 1977: Bell & Jacobs. 1980; Radney & fillings in the teeth or tixed orthodontic appliances.
Jacobs. 1981). The nasal tip is also advanced in a This was done semiautomatically by retaining only
ratio of 2 : 7 with the maxilla. In maxillary impactions the bone information in those scans that were affected
the nasolabial angle is increased; the nasal lip moves and eliminating the soft tissue detail.
up in a I : 6 ratio to the tip of the maxillary incisors All the patients received some degree of orthodon-
(Schcndel et al.. 1976: Radney & Jacobs. 1981; Mans- tic treatment to align the teeth over their respective
305
306 British Journal of Oral and Mnxillofmal Surgcr>

basal bones and to align and coordinate the dental Three landmarks were located on the front profile
arches. All the patients underwent bimaxillary sur- of the scan (Fig. 1):
gery. In 13 of the cases, the maxilla was moved into The mid-point on the right and left orbital margins
its correct relationship with the cranial base by using just below the front0 nasal suture (landmarks
a Le Fort 1 downfracture procedure. in the remaining 1 & 3).
three cases a Kufner (1971) osteotomy was used. The The hard tissue nasion. defined as the most convex
mandible was set back into occlusion with either a point of the horizontal profile and the point of
sagittal split or a vertical subsigmoid osteotomy. maximum concavity on the vertical pro& (land-
Miniature non-compression bone plates were mark 2).
employed to stabilise the maxilla in its new position. The mid point, right and left. on the base of the
In the sagittal split osteotomies the fragments were zygomatic arch near to the articular eminence. on
fixed using either upper border or circumferential the temporal bone (landmarks 4 & 5).
wires. Intcrmaxillary fixation using the fixed ortho- These points were reliably located on all of the scans.
dontic appliances was placed for a minimum period The points were identified in areas of very dense bone
of 6 weeks postoperatively. and were not affected by small differences in the
thresholds between the two scans. Despite the differ-
ence in the slice spacings between the pre and post-
opcrativc scans the landmarks were always matched
The CT scans were loaded from lilt and thresholded to within 1 mm. The points chosen were felt to bc
for bone ( A 150 Houndsheld threshold). The scans sufficiently far apart and reflect large differences in
were orientated in a front view and then saved as a the X, Y. and Z coordinates. Thus the scan image
view file. This enabled the scan to bc loaded at any could be adequately defined in space.
future occasion in the same position.
ltlcasuretnc~~r qfsurgicol change
Lundmarks
Bone mownenrs. The pre and I year postoperative
Landmarks were identified on the surface of each CT scans were loaded individually and registered using
individual scan. The surface illumination image was the five landmarks specified above. Areas of change
displayed and a cursor was driven across the screen. were then demonstrated using a colour mm scale. The
The three dimensional position of the surface at the scale extends from - 9 to + 9 mm. the cold colours
cursor point was computed from the two dimensional representing negative differences and the warm colours
screen position. the value of the 7 buffer at that point positive movements. In areas where there has been no
and the matrix transformation from viewing space to change the original colour of the CT scan remains. In
object space. The location of the landmarks was this way both the area and amount of movement can
assisted by vertical and horizontal profiles of the be seen. An example of one of the patients in the
object at the cursor point being displayed alongside study is illustrated in Figure 2. The image shown is
the image. Five landmarks in total wcrc found to be the superimposition of the postoperative scan on the
adequate to gain a high degree of reproducibility in pre-operative scan. and thus the cold colours represent
the matching of the prc- and postoperative images positive surgical changes and the warm colours ncga-
(Fig. 1). tive surgical changes. The areas of change were calcu-

Fig. I - CT landmarks. see text for defalls of points I 5.

 Bimaxillary orthognathic surgcry 307
-

Bone Soft to bone

ratio of movement

1.5: 1 I:1 0.5: 1 1: 1 1.5: 1

Fig. 2 - Superimposition of pre- and postoperative scans to Indicate hone and soft tissue movements after surgery.

lated from radial measurements (Fright & Linney,

1992) taken from the central axis of the head to the
outer bone surface (Fig. 3).

Sofi tissue to bone rario qf movement. The pre and

one year post operation CT scans were loaded indi-
vidually and registered using the five landmarks spcci-
fied above. The scans were first thresholded at bone
(Hounsfield + 150) to enable the landmarks to be
placed and then re-thresholded at skin (Hounsfield
- 250). Radial measurements of the surface of the
bone were then calculated on each scan, followed by
the radial measurements of the skin surfaces. The
ratio of movement of the soft tissue to the underlying
bone was then calculated. The colour grid rep-
resenting the ratio of soft tissue to bone movements
extends from a negative movement of 1.5 : I to a
positive 1.5: I (Fig. 2). The image shown is superim-
position of both scans upon the pre-operative scan
and thus negative ratios represent positive surgical
changes and the positive ratios negative surgical
movements. Areas of no change retain the original
CT scan colour.

Method errors
Five landmarks on the pre and postoperative CT
Fig.3- Radial measurements from the centrc of rotation of the
scans of all 16 patients were identified on three skull IO either bone or skm surface.
separate occasions at weekly intervals. The method
errors were reported as the mean difference and the
standard deviations in the X, Y and Z coordinates RESULTS
of each landmark identified (Tables I, 2 and 3). The
null hypothesis for the mean difference in each coordi- At present the computer software is unable to average
nate was also tested using a one sample t-test. the CT data and consequently it is only possible to
308 BriIIsh Journal of Oral and Maxlllofacial Surgery

Table I - CT landmark method errors X coordlnaw (mm)

Landmark Mean Stclndard dcwation Standard error T ProbabIhI!

P-r I 0.03 0 I5 0 05 0 07 0.94

I’T 2 0.04 0 12 0 04 I I)? 0 34
pT3 0.1 I 0 I5 0 u4 2.36 u 04
PT4 0 02 0.05 0.02 I 45 0 I8
PT 5 001 001 0.21 04-l 0 64

Table 2 -CT landmark merhod error, Y coordlnares (mm)

Landmark Mean SIandard dcwation Standard error T ProbabiliIy

Fl-I 0 02 0.14 0.05 0 56 0 59

PT 2 0.04 0 I2 0 04 I .02 0.34
PT 3 u 0’) 0 24 0 07 I 21 0.26
PT 4 0.02 0 us 0 I6 I.31 0.22
PT5 0 ox 0 II 0 ui 2.48 0 03

Table 3 - CT landmark method errors 7. coordinates (mm)

L.Indmark Mean Standard de\idrton SIand;trd error T Probability

PT I 001 0 II 0 03 0.01 0.89

PT 2 0 05 0 (18 n.02 0 08 0.94
pr3 00s 0.13 u 04 1.35 021
PT 4 u I3 0 07 u 0’ 5.x9 0 06
PT5 u 05 0 02 001 3.23 O.OR

Table 4 - Bone mowmcnfs Skeletal III pcrIienIs

Patient Maxilla

Anterior Alar ha\e I Molar

R. can Middle L can RIghI LCfI IQhI Left

XI .- 3 mm -3mm -5mm +3mm Omm 13mm -3mm

x2 -8mm -8mm -8mm -8mm - 9mm -5mm -8mm
X1 +5mm A3mm + 5 mm (5mm -3mm + 5nim -9mm
x4 MD
X5 +5mm -5mm +5mm L9mm +8mm .I 5mm +5mm
X6 +3mm +Smm A 3 mm +5mm +5mm Omm I) mm
x7 +5mm +8mm + 3 mm + 5 mm l5mm -Ymm +3mm
XX +5mm +5mm +5mm +3mm -5mm +Imm -3mm
x9 +Ymm AYmm -t 9mm +Ymm -9mm + 5 mm r5mm
xl0 + 1 mm + 5 mm -3mm +9mm -8mm +8 mm +5mm
XII +7mm t 8 mm -5mm 1Xmm +Smm +7mm + 3 mm
XI! 0 mm +3mm T5mm +9mm 19mm - 7 min + 7 mm
XII MD
Xl4 MD
XI5 fYmm + 9 mm A7mm ‘Ymm +Omm .9mm +5mm
Xl6 MD

R. can = right umne repon

L can = IcfI camnc rcpon
I Molar = first molar repon
MD = missing dara.

report upon individual cases for the bone movements positive surgical movements or ratios and warm
and the ratios of soft to hard tissue. The overall colours as negative movements or ratios.
movements achieved arc illustrated in Talks 4 7.
Only a few defined arcas arc reported in the tables
for ease of illustration and comparison of the cases
as a whole (Fig. 4). There was a very varied degree of movement in the
One of the patients from the group is described in maxtlla. the degree of movement did not reduce
detail to illustrate the bone and ratio of soft tissue anteriorly to posteriorly (Table 4). There was a fairly
movements. The pre-operative scan is shown for all constant dcgrec of movement in the mandible over
the comparisons, and thus cold colours rcprescnt the chin and mcntalis region. In those cases where
 Blmdxillary orthognathic surgery 309

Table 5 - Bow mwctnents. Skeletal 111 patients

Patlent Mandible

Body Chin Body R. cdn Inctbor L. can 3 Molar

right left
Right Left

Xl -5mm - 5 mm 8mm -5mm -8mm -Xmm -3mm 5 mm

X2 -7mm -9mm - 5 mm -Xmm 8mm 8mm 3 mm -3mm
X3 5mm - 9 mm _ 9 mm -9mm -9mm -9mm 3mm - 9 mm
x4 MD
X5 -3mm - .5 mm - 5 mm +?mm 5mm 7 mm I.7 mm 3 mm
X6 -5mm 5 mm - 8 mm - 8 mm - 1 mm -8mm -5mm -5mm
Xl - 5 mm -8mm -5mm -8mm Smm --Xmm - 7 mm -3mm
XX -5mm - 3 mm +3mm - 5 mm - 5 mm t3mm -3mm - 3 mm
x9 3mm 3mm -5mm -3mm -5mm 5mm Omm 5 mm
x10 - 3 mm - 9 mm - ! mm 5mm -8mm -5mm ‘Imm -3mm
XII - 5 mm -9mtn .9mm 5 mm 9 mm -9mm - 3 mm -7mm
Xl2 + 3mm I jIllIll 3 mm +-8mm +imm -3mm Omm -5mm
Xl3 -7mm -9 mm - i mm -7mm - 5 mm -7mm - 5mm -5mm
Xl4 MD
Xl5 t 5 mm MD - 1 mm +5mm -3mm -7mm +5mm - 9 tnm
Xl6 MD

R can = right canme rcglon

L. cdn = left can~nc region.
3 Molar = third molx region.
MD = missing data
- = no mowmcnt

Table 6 - Soft tissue ratio to hone mo\cmettt~ Skeletdl 111 patwnts

Patient Max11l.i

Anterior Alar base Paranasal region

R. can hliddle L. an Right I.eft Right Left

XI 1.5: I I I
X2 T.25. I III 1.25: 1 1.25: I I .25 : I I I I.1
X3 I.1 I 5 1.5. I 0 75 I 075.1
X4
X5 1.25 I I.1 1.15: I 1.25 I 1.25: I 1.5. 1.5: I
X6 I:1 1-l
Xl 0.75: I 1.5: I 1.5. I I5 IYI 1.15: I
X8
x9 1:I I.1 111 I:1 l-l I I 1.25: I
x10 1.5: I 1.5: I I:1 1.5: I
XII 1.25. I I:1 I25:l 1.5: I 1.5: I I:1 I:1
Xl2 1.5: I 1.25: I 1.5. I I .25: I 1.5: I
XI? MD
x14 MD
Xl5 MD
Xl6 MD

R. can = right canine region

L. can = left canine region.
- = no mo\emcnt.
MD = mtssing data

there was a small degree ofset back anteriorly (5 mm). a 1 : I ratio in the midline which increased to 1.25 : I
there was a similar movement in the body region and at the alar bases and over the canine regions bilater-
third molars bilaterally. However, in large anterior ally. This increased ratio did not continue out into
set backs the degree of movement progressively the paranasal arcas. where a 1 : 1 ratio was commonly
decreased over the body of the mandible and third found. Cases Xl. X3. and X9 show a very different
molar regions (Table 5). pattern of movement to the rest of the group and
these t hrec patients had undergone a K ufner advance-
ment of the maxilla (Table 6).
Soft rissue ratios
There was a very varied degree of movement over
There was no constant pattern of movement in the the mandible. However. over the chin and mcntalis
maxilla. However, in those cases where a Le Fort I regions there was commonly a 1.25 : 1 ratio or greater
osteotomy had been undertaken there was commonly (Table 7).
3 IO Rrltlsh Journal of Oral and Maxlllofaclat Surgery

Table 7 - Soft t~ssuc ratio IO bone movements Skclctal III pabents

Patient Mandible

Body Chin Body Anterior

Memalls
right left
R. can Middle I.. can

Xl I:I I:1 1.5: I 0.75: I 1.25 : I

x2 0.75: I 0.75. I 1.25: I 1.25: I 1.25: I 1.5: I
X3 l:I 1.25 : I I:1 I .25 : I I25:l I:1 1.25: I
x4
X5 I.1 1.5. I 1.25 : I 1511 1.5: I 1.5: I 1.5: I
Xh 1.5. I 1.5: I 1.25: I I:1 I:1 I:I I 25: 1
Xl 1.5: I 1.5: I t:t I .25 : I I:I 1.5: I
XX 1.5: I 1.5: I I:1 1.25: I I I 1.25: I
x9 t25:l I .2j : I t:t I I I:1 1.5: 1
XI0 Ill I.1 I.1 1.25. I
XII I:I 1.25: I I :I 1.25 : I I:1 I .25. I 1.25: I
Xl2 I.25 : I 1.5. I 1.25.I 125: I 1.5: I I:1 1.5. I
x13 0.75 : I 1.25: I 0 75: I 1.5: I 1.25: I 1.25: 1 1.5: I
x14 MD 15:t
Xl5 I:1 MD 1.5: I 1.25: I MD 1.5: I MD
X16 MD 1.25 : I

R. can = right canine repon.

L can = left canine region.
= no mwement.
MD = missing data.

Mo&hlr: There was a I .5 : 1 ratio of movement of the soft

tissues over the body of the mandible bilaterally. and over
the lower border of the chin in the mid lint. The central
portion of the lower jaw from the incisal tip to the chin
point was set back in a I : 1 ratio.

DISCUSSION

The three dimensional analysis of the bone move-

ments resulting from surgery must bc interpreted with
great cart. The measurements arc the result of radial
measurements taken from the ccntre of rotation of
the skull. Thus if one refers to Figure 5 it becomes
clear that for a 10 mm advancement of the maxilla
or the mandible the degree of change anteriorly would
be 10 mm. However, as the jaws arc U- or V-shaped
k‘ig.4 - Bone regions the degree of change decreases gradually towards the
back. The degree of change at 30’ from the midline
was 9 mm and at 60 only 4 mm. In smaller anterior-
posterior movements the degree of difference from
lndividual case report (Fig. 2)
front to back would bc far less marked and may not
Bone movements be discernible by the colour scale and precision
currently available in the software. Furthermore, as
There was a 5-7 mm advancement of the maxilla and an
indicated in Figure 6, there are also problems in the
8 mm set back of the mandible.
interpretation of the changes in the bone when a
vertical displacement of the jaws is undertaken, or
Sqfi lissuc lo hone ratio movement indeed a rotation. In the example shown in Figure 6,
Maxilla: There was a very varied and irregular movement the maxillary impaction results in 4 mm change in
of the underlying bone movements and thus the ratio of the radial measurement at the original A point and
movements were somewhat bizarre. There was a 1 : 1 ratio a greater movement of 9 mm superiorly. Thus in the
in the region of the base of the nose extending out IO the case of maxillary impactions the bone changes
Icft alar base. recorded on the colour scale would suggest marked
 Bimaxillary orthognathlc surgery 311

ANTERIOR the soft tissues have to adapt to the new bone

position. In the cast of a maxillary impaction when
a wedge of bone is removed and thcrc is a reduction
in the total vertical height of the face anteriorly, the
excess soft tissue will adapt and spread itself along
the lines of least resistance. It is appreciated that the
methods of measurcmcnt in this study are based upon
radial measurements from the centrc of rotation of
the head and are not directly comparable to the linear
measurements recorded from lateral skull radio-
graphs. However. as there are no reports of three
B dimensional changes in the literature, it was felt that
a comparison to existing mid-sagittal values would
bc a useful rcfcrcnce.
Centre of mtation

POSTERIOR

Fig. 5 - Kad~al mcasuremcnt changes. The cffcc~ of radial changes

Muxillu. There was a fairly consistent pattern of
at 30’ intervals around the arch following a IO mm antermr movement following advancement. This was I : I ratio
advancement arc shown. Semwrclc A represents the maxilla or in the midline increasing to 1.25: I in the canine
mandible pre-operdtiwly and semiclrclc B postopcratlvcly. The region, and extending out over the paranasal areas
antcrmr displacement is IO mm bctwccn points I and 2. but the
as a I : I ratio. Previous authors (Lines & Stcinhauser.
dcgrlr of change dccrcases to 9 mm between points 3 and 4. and
further decreases IO 4 mm betwcsn pomts 5 and 6. 1974; Dann et al.. 1976; Bell & Jacobs, 1980; Radney
& Jacobs, 1981) reported that the thickness of’ the
upper lip was reduced by a ratio of I : 2.
3
Mandible. There was a variety of patterns of change
and this is because of the variation in the types of
mandibular movements employed to correct man-
dibular asymmetry as well as prognathism. The chin
and mcntalis region wcrc commonly moved in a
1.25: I or greater ratio, compared to the I : I ratio
over the chin reported by previous authors on their
assessment of lateral skull radiographs (Lines &
Steinhauser. 1974; Worms t’t al.. 1976: Hunt. 1980:
Moshiri. 1982).
Fig. 6 - Rddlal measurement changes. The effect of radial changes
following a maxillary impactIon arc shwn The dwancc from
pomt I to 2 has incrcascd by 3 mm. and the dwmce from 3 10 4
by 7 mm These changes will hc shown as positibc anterior displace-
ments of the bone on the colour scale comparison.
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