This prospective longitudinal study assessed the 3D soft tissue changes following mandibular advancement surgery. Cranial base registration was performed for superimposition of virtual models built from cone beam computed tomography (CBCT) volumes. Displacements at the soft and hard tissue chin ( n = 20), lower incisors and lower lip ( n = 21) were computed for presurgery to splint removal (4–6-week surgical outcome), presurgery to 1 year postsurgery (1-year surgical outcome), and splint removal to 1 year postsurgery (postsurgical adaptation). Qualitative evaluations of color maps illustrated the surgical changes and postsurgical adaptations, but only the lower lip showed statistically significant postsurgical adaptations. Soft and hard tissue chin changes were significantly correlated for each of the intervals evaluated: presurgery to splint removal ( r = 0.92), presurgery to 1 year postsurgery ( r = 0.86), and splint removal to 1 year postsurgery ( r = 0.77). A statistically significant correlation between lower incisor and lower lip was found only between presurgery and 1 year postsurgery ( r = 0.55). At 1 year after surgery, 31% of the lower lip changes were explained by changes in the lower incisor position while 73% of the soft tissue chin changes were explained by the hard chin. This study suggests that 3D soft tissue response to mandibular advancement surgery is markedly variable.
For the surgeon, the ability to plan accurate skeletal movements to correct a mandibular deficiency is critical. Clinicians have assumed that the soft tissue must adapt and follow the hard tissue movements, but even after decades of study, the association between the skeletal and soft tissue movements following mandibular advancement is not well defined. Previous studies have reported that the soft tissue chin tended to follow the movement of the hard tissue chin closely but that the lower lip position was much more difficult to predict .
Assessments of soft tissue changes during and after surgery require three dimensional (3D) analysis and superimposition due to the complexity of the behavior of the soft tissue and the inability to measure asymmetries in two-dimensional (2D) images. Technologies such as 3D photogrammetry and laser scanning of the face have been used for 3D soft tissue superimposition, but their major limitation has been the inability to standardize registration of the images over time. Current procedures to integrate 3D facial images have reported significant errors in head positioning , and potential errors in facial expression have not been assessed .
This study assessed the stability of 3D soft tissue changes following mandibular advancement, and evaluated the association between soft and hard tissue changes using registration on the cranial base for the superimposition of 3D virtual models built from cone beam computed tomography (CBCT) volumes.
Patients and methods
Twenty-five patients (7 men, 18 women; mean age 30.8 ± 13.08 years) scheduled for mandibular advancement surgery were recruited for this prospective observational study. The protocol was approved by the Biomedical Institutional Review Board, and informed consent was obtained from all subjects. All patients had skeletal Class II discrepancies with >5 mm overjet that was severe enough to warrant orthognathic surgery. All patients had pre- and post-surgical orthodontic treatment and had mandibular advancement surgery with bilateral sagittal split osteotomy. Nine participants also had genioplasty as an adjunctive procedure. Patients with anterior open bite, cleft lip or palate, or skeletal disharmonies from trauma or degenerative conditions such as rheumatoid arthritis were excluded.
CBCT scans were taken before surgery, at splint removal (4–6 weeks postsurgery), and 1 year postsurgery (after orthodontic treatment) with the NewTom 3G (AFP Imaging, Elmsford, NY, USA). The imaging protocol involved a 36 s head CBCT scan with a 12 in field of view. All CT scans were acquired with the patient biting on a thin wax bite to maintain centric occlusion . In 5 cases, the CBCT imaging field of view did not include all soft tissue structures, resulting in data for 21 patients for the lower lip and 20 patients for the soft tissue chin (mandibular advancement alone n = 11; and mandibular advancement and genioplasty n = 9). The 3D models were constructed from CBCT images with a voxel dimension of 0.5 mm × 0.5 mm × 0.5 mm. Image segmentation of the anatomic structures of interest and the 3D graphic rendering were done using ITK-SNAP (open-source software, www.itksnap.org ) .
The presurgery and postsurgery images were registered using the cranial base as a reference, since this structure is not altered by surgery . A fully automated voxel-wise rigid registration method was performed with IMAGINE (open-source software, http://www.ia.unc.edu/dev/download/imagine/index.htm ). The software compares two images by using the intensity gray scale for each voxel of the presurgical cranial base. Registration of the images was based on the cranial base surface. Soft tissue structures are not stable enough for accurate registration. Virtual models of the soft and hard tissue were relocated with the cranial base ( Fig. 1 ).
After the registration step, all reoriented virtual models, originally saved in .gipl format, were converted to an open inventor format (.iv) by Vol2Surf (publicly available software). This allowed quantitative evaluation of the greatest surface displacement by the CMF application software (developed at the M.E. Müller Institute for Surgical Technology and Biomechanics, University of Bern, Switzerland, under the funding of the Co-Me network, http://co-me.ch ) . The CMF tool calculates thousands of color-coded point-to-point comparisons (surface distances in mm) between the 3D models, so that the difference between two surfaces at any location can be quantified . For quantitative assessment of the changes between the 3D surface models, the isoline tool was used. It allows the user to define a surface-distance value that is expressed as a contour line (isoline) that corresponds to regions having a surface distance equal to or greater than the defined value. The isoline tool was used to quantitatively measure the greatest displacements between points in the 3D surface models for the lower incisor edges, hard chin, soft chin and lower lip ( Figs. 2 and 3 ). Positive values indicated anterior-inferior displacement and negative values posterior-superior displacement.
For the right lower incisor, the maximum surface distance was measured at the incisor’s border, so that the presence of brackets at splint removal would not interfere with the measurements. The hard tissue chin region included the surface from the chin prominence to the distal surface of the lower canines ( Fig. 2 A). The soft tissue chin region was defined as the area under the lower lip between the lip commissures. The lower lip region was defined as the lip vermilion ( Fig. 2 B).
The largest displacements at each anatomic region of interest were computed for presurgery to splint removal (4–6-week surgical outcome), presurgery to 1 year postsurgery (1 year surgical outcome), and splint removal to 1 year postsurgery (postsurgical adaptation).
The greatest displacement for each region of 10 randomly selected superimpositions was measured twice, at a 2-week interval. Agreement between the displacements of the replicates was assessed by using intraclass correlations (ICC). Paired t -tests were used to assess if the average change from splint removal to 1 year postsurgery as well as the average difference in hard and soft tissue displacement for each time interval was zero. Pearson correlation coefficients were used to assess the association between the soft and hard chin as well as lower incisors and lower lip changes. Level of significance was set at 0.05. The percent of patients for whom the difference in the hard and soft tissue displacement was greater than 2 mm was calculated and displayed graphically.
Agreement between the replicated measurements was excellent ( P < 0.001) for all anatomic regions: hard chin (ICC = 0.98); lower incisor (ICC = 0.94); soft chin (ICC = 0.98); lower lip (ICC = 0.96).
Soft tissue facial results varied regardless of whether they had genioplasty. Some swelling was still present at splint removal, even in cases with mandibular advancement only and no genioplasty. Soft tissue facial results in the 1 year follow-up improved for some patients ( Fig. 4 ), partial relapse was observed in some ( Fig. 5 ) and most remained stable ( Fig. 6 ).
Color maps of the mandibular changes allowed clear visual analysis of the anterior-inferior displacement of the hard chin at splint removal as an outcome of surgery. The color maps also revealed a tendency for slight superior-posterior adaptation of the hard chin in the post-splint removal period. The qualitative evaluation of the soft tissue chin showed that this region had the same behavior as the hard tissue chin at all time points, but changes in soft tissue were in general slightly more marked than skeletal changes.
Color map observation indicated that dental changes were less marked than skeletal changes. The lower incisor edges were also displaced anterior-inferiorly as a result of the mandibular advancement surgery, with slight postsurgical adaptation in the opposite direction. The lower lip anterior-inferior movement at splint removal was greater than the lower incisor movement, and the postsurgical posterior-superior adaptation was also more marked than the lower incisor changes.
The average difference in the change from presurgery to splint removal compared with the change from splint removal to 1 year postsurgery was only statistically significantly different from zero for the inferior lip displacements ( P = 0.01).
The correlation between the soft and hard tissue chin displacements were statistically significant ( P < 0.0001) for presurgery to splint removal ( r = 0.92), splint removal to 1 year postsurgery ( r = 0.77) and presurgery to 1 year postsurgery ( r = 0.86) ( Table 1 ). The average displacement of the soft tissue chin was greater than that of the hard tissue chin for all three time intervals, but the average difference between the hard and soft tissue displacements from splint removal to 1 year after surgery was not statistically significant ( P = 0.98, Table 2 ).
|Hard/soft tissue chin
|Lower incisor/lower lip
|Variability explained **
|Presurgery to splint removal
|Splint removal to 1 year postsurgery
|Presurgery to 1 year postsurgery
|Presurgery to splint removal
|Splint removal to 1 year postsurgery
|Presurgery to 1 year postsurgery