Hard and Soft Tissue Changes After Orthognathic Surgery

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE
CLINICAL AND RADIOGRAPHIC EVALUATION OF HARD AND SOFT TISSUE CHANGES AFTER ORTHOGNATHIC SURGERY
By Dr. MOHAMMED HANEEF

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the requirements for the degree of
MASTER OF DENTAL SURGERY IN ORAL AND MAXILLOFACIAL SURGERY
Under the guidance of Dr. NEELAKAMAL H HALLUR M.D.S.

Professor & HOD
DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY
AL-BADAR RURAL DENTAL COLLEGE AND HOSPITAL GULBARGA - 585 103, KARNATAKA, INDIA. [2011-2014]
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
II
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 Professor & HOD Department of Oral and Maxillofacial Surgery, Al-Badar Rural Dental College &Hospital Gulbarga- 585103.
PLACE: GULBARGA
III
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
Seal & Signature of the Principal
Dr. Neelakamal Hallur

M.D.S
Dr. Girish Katti

M.D.S
Professor and Head Department of Oral Maxillofacial Surgery, Al-Badar Rural Dental College and Hospital GULBARGA
Principal Al-Badar Rural Dental College and Hospital GULBARGA
DATE: PLACE: GULBARGA
DATE: PLACE: GULBARGA
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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
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.
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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, AlBadar 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
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LIST OF ABBREVIATIONS
COGS VAS OPD PAS BSSO OMFS LP SP SD OPG Pt. T A-P PC AMO MM
Cephalometrics for Orthognathic Surgery Visual Analogue Scale Out Patient Department Profile Assessment Score Bilateral Split Sagittal Osteotomy Oral and Maxillofacial Surgeons Laypersons Surgical patient Standard deviation Orthopantogram Patient Throat Point Anteroposterior Personal Computer Anterior Maxillary Osteotomy Millimeter
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ABSTRACT
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 individuals 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 Legans 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.
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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.
TABLE OF CONTENTS
SL. NO. 1 2 3 4 5 6 7 8 9 INTRODUCTION AIMS AND OBJECTIVES REVIEW OF LITERATURE MATERIAL AND METHODS RESULTS DISCUSSION SUMMARY & CONCLUSION BIBLIOGRAPHY ANNEXURES CONTENTS PAGE NO. 01 04 05 34 53 65 72 74 81
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LIST OF TABLES
TABLE NO. 1a 1b 2 3 4 5a 5b 5c 6a 6b 6c 7a 7b
TITLE Hard tissue Cephalometric Land Marks used in this study Soft tissue CephalometricLand Marks used in this study Limited Burstones and Legans Analysis for Hard & Soft tissue changes Comparison of Mean PAS scores Patient details T1-T0 of Hard tissue parameters Students paired t test values Comparison of achieved hard tissue change with Burstonenorms using t test T1-T0 Soft tissue parameters parameters Students paired t test Comparison of achieved Soft tissue change with Legan and Burstone norm using t test PAS score of all groups and Inter and Intra group comparison Intra-group comparison between PAS difference of OMFS, Laypersons and Surgical patient
PAGE NO. 38 39 40 42 53 54 55 55 56 57 57 58 59
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LIST OF FIGURES
FIGURE NO. 1. 2. 3. 4. 5. 6.
TITLE 100mm Visual Analogue Scale Case 1 Silhouettes Case 8 Silhouettes Case 2 Silhouettes Case 7 Silhouettes Case 6 Silhouettes
PAGE NO. 41 44 46 48 50 52
LIST OF GRAPHS
GRAPH NO. 1.
TITLE Intra-group comparison of mean pre- and postoperative PAS
PAGE NO. 59
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LIST OF PHOTOGRAPHS
SL. NO. 1. 2. 3. 4. 5. Case No. 1 Case No. 8 Case No. 2 Case No. 7 Case No. 6
PHOTOGRAPHS
PAGE NO. 43 45 47 49 51
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Introduction
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
For the majority (4189%) 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 orthognathicsurgical 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 individuals 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
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

AIMS AND OBJECTIVES
The objectives of this study are to: 1. To evaluate preoperative and postoperative hard and soft tissue changes after Orthognathic surgery in patients having a convex profile. 2. To evaluate the perceived level of improvement in facial attractiveness by the Surgical patient, Laypersons and Oral and Maxillofacial Surgeons
Review of Literature
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
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 patients 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 students t test. The study concluded that patients with severe Class II dentofacial deformities had a higher motivation.
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 (pretreatment) 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.
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
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
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
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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 11
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 12
mandibular advancement and 30 patients with mandibular setback surgery were included in this study. The patients were divided into three groups according to the mandibulo-nasal plane angle to analyse the influence of hyper- and hypodivergent facial pattern on the surgical outcome. On conclusion the authors conferred that the magnitude of the surgical movement correlated with skeletal relapse without any linear correlation. Hyperdivergent class II facial pattern had a higher relapse rate of about 30% and with hypodivergent facial patterns had less relapse in both advancement and setback surgery. The study concluded that skeletal relapse is affected by the magnitude of surgical movement and different facial patterns according to the mandibulo-nasal plane angle; however, the influence of both factors were different between mandibular advancement and setback surgery.
Knight H & Keith O. (2005)14 did an assessment to compare Orthognathic treatment outcome against a standardized facial spectrum with a sample size of 30 male patients and 30 female patients. They also investigated the relationship between ANB angle and ALFH percentages on facial attractiveness. A panel of six Clinicians and Non-Clinicians ranked standardized photographs from 1-30 on basis of attractiveness. The study found that Anterio-posterior (AP) discrepancy and ALFH percentage showed minimal correlation with facial attractiveness. However face with >5 ANB angle were considered less attractive and ALFH percentage being less was considered more attractive in female patients and while in opposite trend are seen in male patients.
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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
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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 authors 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 15
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.
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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 patients 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 patients 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
17
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 individuals 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
18
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 individuals 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
19
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
20
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
21
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. Students 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 silhouettes 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.
22
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 Burstones and Legans 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
23
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
24
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
25
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
26
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.
27
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) (T1T2). 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
28
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 patients photo was digitally altered to create 7 photos and 7 Silhouettes with lip positions at uniform distances relative to Ricketts E-line
29
standard. 15 evaluators consisting of orthodontic faculty and residents were asked to select the most aesthetically pleasing profile from each patients 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 patients 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 patients perceptions of facial profile attractiveness.
30
Doreen Ng, De Silva RK, Smit R, De Silva H, Farella M. (2012)55 conducted this study to determine the perceived level of improvement in facial attractiveness as assessed by people with different backgrounds in skeletal Class II patients treated by mandibular advancement surgery by BSSO. Frontal and lateral Pre- and Post- operative Photographs of 10 Caucasian patients were selected. Changes in profile attractiveness were assessed by 10 Orthodontists, 10 Art students and 10 Laypersons. The study was carried out in 3 surveys, in first two surveys all three examined the photographs and ranked the attractiveness on VAS, the third survey was given to Orthodontists alone with pre- and postoperative status disclosed. Overall, attractiveness scores after BSSO improved by 11.5% on lateral photographs and 7.5% on frontal photographs. Scores for attractiveness differed significantly between the groups with Orthodontists being more generous with improvement ratings. The ratings almost doubled when the pre- and postoperative status was disclosed to evaluators indicating a bias towards a more favourable outcome.
Bans A, Nedim O, Gulnaz M. (2012)56 authors published this study in which they determined the vertical and Antero-posterior alterations in soft, dental and skeletal tissues associated with facial angle in 21 high angle patients who underwent Lefort I maxillary impaction in conjunction with BSSO advancement. Pre- and postsurgical 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
31
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 Burstones and Legans 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
32
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 1721 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.
33
Materials and Methods

MATERIALS AND METHODS
Source of the data OPD, Department of Oral & Maxillofacial Surgery at Al-Badar Rural Dental College, Gulbarga. OPD, Department of Orthodontics and Dentofacial Orthopedics at Al-Badar Rural Dental College, Gulbarga.
Inclusion Criteria Patients who have completed their growth within the age group of 20 -35 years. Patients with Maxillomandibular discrepancy in convex profile patients that require surgical correction. Patients who have completed their pre surgical orthodontic treatment.
Exclusion Criteria Young Patients where growth has not ceased to occur. Patients having craniofacial syndromes and clefting. Patients having any systemic disease where in surgery are contraindicated.
34
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.
35

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.
36

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
37

TABLE NO. 1a: Hard tissue Cephalometric Land Marks used in this study Sl.No 1 2 Landmark Sella (S) Nasion (N) Meaning The centre of the pituitary fossa. The most anterior point of the nasofrontal suture in the midsagittal plane. The deepest point in the midsagittal plane between the 3 Subspinale (A) 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.
Supramentale (B)
The deepest point in the midsagittal plane between infradentale and Pg, usually anterior to andSlightly below the apices of the mandibular incisors.
Anterior nasal spine (ANS) Menton (Me)
The most anterior point of the nasal foor; the tip of premaxillain the mid sagittal plane. The lowest point on the contour of the mandibular symphysis. The midpoint between Pg and Me, located by bisecting the facial line N-Pg and the mandibular plane. The most posterior point on the contour of the palate. A plane constructed from Me to the angle of the mandible (Go). Located by bisecting the posterior ramal plane and the mandibular plane angle.
Gnathion (Gn) Posterior nasal spine Mandibular plane (MP) Gonion (Go)
10
11
38

TABLE NO. 1b: Soft tissue CephalometricLand Marks used in this study Sl.No 1 Landmark Glabella (G) Columella Point (Cm) Subnasale (Sn) Meaning The most prominent point in the midsagittal plane of the forehead. The most anterior point on the columella of the nose. The point at which the nasal septum merges with the upper cutaneous lip in the midsagittal plane.
Labrale superius A point indicating the mucocutaneous border of the (La) Stomion superius (Stms) Stomion inferius (Stmi) Labial inferius (Li) Mentolabial Sulcus (Si) Soft tissue Pogonion (Pg) Soft tissue Gnathion (Gn) Soft tissue menton (Me) upper lip. The lowermost point on the vermillion of the upper lip. The uppermost point on the vermillion border of the lower lip. A point indicating the mucocutaneous border of the lower lip. The point of the greatest concavity in the midline between the lower lip (Li) and chin (Pg). The most anterior point on soft tissue chin. The constructed midpoint between soft tissue pogonion and soft tissue menton. Lowest point on the contour of the soft tissue chin; found by dropping a perpendicular form horizontal plane through menton. Located by bisecting the posterior ramal plane and the mandibular plane angle.
10
11
Gonion (Go)
39

TABLE NO. 2: Limited Burstones and Legans Analysis for Hard & Soft tissue changes T1 T0 rd Parameter ( 3 month T1-T0 (preoperative) postoperative) Hard tissue N-A-Pg NA NB 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.
40
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
41
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 T1T0 of all the Surgical patients.21,27
TABLE NO.3: Comparison of Mean PAS scores Surgical patient Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Laypersons (Mean score) Oral and Maxillofacial Surgeons (Mean score)
42
43

T1 Fig. 2: Case 1 T0
VISUALANALOGUESCALE 44
45

Fig. 3: Case 8 T1 T0
47

Fig. 4: Case 2 T1 C T0
49

T0 Fig. 5: Case 7 T1
51

Fig. 6: Case 6 T0 T1
Results
RESULTS
In our study all the patients were within the age group of 20 35 years with a mean age of 24.9 years. [Table 4] And had convex profile with mean G-Sn-Pg angle of 22.4 degrees. [Table 4] All the patients that underwent surgery were subjected to standard surgical protocol. TABLE NO. 4: Patient details SL.NO Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 AGE /SEX 25/F 20/F 35/F 25/F 22/F 22/F ANGLE OF FACIAL CONVEXITY G-Sn-Pg 220 260 240 230 170 170 220 250 230 250 PROCEDURE Advancement Genioplasty Advancement Genioplasty Advancement Genioplasty Advancement Genioplasty Advancement Genioplasty Anterior Setback Maxillary Osteotomy and Advancement Genioplasty Anterior Setback Maxillary Osteotomy and Augmentation Genioplasty Anterior Setback Maxillary Osteotomy and Advancement Genioplasty Lefort I Superior Impaction and Advancement Genioplasty Lefort I Superior Impaction and BSSO Advancement 53
Patient 7
20/F
Patient 8
31/F
Patient 9 Patient 10
24/F 25/F
Results
TABLE NO. 5a: T1-T0 of Hard tissue parameters

Sl. No. 1 2 3 4 5 6 7 8 9 Parameter Hard tissue N-A-Pg NA NB N Pg N ANS ANS Gn PNS-ANS Go-Pg B-Pg
T0 18 1 T1 8 T1T0 10 T0 23 2 T1 19 TT0 4 T0 14 3 T1 4 T1T0 10 T0 12 4 T1 8 T1T0 4 T0 12 5 T1 2 T1T0 10 T0 1 6 T1 7 T1T0 6 T0 8 7 T1 2 T1T0 6 T0 12 8 T1 2 T1T0 10 T0 17 9 T1 15 T1T0 2 T0 17 10 T1 6 T1T0 11
10
22
18
26
24
20
20
10
16
18
17
15
15
20
20
18
17
18
16
18
13
22
10
12
28
20
26
16
10
11
19
20
15
11
08
23
12
11
20
16
20
12
20
15
47
47
48
48
43
43
50
50
52
52
44
43
52
52
59
55
54
48
52
58
60
67
54
58
73
75
60
63
44
49
58
64
60
63
72
75
69
72
46
46
46
46
44
44
62
62
47
47
41
38
44
41
47
47
58
58
60
60
64
70
57
64
52
60
86
94
65
71
60
64
52
62
10
65
71
78
86
66
73
12
10
10
11
13
11
14
13
15
54
Results
TABLE NO. 5b: Students paired t test values
Sl. No 1 2 3 4 5 6 7 8 9
Parameter Hard Tissue N-A-Pg NA NB N Pg N ANS ANS Gn PNS-ANS Go-Pg B-Pg
Genioplasty N=5 tMean value change 7.6 5.17* 0 0.12 1.52 0 4.74* 0 15.65* 15.65* 2.132 0 1.8 8.6 0 4.4 0 7 5.8
AMO + Genioplasty N=3 Mean t-value Change 0.69 7.33 1.00 1.00 2.38 1.51 5.29* 2.00 3.78* 4.36* 2.920 3.33 0.33 6 1.33 4.66 2 6.66 6.33
Lefort I + BSSO/ Genioplasty N=2 tMean value Change 1.44 10.5 1.00 2.33 4.33 5.00 0 0 15.00* 1.00 6.314 3 3.5 6.5 5 3 0 7 3.5
t value for P=0.05
CONCLUSION: * Shows significant difference
TABLE NO. 5C: Comparison of achieved hard tissue change with Burstonenorms using t test Sl. No. 1 2 3 4 Mean SD SEM N Attained Values 32.1 25.99 8.66 9 Established Norm as per Burstone 32.02 30.33 10.72 8
Statistically not-significant t-value =0.005, p-value= 0.99
55
Results
TABLE NO. 6a: T1-T0 Soft tissue parameters parameters

Sl. No. Parameter Soft tissue 1 G-Sn-Pg
1 T0
22
2 T 1T0
8
3 TT0
7
4 T1T0
10
5 T1T0
11
6 T 1T0
7
7 T1T0
7
8 T 1T0
4
9 T1T0
7
10 T1T0
5
T1
14
T0
26
T1
19
T0
24
T1
14
T0
23
T1
12
T0
17
T1
10
T0
17
T1
10
T0
22
T1
18
T0
25
T1
18
T0
23
T1
18
T0
25
T1
20
T1T0
5
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
Li- Pg Line
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
Intralabial gap
12
20
12
10
16
14
56
Results
TABLE NO. 6b: Students paired t test AMO + Genioplasty N=3 Mean t-value change 6 6.43* 4.33* 7.00* 20 2.33 Lefort I + BSSO/ Genioplasty N=2 Mean t-value change 0 5 1.94 0.14 11.5 3.5
Sl. No
Parameter Soft Tissue G-Sn-Pg Cm-Sn-Ls Li-Pg Line Vertical lip chin ratio Intralabial gap
Genioplasty N=5 tMean value Change 8.6 7.68* 0 5.48* 0 3
0.91
0.05
0.91
1.41
0.67
0.145
1.47
2.2
2.33
4.33
3.67
11
t value for P=0.05
2.132
2.920
6.314
CONCLUSION: * Shows significant difference
TABLE NO. 6c: Comparison of achieved Soft tissue change with Legan and Burstone norm using t test Sl. No. 1 2 3 4 Mean SD SEM N Attained Values 32.1 25.99 8.66 9 Established Norm as per Legan & Burstone 32.02 30.33 10.72 8
Statistically significant, t-value = 0.005, p=0.9280 57
Results
TABLE NO. 7a: PAS score of all groups and Inter and Intra group comparison
Surgical patient SP T0 Pt. 1 Pt. 2 Pt. 3 Pt. 4 Pt. 5 Pt. 6 Pt. 7 Pt. 8 Pt. 9 Pt. 10 FVALUE MEAN 5 5.5 5 4 4 6 3 6 5 4 3.83 SP T1 8 8.5 8.8 9 9.5 9 7 8.5 8.5 8.5 SP T1T0 3 3 3.8 5 5.5 3 4 3 3.5 4.5 LP1 T0 5 5 5.5 2 5 7 6 6 3 4 T1 8.5 9 9 8 7.5 8.5 7 8 8 7 LP2 T0 5 4 5 4 6 5 3 4 3 2 T1 7 6 8 7 8 9 6 8 7 6 LP3 T0 5 3 6 5 4.5 4 2 3 4 3 T1 8 8 8 5 7 7 5 7 7 7 Laypersons LP4 T0 4 4 4 3 3 5 3 4 4 5 T1 7 7 8 9 8 7 6 7 7 6 LP5 T0 5 5 3 4 5.5 5 3 4 3 5 T1 7 8 6 6 7 7 5 7 8.5 7 Mean LP T0 4.8 4.2 4.7 3.6 4.8 5.2 3.4 4.2 3.4 3.8 T1 7.5 7.6 7.8 7.0 7.5 7.7 5.8 7.4 7.5 6.6 LP T1T0 2.7 3.4 3.1 3.4 2.7 2.5 2.4 3.2 4.1 2.8 OMFS 1 T0 3.5 2 3 1 3 4 1 2.5 3 1.5 T1 8 7 8 8 6 9.5 7 8 7 8 OMFS 2 T0 3 3 4 3 4 5 2 4 4 2 T1 8 6 7 7.5 7 8 6 8 7 7 Oral and Maxillofacial Surgeon OMFS 3 T0 3 4 5 3 2 6 2 4 4 4 T1 7.5 7 6 7 6 7 6 7 8 7 OMFS 4 T0 3 2 5 1 1.5 4 1 2 3 2 T1 8 7 7 6 8 7 4 6 7 6 OMFS 5 T0 5 4 6 4 4 5 1 4 4 3 T1 7 6 8 8 7.5 7 6 7 8 6 Mean OMFS T0 3.5 3 4.6 2.4 2.9 4.8 1.4 3.3 3.6 2.5 T1 7.7 6.6 7.2 7.3 6.9 7.7 5.8 7.2 7.4 6.8 OMFS T1-T0 4.2 3.6 2.6 4.9 4.0 2.9 4.4 3.9 3.8 4.3
T0(F- VALUE = 1.11),
T1 (F- VALUE = 2.49) 3.03
T0(F- VALUE = 3.64*),
T1 (F- VALUE = 1.93) 3.86
T value (<P=0.05) shows significant difference between T1 and T0
T value (<P=0.05) shows significant difference between T1 and T0
58
Results
GRAPH 1: Intra-group comparison of mean pre- and postoperative PAS
TABLE NO. 7b: Intra-group comparison between PAS difference of OMFS, Laypersons and Surgical patient Comparison of PAS difference between OMFS and Laypersons OMFS and Surgical patient Surgical patient and Laypersons Mean 3.86 3.86 3.03 3.83
t-value 3.05* 0.08 2.41*
3..83 3.03
Conclusion: * Shows significant difference (t-value is 1.734 for p=0.05)
59
Results
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 students 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. 60
Results
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.
61
Results
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 students t value test was found to be insignificant with P=0.99, indicating normalization of parameter values postsurgery.[Table 5c]
Comparison of soft tissue parameter was done using Students 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.
62
Results
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.
63
Results
The parameters with respect to soft tissue changes were compared to established norms given by Legan et al20 using students t value test was found to be insignificant with P=0.9280, indicating normalization of parameter values postsurgery. [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 Students 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]
64
Discussion
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
65
Discussion
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
66
Discussion
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 Students 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
67
Discussion
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
68
Discussion
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 69
Discussion
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 70
Discussion
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.
71
Summary & Conclusion

SUMMARY & CONCLUSION
Assessment of an individuals 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 Students 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.
72
Summary & Conclusion

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.
73
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27] Tsang ST, McFadden LR, Wiltshire WA, Pershad N, Baker AB. Profile changes in orthodontic patients treated with mandibular advancement surgery. Am J Orthod Dentofacial Orthop 2009; 135: 66-72 28] Sarver DM, Weissman SM. Long term tissue response to Lefort I maxillary Superior repositioning. Angle Orthod 1991; 61(4): 267-276 29] Ewing M, Bruce RR. Soft tissue response to mandibular advancement surgery and genioplasty. Am J Orthod Dentofac Orthop 1992; 101: 550-555 30] Becelli R,Renzi G, Carbony A, Cerculli G, Perugini M.Evaluation of the esthetic results of a 40-patient group treated surgically for dentoskeletal Class III malocclusion. Int J Adult Orthod Orthognath Surg 2002; 17(3): 171-179 31] Troulis MJ, Kearns GJ, Perrott DH, Kaban LB. Extended genioplasty: long term cephalometric, morphometric and sensory results. In J Oral Maxillofac Surg 2000; 29: 167-175 32] Chang EW, Lam SM, Karen M, Donlevy JL. Sliding genioplasty for correction of chin abnormalities. Arch Facial Plast Surg 2001; 3: 8-15 33] Mobarak KA, Espeland L, Krogstad O, Lyberg T. Mandibular advancement surgery in high-angle and low-angle class II patients: different long term skeletal responses. Am J Orthod Dentofac Orthop 2001; 119: 36881 34] Talebzadeh N, Pogrel MA. Long term hard and soft tissue relapse rate after genioplasty. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91: 153-6. 35] Teitelbaum V, Perin AB, Maertelaer VD, Daelamans P, Glineur R. (2002). Impact of dental and skeletal movements on the facial profile within the framework of orthodontic and surgical treatments. Int J Adult Orthod Orthognath Surg 2002; 17: 82-88.
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Annexures
ANNEXURES
ANNEXURE -1
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY, AL-BADAR RURAL DENTAL COLLEGE & HOSPITAL, GULBARGA.
CASE HISTORY PROFORMA Name: Age/sex: Phone No: DOS: Address: OPD No: Occupation: DOA: DOD:
Chief compliant:
History of present illness:
Past medical history:
Drug history:
81
Annexures
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:
82
Annexures
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:
83
Annexures
Provisional diagnosis:
Radiographs:
Radiographic interpretation: HARD TISSUE ANALYSIS Sl.no Parameter Unit Mean Presurgical (T0) Postsurgical 3rd month (T1)
1 2 3 4
N-A-Pg NA ( II HP ) NB ( II HP ) N Pg ( II HP ) N ANS ( 1 to HP) ANS Gn ( 1 to HP) PNS-ANS ( II-HP ) Go-Pg ( II-MP ) B-Pg ( II-MP )
HORIZONTAL SKELETAL PROFILE Males : 3.9 +/- 0.4, Deg Females: 2.6 +/- 5.1 mm mm mm Males= 0.0 +/ 3.7mm, Females = -2.0 +/- 3.7mm Males=-5.3 +/-6.7mm; Females=-6.9 +/- 4.3 mm Males = -4.3 +/- 8.5mm; Females=-6.5 +/- 5.1 mm Males= 54.7+/- 3.2mm; Females= 50 +/- 2.4mm Males= 54.7+/- 3.2mm; Females= 50 +/- 2.4mm MAXILLA AND MANDIBLE Males =57.7 2.5mm; Females =52.6 3.5mm Males = 83.74.6mm; Females=74.35.8mm Males = 8.9 1.7mm; Female = 7.2 1.9mm
VERTICAL SKELETAL DYSPLASIA 1 2 mm mm
1 2 3
mm mm mm
84
Annexures
SOFT TISSUE ANALYSIS Facial Form To Describe Overall Horizontal Soft Tissue Profile Sl.no 1 Parameter Angle of facial convexity (G-Sn-Pg) Unit Degree Mean 12+/-4 Presurgical (T0) Postsurgical 3rd month (T1)
1 2
LIP POSTION AND FORM 102+/Nasolabial angle Degrees 8 (Cm-Sn-Ls) Mentolabial mm 4+/-2 Sulcus Depth (Li-Pg Line) Vertical Lip Chin Ratio Ratio 1:2 (Sn-Stm1:Stm2Me) Intralabial Gap mm 2+/-2 (Stm1-Stm2)
Treatment plan:
Blood Investigations: RBC Count Hb% Blood group Bleeding time Clotting time Random blood sugar tests Urine routine Albumin Sugar HIV HBsAG ECG Chest X-ray Cells/cumm Gm%
85
Annexures
Treatment done: Approximate blood lossIntraoperative fluidsSutures used-
Name of surgeon:
Anaesthetist:
Assistants:
Doctors orders:
86
Annexures
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:
87

Hard and Soft Tissue Changes After Orthognathic Surgery

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Hard and Soft Tissue Changes After Orthognathic Surgery

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

By Dr. MOHAMMED HANEEF

MASTER OF DENTAL SURGERY IN ORAL AND MAXILLOFACIAL SURGERY

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

DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

Rajiv Gandhi University of Health Sciences, Karnataka.

DECLARATION BY THE CANDIDATE

Dr. MOHAMMED HANEEF

CERTIFICATE BY THE GUIDE

Signature of the Guide

Dr. NEELAKAMAL H HALLUR

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

Professor & HOD, Department of Oral and

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

Seal & Signature of the HOD

Seal & Signature of the Principal

Dr. Neelakamal Hallur

Dr. Girish Katti

Principal Al-Badar Rural Dental College and Hospital GULBARGA

DATE: PLACE: GULBARGA

DATE: PLACE: GULBARGA

DECLARATION BY THE CANDIDATE

Dr. MOHAMMED HANEEF

Rajiv Gandhi University of Health Sciences, Karnataka

Date: Place: Gulbarga Dr. MOHAMMED HANEEF

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

TITLE Intra-group comparison of mean pre- and post- operative PAS

Aims & Objectives

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Cepahlometric Study: Preoperative Lateral Cephalogram (T0) and Postoperative Lateral

Materials and Methods

Anterior nasal spine (ANS) Menton (Me)

Materials and Methods

Materials and Methods

Materials and Methods

Figure 1: 100mm Visual Analogue Scale

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

Materials and Methods

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

TABLE NO. 5b: Students paired t test values

Parameter Hard Tissue N-A-Pg NA NB N Pg N ANS ANS Gn PNS-ANS Go-Pg B-Pg

t value for P=0.05

CONCLUSION: * Shows significant difference

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

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

Vertical lip chin ratio

Genioplasty N=5 tMean value Change 8.6 7.68* 0 5.48* 0 3

t value for P=0.05

CONCLUSION: * Shows significant difference

Statistically significant, t-value = 0.005, p=0.9280 57

T0(F- VALUE = 1.11),