progress in orthodontics 1 2 ( 2 0 1 1 ) 59–65

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/pio

Clinical contribution

Three Dimensional approach for realistic simulation

of facial soft tissue response: a pilot study

Mohammed M. El-Molla a , Amr R. El-Beialy b , Ahmed H. Kandil c ,

Ahmed M. El-Bialy c , Yehya A. Mostafa d,∗
a BSc, MSc. Teaching Assisstant, Systems and Biomedical Engineering Department, Faculty of Engineering, Cairo University, Egypt
b BDS, MSc, MOrth(RCSEd). Associate lecturer, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental
Medicine, Cairo University, Egypt
c BSc, MSc, PhD. Associate Professor, Systems and Biomedical Engineering Department, Faculty of Engineering, Cairo University, Egypt
d BDS, FDSRCS (Ed), MSc, PhD. Professor, Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine,

Cairo University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Facial attractiveness is ranked as a principal priority among patients seeking orthodon-
Received 12 January 2010 tic treatment or combined surgical orthodontic therapy. A successful treatment planning
Accepted 29 July 2010 process necessitates an accurate prediction of the postoperative facial profile. In this
manuscript, the simulation procedure on a real clinical case using virtual volumetric 3D
Keywords: mesh through different scenarios of orthognathic procedures was done. Results depict sev-
Class III eral facial soft tissue outcomes, with the likelihood of sharing with the patient the most
Esthetics esthetically pleasing end result prior to carrying out the surgical procedure.
Orthognathic Surgery © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
Soft tissue Simulation
Virtual Three Dimensional volume

the treatment is invaluable for both the orthodontist and the

1. Introduction
Facial attractiveness is ranked as a principal priority among
patients seeking orthodontic treatment or combined surgical
orthodontic therapy. A successful treatment planning process
necessitates an accurate prediction of the postoperative facial
profile. The composite nature of this prediction, in addition
to the complexity of some cases can result in poor quality
forecasting of the final outcome. Thus, the benefit of hav-
ing a virtual facial three dimensional (3D) outcome preceding
patient. This article introduces a 3D method for virtual sim-
ulation of the soft tissues. The aim is to support the theory
that the planning of surgical orthodontic treatment should be
based upon the final calculation of the soft tissue appearance
after treatment, and is not the matter of attaining a molar and
canine class I relation solely.
The calculation of the soft tissue response to the orthog-
nathic surgical maneuver has been studied by various
investigators. A diversity of tools was used as cephalometric
evaluation,1–9 prediction softwares,10 and videoimaging.11–14

∗
Corresponding author. Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University,
Cairo, Egypt.
E-mail address: mangoury@usa.net (Y.A. Mostafa).
1723-7785/$ – see front matter © 2011 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
doi:10.1016/j.pio.2011.01.001
60 progress in orthodontics 1 2 ( 2 0 1 1 ) 59–65

However, a consensus among the authors that prediction is a

complex procedure, owing to its multifactorial phenomenon.
The concept behind prediction is to determine the appro-
priate procedure, which will result in the most esthetically
pleasing postoperative profile. Since video imaging is in fact
a lateral facial representation, these studies are still based on
two-dimensional records.1–14
Major advances are achieved in the production of a
virtual life-sized 3D replica of the patient head.15 This cur-
rent 3D technology played a role to improve the prediction
procedure.16–18 Studies concerned with the manipulation of
the craniofacial structures using this 3D technology opened
the door for new promises. Primarily, attempts to analyze the
3D data with the generation of normative 3D standard values
for the maxillofacial skeletal and facial morphology was intro-
duced by Terajima et al.19 Followed by 3D virtual simulation
of an orthognathic surgical procedure as reported by Uechi
et al.20 Finally, assessment of the skeletal surgical outcome
was described.19–22 Transmission of the dental and skeletal
manipulations to the overlying soft tissue is currently indis-
pensable. This is in agreement with Terajima et al19 who stated
“in the future, a ratio of soft tissue to bone movement in three
dimensions could be measured, allowing prediction of the 3D
soft-tissue changes that result from surgical changes of the
underlying bone structure.”
In this pilot study, we are introducing a step towards
realistic life-sized simulation of the soft tissue deforma-
tion in response to repositioning of the underlying skeletal
units.

2. Materials and methods

The data used in the current study was collected from a skele-
tal class III patient with a combined maxillary deficiency and
mandibular prognathism scheduled for orthognathic surgery.

2.1. 3D Data and Model Generation

The 3D model that represents the geometry of the skin of

the patient face was created using (computed tomography)
CT data sets. Two sets of records were taken. The first data
set was taken after the end of the presurgical orthodontics
and before the patient is scheduled for orthognathic surgery
(Fig. 1a). While the second set was gathered six months
after the surgery. These data sets comprised a high speed
dental CT system1 scanning of the skull and the mandible.
Effective milli-ampere was used based upon the preliminary
scanogram, about 80mAs. The spiral scanning parameters
were high resolution mode, 120Kv, 0.75 mm scanning slice
thickness and 0.5 mm table increment. The CT scanner had
a field of view of 240 mm.
The CT scans were acquired with the patient in centric
occlusion, the subject’s head was fixed, and the slice plane was
set parallel to the Frankfort horizontal. The CT slices started
at the submandibular region and covered the whole head, for
a total of 241 slices. The CT data was saved in a DICOM format
1
Spiral computed tomography- Multislice-16, Somatom,
Siemens, Germany.
Fig. 1 – a - 3D reconstruction of the presurgical data set.
b - Threshold adjustment for simultaneous soft and hard
tissue visualization.
(Digital Imaging and Communications in Medicine), and were
transferred directly to a personal computer
This study was done on the presurgical data set, while the
post surgical data set was used to validate the algorithm. The
3D reconstruction from the presurgical CT data was made
using Mimics software.23 Automatic segmentation of the bone
and soft tissues was performed on the basis of difference of
the gray values in accordance with their anatomical structure
(Fig. 1b). Further modification of the segmented regions was
carried out using graphical tools to separate the mandible, to
delete the soft tissue of no interest, and to eliminate undesired
details that shall not be released to the 3D objects.
 progress in orthodontics 1 2 ( 2 0 1 1 ) 59–65 61

2.2. Material modeling 2.4. Experimental Results

To simplify the algorithm, the soft tissue was assumed to be We used a 3D volumetric mesh with tetrahedron elements, the
a linear elastic material. The general Hook’s law (A)24–29 was same element type, linear elastic material and bonded MPC
used as a constitutive model. for contact type. We applied the simulation on almost full 3D
model with coarse mesh to decrease memory consumption
⎡ ⎤
⎡ ⎤ 1−   0 0 0 ⎡ ⎤
11 ⎢  1−  0 0 0 ⎥ E11
⎢ 22 ⎥ ⎢ ⎥ ⎢ E22 ⎥
⎢ ⎥ ⎢   1− 0 0 0 ⎥⎢
⎢ 33 ⎥ E ⎢ (1 − 2) ⎥ ⎢ E33 ⎥⎥
⎢ ⎥ = (1 + )(1 − 2) ⎢ 0 ⎥⎢
⎢ 23 ⎥ ⎢ 0 0
2
0 0 ⎥ ⎢ 2E23 ⎥
⎥
(1)
⎣ ⎦ ⎢ ⎥⎣
⎢ 0 0 0 0
(1 − 2)
0 ⎥ 2E31 ⎦
31
⎣ 2 ⎦
12 (1 − 2) 2E13
0 0 0 0 0
2

Hook’s law is characterized by the compressibility and the
stiffness, which are described by two elastic constants, the
Poisson ratio (B) and the Young modulus E. For a perfectly
incompressible material deformed elastically at small strains,
the Poisson’s ratio would be exactly 0.5. The relative change of
volume V/V due to the stretch of the material can be calcu-
lated using a simplified formula (only for small deformations)
as:
V L
= (1 − 2) (2)
V L
where: V is material volume; V is material volume change;
L is original length, before stretch; L is the change of length:
L = Lold − Lnew .
The largest constituent in the structure of soft tissue is
water, hence it is concluded that the soft tissue is considered
as “almost incompressible”. It is generally agreed that the ade-
quate range for modeling of water rich soft tissue is V > 0.4 and
a typical range for Young’s modulus of soft tissue is ranged
between 2 and 200 kPa.25,30 Consequently, we have chosen par-
ticularly ␯ ≈ 0.45 as a preliminary value for this study and for
the Young’s modulus there was no specific criterion to select
it value, so it was set to 15 Kpa.29
2.3. Finite element analysis
The simulations were conducted using an established finite
element package, known as Ansys.31,32 For the surface mesh,
3D triangular elements were used and for the volumetric mesh
tetrahedral elements were used.
The friction was not taken into account in this model. The
interaction between the bone and soft tissue (except for teeth
and lips which have their own sliding phenomena) is always
bonded Multi Point Constrain (MPC).32 In our problem, we
have two sets of boundary conditions. Naturally fixed regions,
and regions of the facial tissue which are not affected by the
changes of their neighborhoods, form the first set. By observ-
ing the nature of human face, we estimated those boundaries
as the forehead, the nose, the ears and the bottom of the neck.
The other set of boundary conditions is defined by the surgical
procedure directly through the contact between the soft tissue
and bone, or indirectly through estimating the effect of bone
repositioning and apply it manually to the soft tissue.
and decrease solution time. The simulation was based upon
linear transformation without rotation of the jaw bases.
The CT examination indicated a skeletal maxillary defi-
ciency and mandibular prognathism, with an intermaxillary
discrepancy of 17 mm (Fig. 1b). Several scenarios were cho-
sen for the osteotomy simulation. Scenario one (I) suggested
a mandibular set back for the entire 17 mm along a direction
parallel to the occlusal plane (yellow arrow in Fig. 2). The out-
put of the first scenario depicts that the chin was withdrawn
backward and the lower lip was elevated to contact the upper
lip (Fig. 3 Scenrio I).
Scenario Two (II) assumed the combination of mandibular
setback and maxillary advancement (yellow arrows in Fig. 2).
This scenario has been applied with different progressive
translations of the maxillary and mandibular jaw bases (Fig. 3
Scenario II a-e). In response to the increasing amounts of max-
illary protraction, the nose and the upper lip progress forward,
while the chin was positioned backward serially follow the
mandibular setback (Fig. 3 Scenario II a-e).
3. Discussion
Orthognathic surgery is sought by patients to improve facial
esthetics. Thus, the patients’ concerns about the final facial
appearance at the start of treatment is anticipated. On the
other hand, the different maneuvers currently available for
treatment of orthognathic cases have different outcomes on
facial esthetics. With some complicated or borderline cases
the orthodontist is challenged to build up the treatment plan
and mechanics upon the end result he foresees in his mind.
Obliged to make a blind decision prior to the start of treatment,
the orthodontist and surgeon bear the risk of missing the most
appropriate plan. Managing such dilemma is a complex issue.
Thus an End Result analysis15 is needed.
In the two dimensional (2D) prediction protocol, tracings
and videoimaging are used, facilitating the orthodontist-
patient communication and encouraging patients to partici-
pate in the decision-making process. Many studies reported
on the spatial positions of hard tissues, though several have
attempted to quantify the relationship between hard and
soft tissues.3,7,33–42 Needless to say, the inaccuracies inher-
ent in the 2D methods is a shortcoming.3 Nevertheless,
the complexity of prediction stems from the fact that the
soft tissue response to the underlying skeletal movement is
62 progress in orthodontics 1 2 ( 2 0 1 1 ) 59–65

Fig. 2 – Surgical maneuver of Scenario One and Two.

multifactorial. some variables are resolved, other parameters
are still disputable and some issues necessitate further inves-
tigation.
The 3D formatting is introduced as a way to manipulate
the life-sized virtual orthodontic patient. Modeling the human
deformable facial soft tissue in response to the orthodontic or
orthognathic operation on a 3D basis is an integral part of the
outcome; in what is called visual realism. Since no single plan
fits all, the treatment plan needs to be individualized. The sim-
ulation procedure permits the evaluation of the postoperative
estimates of the profile using all possible surgical outcomes,3
hence, supports the choice of the best treatment scenario in
terms of soft tissue appeal (Treatment Analysis).15
The aim of this study is to propose a digital 3D method
whereby the response of the soft tissue in relation to the
underlying skeletal movements after orthognathic surgery
can be calculated.
In this preliminary simulation process we generated dif-
ferent surgical scenarios with the anticipated 3D soft tissue
response (Fig. 3). The range of soft tissue response represents
a guide for the most appropriate decision. To place matters
into perspective, it is important to realize that comparison of
our output data to analogous simulation techniques is not our
aim.
Ironically, the surgical operation of the current case was
executed in reality before the utilization of the simulation
procedure. It is to be noted that close matching was found
when we compared the real surgical results with the virtual
Scenario II-a (Fig. 3 Scenario II-a), which validates the possi-
ble use of this digital approach. Although, the live outcome
fits our virtual simulation Scenario II-a with minimal dis-
crepancy of the superimposed profiles, the outcome depicts
a degree of mandibular and chin protrusion which is esthet-
ically compromised (Fig. 4a). Interestingly, these results raise
the importance of such pre-surgical simulation. Had we have
the tools presurgically to simulate various surgical scenar-
ios with their soft tissue outcome, we would have chosen a
more esthetically pleasing outcome (Scenario II-c Fig. 3). The

Fig. 3 – Soft tissue outcome of the different Scenarios.

 progress in orthodontics 1 2 ( 2 0 1 1 ) 59–65 63

Fig. 4 – a - The live surgical outcome. b - The soft tissue prediction of Scenario II-a. c - Superimposed contours of live and
prediction outcome.

outcome of Scenario II-c and the difference in skeletal move-
ment from the presurgical position is presented using the
color mapping tool (Fig. 5).
As a spoken of doctor-patient communication, it is most
important that the case management plan be conveyed to
the patient and parents. This will enhance the patient coop-
eration, temper the expectations and modify the patient
perception of the end result.
Regarding the importance of facial esthetics, the sensible
sequence of accepted wisdom is to establish the most esthet-
ically pleasing facial outcome then convey this profile to the
skeleton and the dentition. The theory we are presenting aims
at shifting the decision of the amount of movement in the
orthognathic surgery to be a totally subjective decision which
depends upon the agreement between the surgeon, orthodon-
tist, and the patient upon upon the soft tissue esthetics.
This inturn will dictate the degree of skeletal movement. The
intention of investigating the realistic simulation of the hard
tissue in response to soft tissue movement is the future
vision.15
One short coming of this one-case based protocol is the
deficiency in the 3D database upon which surgical prediction
software packages was based. The need to incorporate new
specific soft tissue ratios that account for individual patient
variability is indispensible. Since the accuracy and predictabil-
ity of the formula implemented is largely dependent upon
the quality and quantity of data employed,3 the more realistic
simulation is required, the more essential the physical model
should include the properties of a living tissue. The mechani-
cal properties of the skin change with age, health, body weight,
and even vary between individuals. Realizing these shortcom-
ings, while acknowledging the clinical usefulness of treatment
simulations, there is clearly a room for further improvement
and refinement of the currently available database.

Fig. 5 – The preferred Scenario II-c and difference from presurgical position through color mapping.
64 progress in orthodontics 1 2 ( 2 0 1 1 ) 59–65
Another shortcoming is that the simulation of the surgical
moves was subjective. Being a pilot study done to introduce
a theory, the surgical manoeuvres could differ than in real-
ity. However, the article delivers a message that the final soft
tissue outcome follow the underlying skeletal movements
sequentially, and thus the final soft tissue outcome should
be a purely subjective decision. These aesthetics should be
agreed upon by the surgeon, orthodontist and the patient
before the surgical procedure. We cannot deny that refinement
of the algorithm should be done to fit a diversity of surgi-
cal manoeuvres based upon the surgical library fed into the
algorithm.
4. Conclusion
Forecasting soft tissue changes in response to skeletal reposi-
tioning is a valuable treatment planning and communication
tool. The simulation procedure on a real clinical case using
virtual volumetric 3D mesh through different scenarios for
orthognathic procedures was undertaken. It is assumed that
there could be significant benefits in sharing visual and quan-
titative 3D information from this simulation system among
orthodontists, surgeons and patients.
A future study designed to compare 3D based predictions
with larger sample size considering a multitude of parame-
ters and comparing the results with the actual postoperative
patient profiles should be done.
Conflict of interest
The authors have reported no conflicts of interest.
Riassunto
L’attrattività facciale è considerata una priorità principale da parte
di pazienti che richiedono il trattamento ortodontico o un trattamento
combinato ortodontico-chirurgico. Per impostare un piano di tratta-
mento di successo è necessario effettuare una accurata previsione
del profilo facciale post-trattamento. In questo lavoro è stata ese-
guita una procedura di simulazione su un caso clinico reale attraverso
una griglia 3D virtuale volumetrica utilizzando diverse procedure di
chirurgia ortognatica. I risultati mostrano i diversi risultati a livello
dei tessuti molli facciali, con la possibilità di poter condividere con il
paziente il risultato più gradevole da un punto di vista estetico prima
di eseguire la procedura chirurgica.
Résumé
L’attractivité du visage est considérée comme une priorité importante
par les patients qui ont recours à un traitement d’orthodontie ou
bien à un traitement combiné orthodonto-chirurgical. Une planifica-
tion du traitement de succès exige une prédiction précise du profil
facial post-op. Dans cette étude, on a réalisé une procédure de sim-
ulation sur un véritable cas clinique utilisant un mesh volumétrique
3D au travers de différents scénarios de procédure orthognatique.
Il se dégage un éventail de résultats des tissus mous faciaux, ce
qui permet de partager avec le patient le résultat esthétique final
qu’il aime le plus, avant de procéder à la réalisation du geste
chirurgical.
Resumen
Los pacientes que se someten a un tratamiento ortodóncico o
bien combinado quirúrgico-ortodóncico consideran lo atractivo de la
cara como una prioridad relevante. Una planificación exitosa del
tratamiento requiere una precisa predicción del perfil facial post-
operación. En este estudio, se aplicó un procedimiento de simulacro
en un caso clínico verdadero, por medio de un mesh volumétrico
3D, mediante diferentes escenarios de procedimiento ortognático. Se
desprende de lo anterior una serie de resultados de los tejidos blan-
dos faciales, lo cual permite compartir con el paciente el resultado
estético final que le gusta más antes de pasar a llevar a cabo el gesto
quirúrgico.
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