Three-dimensional evaluation of soft tissue changes after mandibular setback surgery in class III malocclusion patients according to extent of mandibular setback, vertical skeletal

Three-dimensional evaluation of soft tissue changes aftermandibular setback surgery in class III malocclusionpatients according to extent of mandibular setback,vertical skeletal pattern, and genioplastyMinji Kim, DDS, MSD, PhD,a Dong-Yul Lee, DDS, MSD, PhD,b

Yong-Kyu Lim, DDS, MSD, PhD,b and Seung-Hak Baek, DDS, MSD, PhD,c Seoul, KoreaKOREA UNIVERSITY AND SEOUL NATIONAL UNIVERSITY

Objective. To investigate the 3-dimensional (3D) changes in the soft tissue after mandibular setback surgery (MSS).Study design. Thirty-three skeletal class III malocclusion (SCIII) patients treated with MSS (bilateral sagittal split ramusosteotomy) were subdivided according to extent of MSS, vertical skeletal pattern (VP), and vertical-reductiongenioplasty. Lateral cephalograms and 3D facial scan images were taken before and 6 months after surgery. Linear andangular variables were measured with Rapidform 2006 (Inus Technology).Results. After MSS, there were significant increases in the upper lip length and decreases in the lower lip length in thelarge setback, hypodivergent, and genioplasty groups. The mentolabial fold deepened less in the genioplasty groupthan in other groups. Although there was no skeletal advancement of the maxilla, the soft tissue convexity in theparanasal area increased more in the hyperdivergent group than in the hypodivergent group after MSS.Conclusion. The extent of MSS, VP, and genioplasty could be used as guidelines for 1- and 2-jaw surgeries in SCIII
borderline cases. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e20-e32)
Improvement in facial esthetics is one of the mostimportant goals of orthodontic treatment and orthog-nathic surgery. Traditionally, cephalometric analysishas been used to evaluate and predict changes in facialprofile after orthodontic treatment and orthognathicsurgery.1-6 However, this conventional 2-dimensional(2D) method can only evaluate the soft tissues of themidsagittal area.2,3 To analyze and evaluate the softtissues in the paranasal, zygomatic, cheek, and otherfacial areas, 3-dimensional (3D) imaging methods suchas 3D computerized tomography (CT)7-9 and 3D facialscan images (3D-FSI)10-15 are needed. Furthermore,several studies16,17 have reported that 3D methods aremore accurate than 2D methods.

The majority of Asian patients seeking orthodontictreatment and orthognathic surgery are class III maloc-clusion patients.18,19 Clinicians sometimes experiencegood improvement in facial esthetics in the midface

aFellow, Department of Dentistry, College of Medicine, Korea Uni-versity.bProfessor, Department of Dentistry, College of Medicine, KoreaUniversity.cAssociate Professor, Department of Orthodontics, School of Den-tistry, Dental Research Institute, Seoul National University.Received for publication Oct 16, 2009; returned for revision Dec 23,2009; accepted for publication Jan 3, 2010.1079-2104/$ - see front matter© 2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2010.01.002
e20

area with the mandibular setback surgery (MSS) only inthe class III malocclusion borderline cases (Fig. 1).19

The purpose of the present study was to investigate, using3D-FSI, changes in the soft tissue after mandibular setbacksurgery. Our hypotheses were that soft tissue changes due tomandibular setback surgery would be seen not only in theupper and lower lips, but also in other areas remote to themidsagittal area, such as the zygomatic, cheek, and paranasalareas, and that these changes would be influenced by theextent of mandibular setback, the vertical skeletal pattern, andgenioplasty.

MATERIALS AND METHODSThirty-three skeletal class III malocclusion patients

(11 male and 22 female; mean age 25.23 � 7.44 years;SNA 80.48 � 3.64°; SNB 82.91 � 4.07°; Wits ap-praisal �11.20 � 4.14 mm; A to N perpendicular�1.10 � 3.17 mm; Pog to N perpendicular 4.08 � 7.49mm; SN-GoGn 35.27 � 6.21°; �3 mm facial asym-metry at the soft tissue pogonion point) who had un-dergone mandibular setback surgery (bilateral sagittalsplit ramus osteotomy, average amount of mandibularsetback 8.16 � 3.74 mm at point B) by a single surgeonwere included in this study.

Patients were subdivided according to the extent ofMSS, the vertical skeletal pattern, and vertical-reduc-tion genioplasty (Table I). Approval for this study wasgranted by the Institutional Review Board of Korea
University Medical Center (IRB no. GR0791).

OOOOEVolume 109, Number 5 Kim et al. e21

Lateral cephalograms, taken immediately before (T1)and 6 months after surgery (T2), with centric occlusion,natural head position,20 and reposed lip, were traced anddigitized using the program V-Ceph 5.0 (Osstem, Seoul,Korea) by a single operator.

To scan the whole face without shadows,21 3D-FSIswere taken from 3 different horizontal angles and from 2different vertical angles. Patients sat with centric occlu-sion, a natural head position,20 reposed lips, a hair band,and slightly closed eyes. Optotop-SE (Breuckmann,Meersburg, Germany; white-light scanner; 30-40 �m ac-curacy according to the manufacturer; scanning time �3 s)was used by a single operator. The 3D-FSIs were recon-structed using Rapidform 2006 and Rapidform XO scan-ning software (Inus Technology, Seoul, Korea).

We chose a period 6 months after surgery as the T2stage because we reasoned that after this period thefacial soft tissue would be stable and any subsequentchanges would be small enough to be ignored.22

Landmarks for superimposition of T1 and T2 im-ages12,23-25 and the reference axes15,26 are defined inFigs. 2 and 3, respectively. The differences between theT1 and T2 images were expressed with 2 color-map-

Fig. 1. An example of a skeletal class III malocclusion patienmidface area after mandibular setback surgery only. Compariand after (right) treatment.

Table I. Demographic data of the subgroups accordinvertical-reduction genioplasty

Variable

Extent of the mandibular setback Small setback group (n � 14; �4.81 � 2.08 mm

Vertical pattern (SN-GoGn) Hypodivergent group (n � 18; S31.28 � 5.46°

Vertical-reduction genioplasty Genioplasty group (n � 12)4.50 � 2.58 mm upward and 0.5

movements at pogonion

ping methods: absolute color and signed color.

The extent and direction of changes in landmarks and thelinear and angular variables between the T1 and T2 stages(Table II and Figs. 4 and 5) were measured by a singleoperator using Rapidform 2006 software (Inus Technology).

Inter- and intraexaminer reliability tests showed that theCronbach coefficient � of all 52 coordinate values of the 66images were 0.9972 and 0.9984, respectively. Because aCronbach coefficient � close to 1 indicates high reliability,the inter- and intraexaminer reliabilities in this study wereexcellent. Therefore, the first set of measurements was usedin this study. Pearson correlation analysis and independent ttests were performed for statistical analysis.

RESULTS

Correlations and ratios of the horizontal andvertical changes between the hard and softtissues in cephalometric analysis

Correlations between hard and soft tissues in Li, B=,and Pog= (the lower lip and chin, respectively) werehigher and the values were less diverse in the antero-posterior direction than in the vertical direction (TableIII). However, correlation between hard and soft tissues

had good results in terms of facial soft tissue changes in thefacial profiles (A) and lateral cephalograms (B) before (left)

he extent of mandibular setback, vertical pattern, and

Subgroup (mean � SD)

Large setback group (n � 19; �7 mm)10.63 � 2.57 mm

n �35°) Hyperdivergent group (n � 15; SN-GoGn �35°)40.06 � 2.62°Nongenioplasty group (n � 21)

19 mm forward —

t whoson of

g to t

7 mm)

N-GoG

8 � 2.

in Ls (the upper lip) was low in the anteroposterior

a line c

OOOOEe22 Kim et al. May 2010

direction, and diverse values were obtained in the ver-tical direction (Table III).

Comparison of changes in soft tissue landmarks,linear variables, and angular variables betweenT1 and T2 according to the amount ofmandibular setback

Although the landmarks in the cheek area and upperlip did not show significant differences between thesmall and large setback groups, there was a greaterdownward movement of landmarks in the stomion andlower lip (landmarks 20, 28, and 34; P � .05) and morebackward movement of the chin (landmark 31, B; P �.001; landmark 35, Pog; P � .01) in the large setbackgroup than in the small setback group (Appendix A).

There were significant increases in the lengths of the

Fig. 2. Reference points (blue) for superimposition of T1 (yel(2), exocanthion (3/4), and endocanthion (5/6).

Fig. 3. Reference axes established on the original point (nasionfloor (Z coordinate, anteroposterior axis), and a parallel line to

upper vermilion (landmarks 17-20, 23-25, and 24-26;

P � .05) and the upper lip (14-20; P � .05) and adecrease in the length of the lower lip (20-35 and34-35; P � .05) in the large setback group (Table IV).However, the other linear and angular variables did notshow significant differences between the 2 groups (Ta-bles IV and V).

Comparison of changes in soft tissue landmarks,linear variables, and angular variables betweenT1 and T2 according to the vertical skeletalpattern

In the hyperdivergent group, lengthening of the up-per lip (landmarks 14-15; P � .05) and shortening ofthe lower lip (20-35 mm; P � .05; 18-31 mm; P � .01)were significantly larger than in the hypodivergent

nd T2 images (green): forehead area (glabella, 1), nasion area

dsagittal line (Y coordinate, vertical axis), a parallel line to theonnecting both exocanthions (X coordinate, transverse axis).

low) a

): a mi

group (Table IV).


There were significant increases in the convexities ofthe angular variables in the midcheek area (38-9-29 and37-52-47; P � .01) and lower cheek area (43-49-47 and45-41-39; P � .05) in the hyperdivergent group com-pared with the hypodivergent group (Table V). Also seeAppendix B.

Comparison of changes in soft tissue landmarks,linear variables, and angular variables betweenT1 and T2 according to genioplasty

Downward movement of the upper lip (landmarks 15and 25; P � .05) and lower lip (32 and 33; P � .001)

Table II. Definitions of the soft tissue landmarks usedSoft tissue landmarks

1 Glabella The most prominent m2 Nasion The point in the midl

3/4 Exocanthion (Rt/Lt) The point at the outer5/6 Endocanthion (Rt/Lt) The point at the inner7/8 Nasal ala (Rt/Lt) The most lateral poin9/10 Alar curvature point (Rt/Lt) The most lateral poin

nasal wing base11/12 Subalare (Rt/Lt) The point at the lowe

the upper lip13 Pronasale The most protruded p14 Subnasale The midpoint of the a

and the surface of15/16 Upper lip point (crista philtri)

(Rt/Lt)The point on each ele

17 Labrale superius The midpoint of the u18/19 Cheilion (Rt/Lt) The point located at e

20 Stomion The point at the midl21 Upper lip prominent The point most promi22 Lower lip prominent The point most promi

23/24 Upper lip boarder (Rt/Lt) The point located latevertically beneath t

25/26 Stomion (Rt/Lt) The point located latebeneath the right an

27/28 Lower lip boarder (Rt/Lt) The point located on29/30 Ac-cheilion midpoint (Rt/Lt) The midpoint between

31 B point The most deepest poi32/33 B-cheilion midpoint (Rt/Lt) The midpoint between

34 Labrale inferius The midpoint of the l35 Pogonion The most anterior mid

36/37 Ac-exocanthion (Rt/Lt) The point where a vemeet

38/39 Mid Ac-endocanthion (Rt/Lt) The midpoint between40/41 Midpoint of upper cheek (Rt/Lt) The point where two

other endocanthion42/43 Mid Ac-Ac-exocanthion (Rt/Lt) The midpoint between44/45 Zygomatic point (Rt/Lt) The most lateral poin

slightly seen46/47 Cheilion-exocanthion (Rt/Lt) The point where a ve48/49 Midpoint of lower cheek (Rt/Lt) The point where two

exocanthion, and th50 Menton The lowest median la

51/52 Lateral point of lower cheek(Rt/Lt)

The midpoint between

and upward movement of menton (50 mm; P � .05)

were significantly greater in the genioplasty group thanin the nongenioplasty group, owing to vertical-reduc-tion genioplasty and eventual relief of soft tissuestretching (Appendix C). However, vertical-reductiongenioplasty induced less posterior movement of men-ton (landmark 50; P � .05; Appendix C) than was seenin the nongenioplasty group.

The genioplasty group showed significant decreasesin the lengths of the lower vermilion (landmarks 22-34;P � .05; Table IV) and lower lip (20-35; P � .05;Table IV) and less deepening of the mentolabial sulcus(18-32-31 and 19-33-31; P � .05; Table V) than the

e studyDefinition

point between the eyebrowsoth the nasal root and the nasofrontal sutureissure of the eye fissureissure of the eye fissureh alar contourcurved base line of each ala, indicating the facial insertion of the

of each alar base,where the alar base disappears into the skin of

the apex nasithe columella base where the lower border of the nasal septum

er lip meetargin of the philtrum on the vermilion line

rmilion lineial commissureabial fissure between gently closed lipsm lateral view on the upper lipm lateral view on the lower lip

om the labrale superius, located on the upper vermilion linet and left subalare pointsom the Stomion, on the labial fissure between gently closed lips,ubalare pointser vermilion line, beneath the right and left Subalare pointsurvature point and cheilionlateral view, on the facial midline, between the lower lip and chin

nt and cheilionrmilion linef the chin

ne from exocanthion and a horizontal line from ala curvature point

urvature point and endocanthionl lines meet, one from exocanthion to alar curvature point, and the

exocanthionurvature point and Ac-exocanthionh zygomatic arch, viewed from an angle where exocanthion is

ne from Exocanthion and a horizontal line from Cheilion meetl lines meet, one from alar curvature point to cheilion-Ac-exocanthion to cheilionon the lower border of the mandible

ocanthion and cheilion-exocanthion

in th

idlineine of bcommcomm

t on eact in the

r limit

oint ofngle at

the uppvated m

pper veach lab

ine of lnent fronent frorally frhe righrally frd left s

the lowAlar c

nt fromB poi

ower vepoint o

rtical li

alar cdiagonato Ac-alar c

t of eac

rtical lidiagonae otherndmark

Ac-ex

nongenioplasty group.


Changes in 3D images between the T1 and T2stages

Changes in 3D images from each subject due tomandibular setback surgery were examined by abso-lute- and signed-color mapping methods (Fig. 6). Thesoft tissue of the cheek area moved mostly backwardafter surgery with an increasing gradient from the upperto the lower cheek area as well as from the midline tothe lateral area (Fig. 6). Although the greatest change inthe chin area was seen after mandibular setback sur-gery, several patients, especially those in the hyperdi-vergent group, showed significant soft tissue changes inthe paranasal area, as illustrated by the top left case inFig. 6.

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3Fig. 5. Changes in linear (A) and angular variables (B and C)after mandibular setback surgery. A red line indicates anincrease in values and a blue line indicates a decrease in

Fig. 4. Soft tissue landmarks: 7/8, nasal ala; 9/10, alar cur-vature point; 11/12, subalare; 13, pronasale; 14, subnasale;15/16, upper lip point (crista philtri); 17, labrale superius;18/19, cheilion; 20, stomion; 21, upper lip prominent; 22,lower lip prominent; 23/24, upper lip border; 25/26, stomion;27/28, lower lip border; 29/30, Ac-cheilion midpoint; 31, Bpoint; 32/33, B-cheilion midpoint; 34, labrale inferius; 35,pogonion; 36/37, Ac-exocanthion; 38/39, mid-Ac-endocan-thion; 40/41, midpoint of the upper cheek; 42/43, mid-Ac-Ac-exocanthion; 46/47, cheilion-exocanthion; 48/49, mid-point of the lower cheek; 51/52, lateral point of the lowercheek.

values.


DISCUSSIONCorrelations and ratios of horizontal and verticalchanges between hard and soft tissues incephalometric analysis

Changes in the soft tissue thicknesses of the upperand lower lips and the chin area are known to beinfluenced by the initial preoperative thickness of thecorresponding area1 and are closely correlated with theamount and direction of hard tissue movement aftermandibular surgery.2

In the present study, the ratios of Pog-Pog= and pointB-B= in the horizontal direction were 88.4% and 88.7%(Table III), which are similar to the values reported byMcCance et al.7 and Chew27 but lower than thosereported by Gjørup and Athanasiou1 and Hu et al.2 Thefinding that the vertical movements of the landmarks inthe hard and soft tissues had low correlations comparedwith those of the horizontal movements (Table III) isconsistent with earlier studies.4,5,9,27

Comparison of changes in soft tissue landmarks,linear variables, and angular variables betweenT1 and T2 according to the amount ofmandibular setback, the vertical skeletal pattern,and genioplasty

The upper lip moved downward and backward andthe upper lip length increased after mandibular setbacksurgery (Tables IV and V; Appendices A-C). Theseresults are similar to other cephalometric studies thatreported backward movement of the upper lip1,2 and adecrease in the upper lip thickness after mandibularsetback surgery.1,4,28

In the present study, upper lip length increased aftersurgery, especially in the large setback group and thehypodivergent group (P � .05 [both]; Table IV). Be-cause the lower incisors in the prognathic mandible

Table III. Correlations and ratios between the anteroptissues

Ls Li

AP V AP

L1 0.37* 0.61*** 0.90***(7.4%) (�47.1%) (81.0%) (�

Point B 0.38* 0.52** 0.88***(7.9%) (�101.2%) (86.6%) (�

Pog 0.42** 0.26 0.86***(8.0%) (�29.6%) (87.7%) (�

From the cephalometric measurements, correlations and ratios of themidsagittal plane were examined.Pearson correlation analysis was done. Ratio means amount of chanvalue, the change with the same direction; negative (�) value, the op**P � .01; ***P � .001.

squeeze the upper lip upward and forward, the upper lip

is shortened and thickened before surgery.1 Therefore,the upper lip can lengthen to a greater extent in indi-viduals with hypodivergence or a large setback. Withincrease in the upper lip length after surgery, the sto-mion moved downward and backward (Table IV; Ap-pendices A-C), which is in accordance with earlierstudies.1,4,28 When a normal incisor relationship isachieved, the soft tissue overlying the incisors cannormalize the lip posture.

The cheilion moved toward the midline, resulting ina decrease in the intercheilion width after surgery (Ta-ble IV; Appendices A-C). Stretching of the soft tissueof the chin area in the prognathic mandible can pull thelower lip downward. When normal lip posture isachieved after surgery, the original convexity of thelower lip can be restored. Therefore, the convexity ofthe lower lip decreased after surgery (Tables IV and V).

The finding that lengths of the lower vermilion andlower lip decreased after surgery (Table IV) is consis-tent with Gjorup and Athanasiou.1 A greater decreasewas observed in the genioplasty group because verticalreduction genioplasty was performed. In addition, thelower lip length decreased in the large setback andhypodivergent groups.

Because the mandible moved upward and backwardaccording to the inclination of upper occlusal plane bysurgery, a larger mandibular setback could decrease thelower face height and the lower lip length to a greaterextent than could less setback of the mandible (Table IV).

Patients with a hypodivergent skeletal pattern have atendency to overclose the mandible before surgery,which can make the soft tissue in the chin area redun-dant. As the mandible moves to its normal position, thelower lip length in the hypodivergent group recoveredto a greater extent than in the hyperdivergent group.

In this study, the mentolabial sulcus became deeper

or (AP) and vertical (V) changes in the hard and soft

B= Pog=

AP V AP V

0.90*** 0.79*** 0.78*** 0.51**) (83.0%) (49.2%) (81.7%) (78.0%)

0.95*** 0.74*** 0.88*** 0.68***) (88.7%) (105.8%) (87.3%) (167.6%)

0.92*** 0.43** 0.91*** 0.67***) (89.8%) (28.0%) (88.4%) (44.4%)

osterior and vertical changes between the hard and soft tissues in the

e soft tissue/amount of change in the hard tissue (%); positive (�)direction; AP, anteroposterior change; V, vertical change; *P � .05;

osteri

V

0.38*71.6%0.52**154.0%0.2839.5%

anterop

ge in thposite

after surgery (Table V), as reported in previous stud-


ies.1,3,28 However, less deepening was observed in thegenioplasty group compared to the other groups (TableV). Because we performed vertical reduction genio-plasty in this study, the vertically redundant soft tissuein the chin area might have resulted in less deepening ofthe mentolabial sulcus.

Although there are some reports that the nasolabialangle increased after mandibular setback surgery,3,9,28

we could not observe any significant changes in thenasolabial angle in the present study (Table V).

The soft tissue of the cheek area generally movedbackward after surgery with an increasing gradient

Table IV. Comparison of the change (from T1 to T2according to the extent of mandibular setback, the ver

Small setbackgroup

Largesetbackgroup

Sig.

H

Variable Mean SD Mean SD M

Upper lip length (mm)14-15 �0.04 0.78 0.55 0.88 .057014-16 0.20 0.68 0.37 0.96 .584214-17 0.45 0.80 1.00 1.18 .139914-18 0.43 1.03 0.93 1.12 .192514-19 0.62 2.05 1.71 1.68 .102314-20 1.36 0.89 2.50 1.37 .0110*

Cheilion (mm)9-18 0.43 1.08 0.88 1.37 .318810-19 0.15 1.72 1.22 1.59 .0737

Upper vermilion length (mm)17-20 1.73 0.94 2.83 1.54 .0248*23-25 1.61 0.89 2.45 0.93 .0142*24-26 1.52 1.19 2.53 1.23 .0241*17-21 0.63 0.72 0.98 0.94 .257621-20 1.35 1.24 2.19 1.32 .0740

Lower vermilion length (mm)25-27 �2.07 1.85 �3.02 1.92 .1662 �

20-34 �2.65 1.34 �2.94 2.14 .6641 �

26-28 �2.29 1.45 �2.81 2.07 .4225 �

20-22 �2.14 1.22 �2.00 1.71 .8003 �

22-34 �1.01 1.12 �1.43 1.25 .3252 �

Horizontal lip width (mm)15-16 �0.18 0.92 �0.52 1.09 .3453 �

18-19 �3.19 2.13 �3.38 2.53 .8141 �

15-18 0.93 1.14 1.12 1.27 .658816-19 0.74 2.04 1.91 1.79 .0903

Lower lip length (mm)20-31 �2.48 1.45 �2.75 1.93 .6631 �

20-35 �2.25 2.49 �4.97 3.17 .0121* �

34-31 �1.41 1.78 �1.20 1.96 .7538 �

18-31 �3.00 1.33 �3.87 1.93 .1570 �

19-31 �2.82 1.56 �3.32 2.19 .4775 �

34-35 �1.10 2.84 �3.55 3.47 .0385* �

Nasal width (mm)9-10 0.34 0.54 0.72 2.09 .453211-12 �0.02 0.26 �0.08 0.34 .5677 �

Zygomatic width (mm)44-45 0.22 4.24 �0.04 3.11 .8404 �

Independent t test was done.*P � .05; **P � .01.

from the upper to the lower cheek area as well as from

the midline to the lateral area (Appendices A-C). Thesefindings are similar to those of McCance et al.7 whoreported greater changes in the lateral areas than in themidline of the chin and mentalis regions after MSS.

The finding that changes in the facial soft tissueoccurred in the paranasal area after MSS despite noactual advancement of the maxilla (Tables IV and V;Appendices A, B and C; Figs. 1 and 6) is similar to thatreported by Jung et al.9 They reported soft tissuechanges in the upper lip and philtrum after asymmetricmandibular setback surgery and hypothesized that thiswas due to muscle and soft tissue tension. After assess-

he 3-dimensional linear variables between subgroupsattern, and vertical-reduction genioplasty

gent Hyperdivergentgroup

Sig.

Nongenioplasty Genioplasty

Sig.SD Mean SD Mean SD Mean SD

0.73 0.64 0.94 .0367* 0.21 0.73 0.45 1.10 .46570.69 0.37 1.02 .6421 0.22 0.80 0.42 0.93 .52511.18 1.02 0.87 .2199 0.78 1.02 0.74 1.18 .92911.02 1.11 1.09 .0611 0.67 0.95 0.80 1.35 .74921.47 1.56 2.32 .3815 1.12 2.03 1.47 1.68 .61781.44 1.83 1.14 .4826 1.92 1.58 2.18 0.59 .4998

1.21 0.77 1.34 .7469 0.68 1.15 0.70 1.48 .96731.49 1.11 1.94 .3026 0.68 1.79 0.93 1.62 .6950

1.58 1.82 0.97 .0395* 2.18 1.44 2.68 1.36 .33221.13 2.08 0.84 .9386 1.94 1.09 2.36 0.77 .24291.46 2.18 1.12 .7691 2.04 1.50 2.21 0.91 .71450.98 0.54 0.60 .0738 0.91 0.94 0.70 0.72 .51211.55 1.58 1.00 .3211 1.52 1.19 2.37 1.44 .0770

2.00 �2.67 1.89 .8939 �2.49 2.16 �2.84 1.47 .62331.72 �2.73 1.99 .8107 �2.59 1.83 �3.22 1.82 .34861.67 �2.85 2.02 .4746 �2.35 1.91 �3.01 1.64 .32111.34 �2.20 1.71 .6328 �2.11 1.70 �1.99 1.14 .82621.28 �1.03 1.09 .3417 �0.93 1.01 �1.82 1.33 .0395*

1.08 �0.26 0.98 .5798 �0.09 0.85 �0.87 1.15 .0340*2.49 �2.52 1.94 .0790 �3.37 2.36 �3.18 2.40 .82841.41 1.18 0.91 .5273 0.98 1.18 1.13 1.28 .73341.76 1.83 2.16 .2776 1.33 2.11 1.56 1.74 .7510

1.58 �2.09 1.79 .0955 �2.48 1.78 �2.92 1.66 .49103.54 �2.46 2.03 .0177* �2.95 2.46 �5.35 3.76 .0339*1.61 �0.86 2.09 .2262 �1.16 1.93 �1.51 1.80 .60861.64 �2.66 1.48 .0081** �3.54 1.85 �3.43 1.58 .87072.17 �2.98 1.68 .7445 �3.39 1.87 �2.61 2.03 .27393.64 �1.32 2.75 .0671 �1.78 2.86 �3.78 4.00 .1044

2.03 0.04 0.63 .0729 0.66 1.93 0.39 0.85 .58400.33 �0.07 0.28 .8129 �0.04 0.31 �0.08 0.32 .7865

3.42 0.37 3.85 .6681 0.67 3.59 �0.99 3.44 .2031

) in ttical p

ypodivergroup

ean

0.010.230.560.390.982.16

0.620.48

2.822.102.041.072.05

2.572.892.381.951.44

0.473.950.911.07

3.104.951.654.213.213.49

0.990.04

0.18

ing hard and soft tissue changes, they concluded that


the soft tissues in the upper lip, mouth corner, andparanasal areas also changed in relation to the lower lip

Table V. Comparison of the change (from T1 to T2)according to the extent of mandibular setback, the ver

Variable

Small setbackgroup

Large setbackgroup

Sig.

Hypog

Mean SD Mean SD Mea

Upper cheek angle (°)5-38-9 �0.72 2.62 �1.70 3.35 .3673 �1.6-39-10 �0.13 2.90 �0.09 3.33 .9709 �0.5-40-42 0.45 1.49 1.20 1.29 .1316 0.6-41-43 �0.21 1.47 �0.04 1.12 .7084 �0.5-40-36 �0.18 2.18 �3.15 3.64 .0109* �2.6-41-37 �0.68 2.39 �1.98 2.86 .1788 �1.3-40-9 0.68 1.76 0.16 1.68 .3899 0.4-41-10 0.10 1.79 1.47 1.90 .0438* 0.

Midcheek angle (°)38-09-29 3.50 3.57 3.29 3.52 .8710 4.39-10-30 2.79 4.37 5.53 6.68 .1922 4.40-42-48 �1.27 2.92 �1.83 2.99 .5929 �2.41-43-47 �3.12 3.91 �3.29 3.26 .8907 �4.36-51-46 �2.78 4.77 �0.79 7.50 .3910 �1.37-52-47 �1.35 6.83 �5.16 6.26 .1064 �0.9-29-18 �7.64 3.61 �7.42 5.78 .9034 �6.10-30-19 �6.01 4.56 �7.31 7.84 .5836 �7.

Lower cheek angle (°)42-48-46 1.00 3.34 1.81 4.21 .5555 2.43-49-47 2.27 3.95 1.58 4.23 .6398 3.9-48-46 1.07 3.42 0.99 4.30 .9543 1.10-49-48 0.18 1.15 1.29 3.25 .1816 1.36-48-18 �6.18 5.15 �6.24 6.48 .9770 �6.37-49-19 �4.20 4.79 �5.47 7.39 .5808 �6.29-48-46 �0.42 2.02 �0.96 2.99 .5568 �1.30-49-47 �0.01 2.90 �1.43 2.63 .1512 �0.44-40-38 0.41 2.45 1.05 1.88 .3962 0.45-41-39 1.34 3.46 0.67 2.49 .5209 �0.36-42-9 0.85 2.34 �0.21 5.94 .4872 �0.37-43-10 0.48 3.25 2.34 3.56 .1330 1.51-48-29 1.23 1.90 1.46 3.56 .8117 1.52-49-30 0.41 2.24 0.86 3.84 .6985 0.

Lip angle (°)17-21-20 �10.93 10.01 �14.87 15.02 .4018 �14.20-22-34 13.73 8.44 13.34 10.19 .9078 13.25-20-26 1.03 5.61 5.05 6.58 .0750 4.18-20-19 �5.12 3.53 �4.14 5.10 .5423 �3.23-17-24 �0.82 2.51 �0.28 3.54 .6319 �0.15-17-16 �4.04 7.75 �6.32 10.31 .4923 �5.27-34-28 3.35 2.90 0.85 5.53 .1037 1.21-20-22 6.84 10.29 2.71 13.27 .3411 4.18-21-19 �10.58 4.81 �12.70 6.16 .2931 �11.18-22-19 3.92 3.53 4.42 5.67 .7717 4.

Lower lip angle (°)34-31-35 �3.16 7.71 �8.50 11.29 .1372 �6.27-31-35 �6.46 5.19 �7.09 6.64 .7718 �7.28-31-35 �6.36 5.21 �7.07 7.43 .7630 �7.18-32-31 0.06 7.61 2.30 8.70 .4472 0.19-33-31 2.48 12.76 4.35 7.69 .6309 2.

Nasolabial angle (°)13-14-17 5.88 2.36 6.11 5.94 .8779 6.

Independent t test was done.*P � .05; **P � .01.

and chin area.9

Angular variables in the cheek area indicated anincrease in convexity, and this increase was greater in

e 3-dimensional angular variables between subgroupsattern, and vertical-reduction genioplastyt Hyperdivergent

group

Sig.


Sig.Mean SD Mean SD Mean SD

3 �1.41 2.09 .8305 �1.93 2.63 �0.15 3.52 .10735 0.44 2.95 .3665 �0.33 3.14 0.28 3.16 .59771 1.12 1.28 .3848 0.96 1.60 0.74 1.04 .66263 �0.06 1.44 .8408 0.07 1.11 �0.42 1.50 .28958 �1.20 2.53 .2956 �2.33 3.30 �1.12 3.62 .33584 �1.10 2.31 .5296 �1.93 3.01 �0.55 1.88 .16482 0.36 1.49 .9445 0.42 1.73 0.31 1.74 .86506 1.43 1.98 .1479 0.98 2.19 0.73 1.54 .7230

9 1.65 3.08 .0070** 2.55 3.75 4.83 2.48 .07061 3.97 4.60 .7314 3.56 5.76 5.78 6.12 .30554 �0.57 1.77 .0527 �1.57 3.26 �1.64 2.36 .95256 �2.10 2.72 .0920 �3.30 4.18 �3.09 1.93 .84426 �2.17 4.25 .6542 �1.57 5.42 �1.74 8.26 .94358 �7.06 7.52 .0075** �4.28 7.72 �2.25 4.32 .40930 �8.68 3.79 .2165 �7.30 4.89 �7.88 5.13 .75148 �6.28 6.81 .7086 �6.31 5.09 �7.53 8.85 .6170

2 0.33 3.21 .1210 1.36 4.01 1.65 3.65 .83340 0.29 3.05 .0390* 2.24 4.16 1.22 3.98 .49387 0.00 4.02 .1693 1.03 4.23 1.02 3.40 .99437 0.19 0.98 .1804 1.21 3.08 0.13 1.29 .17307 �5.98 5.26 .8379 �6.97 6.21 �4.91 5.20 .33881 �3.41 6.64 .2156 �5.41 5.02 �4.10 8.41 .63109 �0.28 2.22 .3704 �0.34 2.79 �1.42 2.16 .25812 �1.02 2.27 .7165 �0.45 2.75 �1.48 2.87 .31647 1.24 1.77 .2674 1.34 2.05 �0.19 1.98 .0454*9 2.18 3.07 .0250* 1.18 3.25 0.56 2.26 .56305 0.59 2.53 .6840 �0.14 5.57 0.89 2.81 .48998 1.23 2.79 .6419 1.16 3.25 2.23 3.98 .41209 1.44 1.76 .8855 1.37 3.28 1.37 2.32 .99680 1.10 3.06 .4900 0.57 3.14 0.84 3.50 .8229

1 �11.60 12.61 .5303 �11.42 14.99 �16.30 8.60 .31149 13.08 10.06 .8127 11.85 10.36 16.41 6.68 .18160 2.50 5.47 .4969 3.40 6.20 3.25 7.08 .94813 �5.96 4.11 .0996 �5.56 4.29 �2.78 4.38 .08537 �0.11 3.53 .5077 �0.75 3.32 �0.10 2.80 .56857 �5.55 9.99 .9139 �6.71 9.10 �2.98 9.41 .27145 1.82 3.03 .9158 3.11 4.31 �0.19 4.82 .05160 4.86 14.25 .8681 5.39 14.04 2.85 7.92 .57069 �12.63 5.56 .4516 �11.85 5.69 �11.72 5.83 .94970 4.20 5.63 .9907 3.47 5.42 5.50 3.35 .2495

7 �5.47 9.81 .6992 �8.12 10.63 �2.94 8.69 .16110 �6.31 5.77 .6592 �7.89 6.12 �4.97 5.50 .18166 �5.50 7.64 .3119 �6.82 5.81 �6.67 7.82 .94972 2.24 6.68 .5757 �0.92 7.12 5.31 8.78 .0337*7 5.07 10.08 .4366 0.59 8.93 8.74 10.04 .0220*

6 5.90 3.41 .9013 5.09 5.44 7.63 2.46 .0766

in thtical pdivergenroup

n SD

18 3.756 3.268 1.515 1.146 3.970 3.040 1.944 1.8

82 3.170 6.945 3.416 3.818 7.961 4.154 5.616 6.5

41 4.119 4.488 3.634 3.341 6.420 6.011 2.866 3.240 2.307 2.306 6.082 4.030 3.631 3.4

53 13.787 8.905 7.238 4.585 2.719 8.899 5.814 10.411 5.722 4.2

87 10.625 6.383 5.360 9.429 10.0

11 5.6

patients with a hyperdivergent skeletal pattern com-


pared to those with a hypodivergent pattern (Table V).This may be due to midfacial soft tissue laxity andalterations in the general drape of the soft tissues,especially in patients with hyperdivergent skeletal pat-terns.

To determine changes in hard and soft tissue moreprecisely after surgery, 3D surface scanning data and3D CT data should be combined. Furthermore, exami-nation of soft tissue changes after 2-jaw surgery isimportant to enable clinically accurate predictions of

Fig. 6. Examples of different patterns of change in 3D im-ages between T1 and T2 using absolute color (A) and signedcolor (B). Absolute color expresses the absolute amount ofdeviation between the 2 images (blue color indicates almostno deviation, and color changes toward red indicate largerdeviations). Signed color is expressed with a “�” and “�” toshow the direction of deviation. Blue indicates backward (�)movement and red indicates forward (�) movement. Al-though the greatest change occurred in the chin area aftermandibular setback surgery, several patients showed signifi-cant changes in their paranasal area, as illustrated in the casein the top left of the figure.

cosmetic outcomes.

CONCLUSIONS

1. By comparing 3D-FSIs before and after MSS sur-gery, soft tissue changes were confirmed in theupper and lower lips as well as in other areas remotefrom the midline, such as the zygomatic, cheek, andparanasal areas. These changes were influenced bythe amount of mandibular setback, vertical skeletalpattern, and genioplasty, confirming our hypotheses.

2. These variables can be used as guidelines to deter-mine whether 1- or 2-jaw surgery should be per-formed for skeletal class III malocclusion borderlinecases.

REFERENCES1. Gjørup H, Athanasiou AE. Soft-tissue and dentoskeletal profile

changes associated with mandibular setback osteotomy. Am JOrthod Dentofac Orthop 1991;100:312-23.

2. Hu J, Wang D, Luo S, Chen Y. Differences in soft tissue profilechanges following mandibular setback in Chinese men andwomen. J Oral Maxillofac Surg 1999;57:1182-6.

3. Enacar A, Taner T, Toroglu S. Analysis of soft tissue profilechanges associated with mandibular setback and double-jaw sur-geries. Int J Adult Orthod Orthognath Surg 1999;14:27-35.

4. Mobarak KA, Krogstad O, Espeland L, Lyberg T. Factors influ-encing the predictability of soft tissue profile changes followingmandibular setback surgery. Angle Orthod 2001;71:216-27.

5. Koh CH, Chew MT. Predictability of soft tissue profile changesfollowing bimaxillary surgery in skeletal class III Chinese pa-tients. J Oral Maxillofac Surg 2004;62:1505-9.

6. Johnston C, Burden D, Kennedy D, Harradine N, Stevenson M.Class III surgical-orthodontic treatment: a cephalometric study.Am J Orthod Dentofac Orthop 2006;130:300-9.

7. McCance AM, Moss JP, Fright WR, James DR, Linney AD. Athree dimensional analysis of soft and hard tissue changes fol-lowing bimaxillary orthognathic surgery in skeletal III patients.Br J Oral Maxillofac Surg 1992;30:305-12.

8. Cavalcanti MG, Rocha SS, Vannier MW. Craniofacial measure-ments based on 3D-CT volume rendering: implications for clin-ical applications. Dentomaxillofac Radiol 2004;33:170-6.

9. Jung YJ, Kim MJ, Baek SH. Hard and soft tissue changes aftercorrection of mandibular prognathism and facial asymmetry bymandibular setback surgery: three-dimensional analysis usingcomputerized tomography. Oral Surg Oral Med Oral Pathol OralRadiol Endod 2009;107:763-771.e8.

10. McCance AM, Moss JP, Wright WR, Linney AD, James DR. Athree-dimensional soft tissue analysis of 16 skeletal class IIIpatients following bimaxillary surgery. Br J Oral MaxillofacSurg 1992;30:221-32.

11. Da Silveira AC, Daw JL Jr, Kusnoto B, Evans C, Cohen M.Craniofacial applications of three-dimensional laser surfacescanning. J Craniofac Surg 2003;14:449-56.

12. Soncul M, Bamber MA. Evaluation of facial soft tissue changeswith optical surface scan after surgical correction of class IIIdeformities. J Oral Maxillofac Surg 2004;62:1331-40.

13. Kau CH, Zhurov A, Bibb R, Hunter L, Richmond S. The inves-tigation of the changing facial appearance of identical twinsemploying a three-dimensional laser imaging system. OrthodCraniofac Res 2005;8:85-90.

14. Holberg C, Schwenzer K, Mahaini L, Rudzki-Janson I. Accuracy
of facial plaster casts. Angle Orthod 2006;76:605-11.


15. Baik HS, Jeon JM, Lee HJ. Facial soft-tissue analysis of Koreanadults with normal occlusion using a 3-dimensional laser scan-ner. Am J Orthod Dentofacial Orthop 2007;131:759-66.

16. Ghoddousi H, Edler R, Haers P, Wertheim D, Greenhill D.Comparison of three methods of facial measurement. 1. Int J OralMaxillofac Surg 2007;36:250-8.

17. Ozsoy U, Demirel BM, Yildirim FB, Tosun O, Sarikcioglu L.Method selection in craniofacial measurements: advantages anddisadvantages of 3D digitization method. J CraniomaxillofacSurg 2009;37:285-90.

18. Im DH, Kim TW, Nahm DS. Current trends in orthodonticpatients in Seoul National University Dental Hospital. KoreanJ Orthod 2003;33:63-72.

19. Chew MT. Spectrum and management of dentofacial deformitiesin a multiethnic Asian population. Angle Orthod 2006;76:806-9.

20. Solow B, Tallgren A. Natural head position in standing subjects.Acta Odontol Scand 1971;29:591-607.

21. Kusnoto B, Evans CA. Reliability of a 3D surface laser scannerfor orthodontic applications. Am J Orthod Dentofac Orthop2002;122:342-8.

22. Kau CH, Cronin AJ, Richmond S. A three-dimensional evalua-tion of postoperative swelling following orthognathic surgery at6 months. Plast Reconstr Surg 2007;119:2192-9.

23. McCance AM, Moss JP, Fright WR, Linney AD, James DR,Coghlan K, Mars M. Three-dimensional analysis techniques—part 4: three-dimensional analysis of bone and soft tissue to boneratio of movements in 24 cleft palate patients following Le Fort

I osteotomy: a preliminary report. Cleft Palate Craniofac J 1997;34:58-62.

24. Kau CH, Richmond S, Savio C, Mallorie C. Measuring adultfacial morphology in three dimensions. Angle Orthod 2006;76:773-8.

25. Miller L, Morris DO, Berry E. Visualizing three-dimensionalfacial soft tissue changes following orthognathic surgery. EurJ Orthod 2007;29:14-20.

26. Ferrario VF, Sforza C, Schmitz JH, Santoro F. Three-dimen-sional facial morphometric assessment of soft tissue changesafter orthognathic surgery. Oral Surg Oral Med Oral Pathol OralRadiol Endod 1999;88:549-56.

27. Chew MT. Soft and hard tissue changes after bimaxillary surgeryin Chinese class III patients. Angle Orthod 2005;75:959-63.

28. Naoumova J, Söderfeldt B, Lindman R. Soft tissue profilechanges after vertical ramus osteotomy. Eur J Orthod 2008;30:359-65.

Reprint requests:

Dr. Seung-Hak BaekDepartment of OrthodonticsSchool of DentistryDental Research InstituteSeoul National UniversityYeonkun-dong #28Jongro-ku, Seoul [email protected]

mailto:[email protected]


Appendix A. Comparison of the changes in the coordinate values (X, Y, and Z) of the soft tissue landmarks betweensmall setback group and large setback group (mm)

X Y Z

Small setback Large setback Small setback Large setback Small setback Large setback

Variable Mean SD Mean SD Sig. Mean SD Mean SD Sig. Mean SD Mean SD Sig.

Upper lip

15 Upper lip point (Rt) 0.19 0.69 0.24 0.67 .8455 �0.39 0.76 �0.91 1.25 .1790 �0.78 0.77 �0.94 1.01 .6182

16 Upper lip point (Lt) 0.02 0.84 �0.29 0.70 .2476 �0.48 0.97 �0.70 1.33 .6009 �0.93 0.88 �1.01 1.22 .8239

17 Labrale superius 0.12 0.67 0.05 0.64 .7735 �0.88 0.87 �1.44 1.49 .2164 �1.13 0.91 �1.33 1.35 .6384

21 Upper lip prominent 0.21 0.76 0.01 0.41 .3809 �1.33 1.09 �2.26 1.73 .0884 �1.48 1.37 �1.93 1.93 .4682

23 Upper lip border (Rt) 0.13 0.29 �0.07 0.27 .0439* �1.21 0.75 �1.35 1.27 .7274 �0.93 0.86 �1.24 1.33 .4541

24 Upper lip border (Lt) 0.04 0.62 �0.08 0.36 .5119 �1.25 0.86 �1.48 1.34 .5699 �1.32 1.02 �1.39 1.81 .8856

29 Ac-cheilion midpoint (Rt) �0.04 0.31 0.16 0.54 .2104 �0.19 0.50 �0.30 0.73 .6228 �0.79 0.92 �1.08 0.95 .3859

30 Ac-cheilion midpoint (Lt) 0.18 0.12 0.16 0.46 .8723 0.01 0.45 �0.34 1.14 .2305 �1.19 0.81 �1.14 1.27 .9071

18 Cheilion (Rt) 1.76 0.92 1.86 1.32 .8071 �0.88 1.17 �1.32 1.27 .3172 �4.04 1.83 �5.07 1.92 .1334

19 Cheilion (Lt) �1.42 1.74 �1.50 1.84 .8895 �0.50 1.88 �1.65 1.72 .0770 �3.95 1.82 �5.36 2.45 .0784

Stomion

20 Stomion 0.16 0.74 �0.01 0.33 .4232 �1.43 0.97 �2.59 1.50 .0168* �3.28 1.15 �4.66 2.03 .0192*

25 Stomion (Rt) �0.07 0.37 �0.11 0.46 .7709 �1.69 0.96 �2.41 1.25 .0793 �2.89 1.18 �3.93 1.58 .0475*

26 Stomion (Lt) 0.22 0.29 0.22 0.41 .9947 �1.44 1.57 �2.44 1.40 .0637 �3.47 1.51 �4.23 2.23 .2816

Lower lip

22 Lower lip prominent 0.32 0.87 �0.19 0.73 .0806 �0.75 1.51 �2.34 1.81 .0119* �6.03 1.84 �7.66 2.63 .0564

27 Lower lip border (Rt) �0.11 0.34 �0.22 0.51 .4914 �1.11 1.62 �1.71 1.30 .2421 �6.31 1.68 �8.59 2.75 .0099**

28 Lower lip border (Lt) 0.32 0.69 0.22 0.68 .6762 �0.50 1.76 �1.94 1.45 .0148* �6.78 2.20 �9.16 3.14 .0214*

32 B-cheilion midpoint (Rt) 0.21 0.41 0.13 0.62 .6666 0.13 1.45 �0.67 1.44 .1264 �6.03 1.99 �8.65 1.63 .0002***

33 B-cheilion midpoint (Lt) 0.33 0.98 �0.23 1.55 .2423 0.16 1.36 �0.57 1.38 .1399 �6.78 2.70 �9.13 2.88 .0232*

34 Labrale inferius 0.22 0.56 �0.30 0.98 .0669 0.27 1.44 �1.02 1.67 .0273* �6.63 1.78 �8.58 2.61 .0217*

Chin area

31 B point 0.15 0.87 �0.35 1.01 .1491 1.57 1.94 0.70 2.13 .2405 �5.87 1.64 �9.04 2.88 .0004***

35 Pogonion 0.35 0.64 �0.47 1.40 .0325� 1.08 2.77 2.58 3.13 .1621 �5.54 1.79 �8.70 4.03 .0054**

50 Menton �0.10 1.14 �0.79 2.40 .2819 0.94 3.35 2.45 3.62 .2316 �7.38 4.07 �10.49 6.21 .1128

Cheek area

36 Ac-exocanthion (Rt) �0.06 0.27 �0.31 0.50 .0695 �0.02 0.28 �0.08 0.35 .5498 �0.44 1.09 �1.67 1.77 .0286*

37 Ac-exocanthion (Lt) 0.20 0.43 0.30 0.47 .5372 0.13 0.24 �0.03 0.20 .0420* �0.76 1.57 �1.28 2.26 .4671

38 Mid-Ac-endocanthion (Rt) 0.12 0.21 0.16 0.23 .6629 0.06 0.26 �0.09 0.21 .0780 0.09 0.30 0.20 0.85 .5922

39 Mid-Ac-endocanthion (Lt) 0.12 0.28 �0.01 0.25 .2015 0.01 0.23 0.00 0.35 .9117 �0.02 0.30 0.17 0.86 .3762

40 Midpoint of upper cheek (Rt) �0.01 0.28 0.07 0.28 .4276 �0.04 0.19 �0.02 0.25 .7666 �0.15 0.57 �0.21 0.96 .8418

41 Midpoint of upper cheek (Lt) 0.06 0.27 0.11 0.24 .5759 0.03 0.33 �0.04 0.21 .4615 �0.24 0.49 �0.18 1.07 .8254

42 Mid-Ac-Ac-exocanthion (Rt) �0.11 0.26 �0.12 0.29 .9295 �0.01 0.20 �0.02 0.25 .9191 �0.28 0.72 �0.65 1.55 .4119

43 Mid-Ac-Ac-exocanthion (Lt) �0.03 0.28 0.10 0.26 .1833 �0.03 0.17 0.02 0.21 .4545 �0.43 0.64 �0.56 1.68 .7515

44 Zygomatic point (Rt) �0.23 2.73 0.08 2.23 .7219 �0.19 0.70 �0.24 0.85 .8625 �0.47 2.91 �0.69 2.20 .8022

45 Zygomatic point (Lt) �0.01 1.77 0.01 2.14 .9786 �0.50 0.89 �0.33 0.68 .5387 �0.29 1.44 �0.57 2.08 .6712

46 Cheilion-exocanthion (Rt) �0.46 0.54 �0.46 1.41 .9943 �0.32 0.53 �0.76 0.90 .1104 �2.39 3.44 �4.65 6.09 .1868

47 Cheilion-exocanthion (Lt) 0.23 1.38 0.50 1.57 .6175 �0.58 0.64 �0.68 0.80 .6918 �4.50 5.39 �6.02 6.84 .4961

48 Midpoint of lower cheek (Rt) �0.20 0.17 �0.13 0.27 .4231 �0.15 0.21 �0.05 0.21 .2010 �0.99 0.99 �1.94 1.87 .0687

49 Midpoint of lower cheek (Lt) 0.23 0.29 0.31 0.31 .4619 �0.14 0.30 �0.16 0.26 .8617 �1.63 0.95 �2.07 1.81 .3756

51 Lateral point of lower cheek (Rt) �0.15 0.35 �0.38 0.52 .1685 �0.11 0.30 �0.34 0.25 .0223* �0.43 1.73 �2.76 3.36 .0151*

52 Lateral point of lower cheek (Lt) 0.48 0.40 0.45 0.61 .8765 �0.27 0.34 �0.22 0.30 .6091 �2.21 2.84 �2.99 3.99 .5372

The reference axes are established on the original point (nasion) as follows: a midfacial line (Y coordinate, vertical axis), a parallel line to thefloor (Z coordinate, anteroposterior axis), and a parallel line to a line connecting both exocanthions (X coordinate, transverse axis). Independentt test was done.
*P � .05; **P � .01; ***P � .001.


Appendix B. Comparison of the changes in the coordinate values (X, Y, and Z) of the soft tissue landmarksbetween hypodivergent group and hyperdivergent group (mm)

Variable

X Y Z

Hypodivergent Hyperdivergent

Sig.


Sig.


Sig.Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Upper lip

15 Upper lip point (Rt) 0.43 0.74 �0.03 0.48 .0433� �0.48 0.83 �0.94 1.31 .2283 �1.10 0.96 �0.61 0.79 .1228

16 Upper lip point (Lt) �0.04 0.85 �0.30 0.65 .3315 �0.49 0.92 �0.75 1.45 .5266 �1.22 1.23 �0.69 0.79 .1605

17 Labrale superius 0.18 0.76 �0.04 0.46 .3381 �1.01 1.31 �1.44 1.24 .3483 �1.51 1.40 �0.92 0.73 .1343

21 Upper lip prominent 0.10 0.72 0.07 0.37 .8787 �1.88 1.68 �1.85 1.43 .9608 �2.11 2.02 �1.29 1.14 .1540

23 Upper lip border (Rt) 0.05 0.32 �0.04 0.26 .4007 �1.33 1.06 �1.25 1.11 .8322 �1.41 1.24 �0.74 0.94 .0937

24 Upper lip border (Lt) 0.02 0.60 �0.09 0.31 .5213 �1.41 1.30 �1.35 0.99 .8883 �1.66 1.77 �1.00 1.05 .2143

29 Ac-cheilion midpoint (Rt) 0.18 0.54 �0.05 0.32 .1671 �0.22 0.71 �0.29 0.55 .7615 �1.00 0.93 �0.91 0.96 .7734

30 Ac-cheilion midpoint (Lt) 0.19 0.46 0.14 0.15 .7045 �0.17 0.97 �0.23 0.88 .8553 �1.02 1.16 �1.32 1.00 .4409

18 Cheilion (Rt) 2.28 1.22 1.26 0.80 .0092** �1.13 1.13 �1.13 1.38 .9975 �4.75 1.87 �4.49 2.03 .6977

19 Cheilion (Lt) �1.66 1.88 �1.23 1.66 .4994 �0.85 1.70 �1.53 2.01 .2964 �4.89 2.43 �4.61 2.17 .7314

Stomion

20 Stomion 0.14 0.68 �0.03 0.31 .3406 �2.25 1.53 �1.91 1.28 .5050 �4.55 2.01 �3.50 1.43 .1000

25 Stomion (Rt) �0.11 0.46 �0.07 0.38 .7559 �2.10 1.10 �2.11 1.31 .9669 �3.83 1.66 �3.08 1.19 .1530

26 Stomion (Lt) 0.29 0.37 0.14 0.34 .2351 �1.79 1.66 �2.29 1.37 .3556 �4.39 2.27 �3.33 1.38 .1230

Lower lip

22 Lower lip prominent 0.07 1.07 �0.02 0.38 .7456 �1.92 2.16 �1.36 1.39 .3936 �7.36 2.55 �6.50 2.29 .3196

27 Lower lip border (Rt) �0.07 0.46 �0.30 0.39 .1424 �1.65 1.60 �1.22 1.28 .4036 �7.99 2.95 �7.19 2.10 .3850

28 Lower lip border (Lt) 0.27 0.70 0.24 0.68 .8857 �1.43 1.82 �1.20 1.65 .7062 �8.62 3.21 �7.59 2.70 .3346

32 B-cheilion midpoint (Rt) 0.04 0.54 0.31 0.51 .1589 �0.46 1.45 �0.17 1.54 .5862 �7.77 2.23 �7.27 2.20 .5270

33 B-cheilion midpoint (Lt) �0.20 1.65 0.26 0.86 .3438 �0.48 1.29 0.01 1.52 .3289 �8.34 3.05 �7.89 3.02 .6739

34 Labrale inferius �0.08 1.07 �0.08 0.54 .9950 �0.57 2.04 �0.36 1.18 .7178 �8.15 2.69 �7.28 2.16 .3206

Chin area

31 B point �0.26 1.09 0.01 0.82 .4280 1.31 1.88 0.79 2.30 .4816 �7.92 3.18 �7.43 2.57 .6310

35 Pogonion �0.22 1.17 �0.01 1.26 .6347 2.75 3.27 0.97 2.50 .0941 �7.58 4.09 �7.10 3.03 .7099

50 Menton �0.64 1.54 �0.33 2.43 .6641 2.10 4.27 1.45 2.49 .5919 �10.03 6.53 �8.14 4.08 .3382

Cheek area

36 Ac-exocanthion (Rt) �0.23 0.54 �0.17 0.27 .6373 �0.07 0.35 �0.04 0.29 .8348 �1.17 1.86 �1.11 1.33 .9154

37 Ac-exocanthion (Lt) 0.15 0.48 0.38 0.39 .1343 �0.01 0.22 0.10 0.24 .1894 �0.43 2.14 �1.82 1.52 .0439*

38 Mid-Ac-endocanthion (Rt) 0.18 0.25 0.10 0.17 .2856 �0.02 0.28 �0.04 0.21 .8632 0.31 0.83 �0.03 0.35 .1457

39 Mid-Ac-endocanthion (Lt) 0.02 0.28 0.08 0.25 .5677 0.04 0.30 �0.05 0.30 .4059 0.31 0.78 �0.17 0.43 .0346*

40 Midpoint of upper cheek (Rt) 0.05 0.30 0.01 0.26 .6737 �0.05 0.19 0.00 0.27 .4858 �0.03 1.00 �0.37 0.48 .2209

41 Midpoint of upper cheek (Lt) 0.07 0.19 0.11 0.31 .6325 �0.05 0.28 0.03 0.26 .4305 0.15 0.93 �0.64 0.54 .0052**

42 Mid-Ac-Ac-exocanthion (Rt) �0.07 0.30 �0.18 0.23 .2544 �0.01 0.27 �0.02 0.17 .8542 �0.28 1.59 �0.75 0.67 .2743

43 Mid-Ac-Ac-exocanthion (Lt) �0.04 0.20 0.15 0.32 .0484 0.01 0.16 �0.01 0.23 .8339 �0.09 1.61 �1.00 0.61 .0371*

44 Zygomatic point (Rt) 0.03 2.25 �0.16 2.68 .8230 �0.24 0.86 �0.20 0.71 .8779 �0.79 2.19 �0.37 2.86 .6410

45 Zygomatic point (Lt) �0.16 1.70 0.20 2.28 .6100 �0.27 0.51 �0.56 0.99 .3165 �0.06 1.61 �0.92 1.99 .1813


47 Cheilion-exocanthion (Lt) 0.37 1.42 0.41 1.58 .9428 �0.37 0.55 �0.96 0.79 .0160� �4.07 6.67 �6.94 5.44 .1925



51 Lateral point of lower cheek (Rt) �0.28 0.51 �0.29 0.42 .9772 �0.28 0.25 �0.20 0.34 .4112 �1.80 3.51 �1.73 2.33 .9537


Independent t test was done. SD means standard deviation; Sig., significance; *P � .05; **P � .01; positive (�) value, upward, forward, patient’s
left side movements; negative (�) value, downward, backward, patient’s right side movements.


Appendix C. Comparison of the changes in the coordinate values (X, Y, and Z) of the soft tissue landmarksbetween nongenioplasty group and genioplasty group (mm)

Variables

X Y Z


Sig.


Sig.


Sig.Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Upper lip

15 Upper lip point (Rt) 0.10 0.65 0.44 0.67 .1640 �0.38 0.82 �1.22 1.31 .0292� �0.80 0.99 �1.01 0.75 .5207

16 Upper lip point (Lt) �0.01 0.65 �0.42 0.90 .1335 �0.31 1.07 �1.12 1.23 .0557 �0.89 1.14 �1.13 0.97 .5492

17 Labrale superius 0.20 0.72 �0.14 0.41 .1393 �1.02 1.25 �1.52 1.33 .2945 �1.09 1.26 �1.50 1.00 .3413

21 Upper lip prominent 0.24 0.61 �0.17 0.45 .0483* �1.73 1.64 �2.10 1.39 .5111 �1.67 1.97 �1.86 1.17 .7710

23 Upper lip border (Rt) 0.01 0.30 0.03 0.29 .8599 �1.00 0.91 �1.81 1.16 .0336* �0.98 1.24 �1.32 1.00 .4296

24 Upper lip border (Lt) 0.07 0.52 �0.20 0.38 .1268 �1.05 1.14 �1.97 0.95 .0247* �1.26 1.69 �1.55 1.16 .6021

29 Ac-cheilion midpoint (Rt) 0.12 0.51 �0.01 0.35 .4478 �0.17 0.53 �0.39 0.79 .3573 �0.91 1.07 �1.04 0.66 .7141

30 Ac-cheilion midpoint (Lt) 0.08 0.23 0.31 0.47 .1324 �0.08 0.76 �0.40 1.15 .3367 �1.23 1.18 �1.03 0.92 .6199

18 Cheilion (Rt) 1.89 1.12 1.70 1.25 .6620 �1.01 1.23 �1.34 1.26 .4644 �4.38 1.85 �5.07 2.04 .3340

19 Cheilion (Lt) �1.46 1.82 �1.47 1.77 .9851 �1.00 1.98 �1.43 1.66 .5315 �4.59 2.28 �5.06 2.36 .5785

Stomion

20 Stomion 0.16 0.60 �0.11 0.38 .1712 �1.84 1.57 �2.54 0.99 .1721 �3.70 1.89 �4.73 1.58 .1216

25 Stomion (Rt) 0.03 0.33 �0.30 0.49 .0299* �1.87 1.26 �2.51 0.95 .1342 �3.03 1.52 �4.29 1.11 .0180*

26 Stomion (Lt) 0.28 0.38 0.13 0.32 .2434 �1.80 1.69 �2.39 1.19 .2910 �3.58 2.22 �4.49 1.29 .2072

Lower lip

22 Lower lip prominent 0.09 0.93 �0.09 0.62 .5473 �1.29 2.00 �2.32 1.39 .1240 �6.60 2.66 �7.60 1.94 .2663

27 Lower lip border (Rt) �0.08 0.42 �0.34 0.45 .1009 �1.34 1.59 �1.65 1.22 .5674 �7.35 2.76 �8.10 2.30 .4329

28 Lower lip border (Lt) 0.33 0.78 0.13 0.44 .4248 �1.15 1.88 �1.64 1.42 .4346 �7.70 3.22 �8.94 2.46 .2561

32 B-cheilion midpoint (Rt) 0.17 0.53 0.15 0.57 .9210 0.40 1.20 �1.61 0.96 � .0001*** �7.22 2.30 �8.11 1.96 .2689

33 B-cheilion midpoint (Lt) 0.05 1.52 �0.07 1.05 .8134 0.36 1.30 �1.34 0.79 .0003*** �7.72 3.36 �8.86 2.18 .3002

34 Labrale inferius �0.01 0.95 �0.20 0.69 .5413 �0.40 1.62 �0.60 1.85 .7441 �7.48 2.61 �8.23 2.21 .4087

Chin area

31 B point 0.09 1.05 �0.53 0.69 .0770 1.35 2.22 0.58 1.74 .3063 �7.94 3.25 �7.27 2.16 .5250

35 Pogonion 0.07 1.18 �0.46 1.21 .2271 1.47 2.36 2.77 3.95 .3173 �7.68 3.85 �6.80 3.20 .5036

50 Menton 0.20 1.57 �1.72 2.06 .0051** 0.62 2.42 3.88 4.29 .0285* �10.80 5.40 �6.32 4.76 .0232�

Cheek area

36 Ac-exocanthion (Rt) �0.22 0.44 �0.17 0.43 .7334 �0.12 0.26 0.06 0.39 .1153 �1.38 1.71 �0.74 1.43 .2865

37 Ac-exocanthion (Lt) 0.29 0.48 0.19 0.39 .5337 0.03 0.22 0.06 0.26 .7365 �1.48 2.17 �0.32 1.39 .1051

38 Mid-Ac-endocanthion (Rt) 0.17 0.19 0.10 0.26 .4119 �0.09 0.21 0.08 0.27 .0449� 0.12 0.77 0.20 0.46 .7525

39 Mid-Ac-endocanthion (Lt) 0.11 0.22 �0.07 0.30 .0628 �0.02 0.27 0.03 0.35 .6495 �0.03 0.69 0.30 0.64 .1855

40 Midpoint of upper cheek (Rt) 0.04 0.31 0.03 0.21 .9327 �0.06 0.22 0.02 0.23 .3491 �0.28 0.90 �0.01 0.62 .3532

41 Midpoint of upper cheek (Lt) 0.09 0.25 0.07 0.26 .7586 �0.05 0.27 0.05 0.26 .2746 �0.37 0.85 0.08 0.84 .1557

42 Mid-Ac-Ac-exocanthion (Rt) �0.07 0.25 �0.20 0.28 .1803 0.04 0.23 �0.11 0.19 .0631 �0.58 1.53 �0.33 0.60 .5125

43 Mid-Ac-Ac-exocanthion (Lt) 0.08 0.31 �0.02 0.18 .3257 �0.01 0.17 0.02 0.24 .6365 �0.68 1.54 �0.21 0.80 .2606

44 Zygomatic point (Rt) �0.59 2.43 0.88 2.20 .0949 �0.38 0.85 0.07 0.56 .1097 �1.04 2.62 0.17 2.13 .1839

45 Zygomatic point (Lt) 0.08 2.05 �0.13 1.88 .7739 �0.50 0.81 �0.23 0.70 .3385 �0.64 1.85 �0.11 1.77 .4281


47 Cheilion-exocanthion (Lt) 0.13 1.73 0.84 0.72 .1136 �0.62 0.76 �0.66 0.69 .8801 �5.53 6.85 �5.11 5.20 .8541



51 Lateral point of lower cheek (Rt) �0.26 0.49 �0.32 0.42 .7149 �0.25 0.28 �0.23 0.32 .8266 �1.68 3.19 �1.92 2.74 .8275


Independent t test was done.
*P � .05; **P � .01; ***P � .001.

Documents

Three-dimensional evaluation of soft tissue changes after mandibular setback surgery in class III malocclusion patients according to extent of mandibular setback, vertical skeletal