Professional Documents
Culture Documents
SUMMAH Y. The three dimensional changes in the bone and the ratio of soft tissue to bone movement were
investigated in a group of 16 Skeletal 111 patients following orthognathic surgery. Computerised tomogram scans
were taken for each patient pre-operatively and 1 year postoperatively. The scans were superimposed, radial
measurements calculated, and the changes illustrated by two separate colour scales. There was no constant pattern
of movement in the maxilla or mandible in these patients. However, following a Le Fort 1 osteotomy there was
commonly a 1 : 1 ratio in the midline which increased to 1.25: I at the alar bases and over the canine regions
bilaterally. There was also a 1.25 : 1 ratio or greater over the chin and mentalis regions following mandibular set
back.
IR’TRODLCTIOIV our et (II., 1983j., and the upper lip shortens by 20%
of the degree of impaction (Bell VI al.. 1980).
An increasing amount of surgery is being performed The purpose of the study was to investigate the
to correct the underlying skeletal problem in the three dimensional changes in the bone and the ratio
treatment of adult malocclusion and facial deformity. of movements of the overlying soft tissues across the
However the ability to measure and predict the whole of the facial complex following orthognathic
changes as the result of surgery is usually limited to surgery.
two dimensional assessment of lateral skull radio-
graphs. Traditionally, attempts at comparing profiles
with a view to quantifying changes due to growth or
surgery have involved an operator identifying and METHOD
locating landmarks (Walker & Kowalski, 197 I : Dcnis
& Speidel, 1987). The landmarks are often sparse. The patient sample comprised 16 adult patients with
and objections have been voiced on their use. The a class III skeletal I11 malocclusion (9 male and 7
main objections have been that individual analysis female) who required a combination of orthodontics
may bc dependent on profile orientation and that the and surgery to correct their malocclusion. All the
landmarks provide no information on shape or patients in the group were aged I7 years and over.
change in shape in the segments joining them. The Computeriscd tomogram (CT) scans wcrc taken
determination of landmarks also relies on expert of each patient pre-opcrativcly and I year postopera-
opinion to create homologous points (Mardia. 1989). tively. A typical prc-operative scan consisted of 30
Also many of the bony landmarks commonly used 60 I.5 mm thick slices separated by a gap of 3 mm
to evaluate change are destroyed during the surgery throughout the area of surgical interest. The slice
itself (Houston et ~11.. 1987). spacing was increased over the immediate neighbour-
There have been varying values published for the ing areas such as the eyes. The postoperative scans
ratios of soft tissue to bone movement in the midsagit- were restricted to 6 mm slice spacings and the patients
tal plant. In mandibular setbacks the most consistent were scanned only from the supraorbital ridges to
findings arc a 1 : I ratio over the chin (Lines & just below the mandible. This increase in slice spacing
Steinhauser, 1974; Worms et ul., 1976: Moshiri rt al., was to minimize the amount of radiation to the
1982). The ratio of movement then reduces to 0.9: I patient. However. it was important to have sufficient
over B point and 0.8 : I over the lower lip in relation arca scanned to permit superimposition of the scans
to the lower incisor. In maxillary advancements the over a stable and unchanged area of the face. The
thickness of the upper lip is reduced by a ratio of CT data invariably required modification to exclude
I : 2 (Lines & Steinhauser, 1974; Dann er (II.. 1976: the presence of streak artifacts caused by amalgam
Freihofcr, 1977: Bell & Jacobs. 1980; Radney & fillings in the teeth or tixed orthodontic appliances.
Jacobs. 1981). The nasal tip is also advanced in a This was done semiautomatically by retaining only
ratio of 2 : 7 with the maxilla. In maxillary impactions the bone information in those scans that were affected
the nasolabial angle is increased; the nasal lip moves and eliminating the soft tissue detail.
up in a I : 6 ratio to the tip of the maxillary incisors All the patients received some degree of orthodon-
(Schcndel et al.. 1976: Radney & Jacobs. 1981; Mans- tic treatment to align the teeth over their respective
305
306 British Journal of Oral and Mnxillofmal Surgcr>
basal bones and to align and coordinate the dental Three landmarks were located on the front profile
arches. All the patients underwent bimaxillary sur- of the scan (Fig. 1):
gery. In 13 of the cases, the maxilla was moved into The mid-point on the right and left orbital margins
its correct relationship with the cranial base by using just below the front0 nasal suture (landmarks
a Le Fort 1 downfracture procedure. in the remaining 1 & 3).
three cases a Kufner (1971) osteotomy was used. The The hard tissue nasion. defined as the most convex
mandible was set back into occlusion with either a point of the horizontal profile and the point of
sagittal split or a vertical subsigmoid osteotomy. maximum concavity on the vertical pro& (land-
Miniature non-compression bone plates were mark 2).
employed to stabilise the maxilla in its new position. The mid point, right and left. on the base of the
In the sagittal split osteotomies the fragments were zygomatic arch near to the articular eminence. on
fixed using either upper border or circumferential the temporal bone (landmarks 4 & 5).
wires. Intcrmaxillary fixation using the fixed ortho- These points were reliably located on all of the scans.
dontic appliances was placed for a minimum period The points were identified in areas of very dense bone
of 6 weeks postoperatively. and were not affected by small differences in the
thresholds between the two scans. Despite the differ-
ence in the slice spacings between the pre and post-
opcrativc scans the landmarks were always matched
The CT scans were loaded from lilt and thresholded to within 1 mm. The points chosen were felt to bc
for bone ( A 150 Houndsheld threshold). The scans sufficiently far apart and reflect large differences in
were orientated in a front view and then saved as a the X, Y. and Z coordinates. Thus the scan image
view file. This enabled the scan to bc loaded at any could be adequately defined in space.
future occasion in the same position.
ltlcasuretnc~~r qfsurgicol change
Lundmarks
Bone mownenrs. The pre and I year postoperative
Landmarks were identified on the surface of each CT scans were loaded individually and registered using
individual scan. The surface illumination image was the five landmarks specified above. Areas of change
displayed and a cursor was driven across the screen. were then demonstrated using a colour mm scale. The
The three dimensional position of the surface at the scale extends from - 9 to + 9 mm. the cold colours
cursor point was computed from the two dimensional representing negative differences and the warm colours
screen position. the value of the 7 buffer at that point positive movements. In areas where there has been no
and the matrix transformation from viewing space to change the original colour of the CT scan remains. In
object space. The location of the landmarks was this way both the area and amount of movement can
assisted by vertical and horizontal profiles of the be seen. An example of one of the patients in the
object at the cursor point being displayed alongside study is illustrated in Figure 2. The image shown is
the image. Five landmarks in total wcrc found to be the superimposition of the postoperative scan on the
adequate to gain a high degree of reproducibility in pre-operative scan. and thus the cold colours represent
the matching of the prc- and postoperative images positive surgical changes and the warm colours ncga-
(Fig. 1). tive surgical changes. The areas of change were calcu-
Method errors
Five landmarks on the pre and postoperative CT
Fig.3- Radial measurements from the centrc of rotation of the
scans of all 16 patients were identified on three skull IO either bone or skm surface.
separate occasions at weekly intervals. The method
errors were reported as the mean difference and the
standard deviations in the X, Y and Z coordinates RESULTS
of each landmark identified (Tables I, 2 and 3). The
null hypothesis for the mean difference in each coordi- At present the computer software is unable to average
nate was also tested using a one sample t-test. the CT data and consequently it is only possible to
308 BriIIsh Journal of Oral and Maxlllofacial Surgery
Patient Maxilla
report upon individual cases for the bone movements positive surgical movements or ratios and warm
and the ratios of soft to hard tissue. The overall colours as negative movements or ratios.
movements achieved arc illustrated in Talks 4 7.
Only a few defined arcas arc reported in the tables
for ease of illustration and comparison of the cases
as a whole (Fig. 4). There was a very varied degree of movement in the
One of the patients from the group is described in maxtlla. the degree of movement did not reduce
detail to illustrate the bone and ratio of soft tissue anteriorly to posteriorly (Table 4). There was a fairly
movements. The pre-operative scan is shown for all constant dcgrec of movement in the mandible over
the comparisons, and thus cold colours rcprescnt the chin and mcntalis region. In those cases where
Blmdxillary orthognathic surgery 309
Patlent Mandible
Patient Max11l.i
XI 1.5: I I I
X2 T.25. I III 1.25: 1 1.25: I I .25 : I I I I.1
X3 I.1 I 5 1.5. I 0 75 I 075.1
X4
X5 1.25 I I.1 1.15: I 1.25 I 1.25: I 1.5. 1.5: I
X6 I:1 1-l
Xl 0.75: I 1.5: I 1.5. I I5 IYI 1.15: I
X8
x9 1:I I.1 111 I:1 l-l I I 1.25: I
x10 1.5: I 1.5: I I:1 1.5: I
XII 1.25. I I:1 I25:l 1.5: I 1.5: I I:1 I:1
Xl2 1.5: I 1.25: I 1.5. I I .25: I 1.5: I
XI? MD
x14 MD
Xl5 MD
Xl6 MD
there was a small degree ofset back anteriorly (5 mm). a 1 : I ratio in the midline which increased to 1.25 : I
there was a similar movement in the body region and at the alar bases and over the canine regions bilater-
third molars bilaterally. However, in large anterior ally. This increased ratio did not continue out into
set backs the degree of movement progressively the paranasal arcas. where a 1 : 1 ratio was commonly
decreased over the body of the mandible and third found. Cases Xl. X3. and X9 show a very different
molar regions (Table 5). pattern of movement to the rest of the group and
these t hrec patients had undergone a K ufner advance-
ment of the maxilla (Table 6).
Soft rissue ratios
There was a very varied degree of movement over
There was no constant pattern of movement in the the mandible. However. over the chin and mcntalis
maxilla. However, in those cases where a Le Fort I regions there was commonly a 1.25 : 1 ratio or greater
osteotomy had been undertaken there was commonly (Table 7).
3 IO Rrltlsh Journal of Oral and Maxlllofaclat Surgery
Patient Mandible
DISCUSSION
POSTERIOR