- Email: [email protected]
Aesthetic changes in mandibular midline osteotomy for constriction
Oral Presentations / O38, Orthognathic Surgery IV between long term chronic inflammatory change and carcino-genesis is suggested. We present a case of pemphigus vulgaris with multiple primary oral cancers on Long Period. Patient was 63 years old, Japanese women. She visited us with chief complaint of contact soreness at oral mucosa in December 3rd, 1986. Anti-hypertensives had been medicated. Intra-oral findings, erosive lesions could be recognized at maxillary alveolus, palatal and tongue mucosa. No skin legion had been recognized. Laboratory data showed no particular abnormality except 40 mm/h of ESR. Biopsy specimens taken from tongue edge lesion showed acantholitic bulla in prickle cell layer of suprabasal position as typical pemphigus vulgaris histopathologically and indirect immunofluorescens testing. For this lesion, local and systemic treatment by predonisolon (PSL) was employed. The effects were not enough and erosive lesions remained. Three years later, papillomatous change could be recognized at maxillary gingiva and mucobuccal fold. Seven years later, biopsied specimens were taken again from three oral mucosal lesions and showed multi centric oral cancers. Further more, 17 years later from the first visit, the 4th oral cancer was recognized on the lower lip. Surgical excision was selected for the treatment of these lesions. The lip cancer was controlled well, but 1 year and 5 months after this treatment, the 5th oral cancer was recognized on the right buccal mucosa. The first cancer was verrucous carcinoma on the right upper gingival, the 2nd was squamous cell carcinoma on the left mucobuccal fold, 3rd was carcinoma in situ on the right cheek mucosa, 4th was early invasive squamous cell carcinoma on the lower lip and 5th was squamous cell calcinoma. At present, there are wide spread severe erosions on the oral mucosa by pemphigus vulgaris, and the patient did not agree for surgical cancer treatment. Only chemotherapy for cancer and predonine per os treatment are continued. 1. A rare case with pemphigus vulgaris complicated with 5 primary oral cancers under the long term observation is presented. 2. All the oral cancers occurred on the erosive lesion of pemphigus vulgaris. 3. It is suggested that there may be a relation between a long term chronic inflammatory change of poorly controlled pemphigus vulgaris and carcinogenesis. [-~-~
RECURRENT AMELOBLASTIC CARCINOMA EX AMELOBLASTOMA OF MAXILLA - A CASE REPORT
L.H. Chi, "~H. Li, B.'~ Pemg. Department of Oral & Maxillofacial Surgery,
Taipei Medical University Hospital 252, Wu-Xing Street, Taipei, Taiwan (ROC) We report the 19th case of a maxillary ameloblastic carcinoma in the English literature. It is a rare odontogenic malignancy. A 23-yearold male presented to us for a recurrent right maxillary tumor. Surgical history of this site was performed 2 years ago, histology diagnosis as ameloblatoma. After a thorough head and neck examination, CT/MRI evaluation, tumor excision surgery was performed via CaldwellLuc approach. Surgical pathology revealed ameloblastic carcinoma ex ameloblastoma, because of focal squamous metaplasia, frequent mitotic figures, apoptosis, tumor necrosis and mild pleomorphism present. Post-operative adjuvant radiotherapy with IMRT mode was performed. Ameloblastoma is 1% of all odontogenic tumor, and 20% in maxilla. The malignant transformation from ameloblatoma is very rare, compared with arising de novo. In the English literature, no report is mentioned about IMRT for this cancer. References
[1] Dhir K, Sciubba JJ, Tufano R. Ameloblastic carcinoma. Oral Oncology 2003; 39:736-741. [ - ~ - - ~ - - 1 S Y N O V I A L SARCOMA OF THE PALATE - CASE REPORT AND REVIEW OF LITERATURE S. Ramachandra, R. Lee, M. Bailey. Ashford and St. Peters Hospitals
71 [-~--~
SURGICAL MANAGEMENT OF LARGE CYSTIC ODONTOGENIC TUMORS; A CONSERVATIVE APPROACH
W. Qadri, S.M. Haider, H.M. Zaidi. Joint departments of oral and
maxillofacial surgery, Karachi Medical and Dental College & Abbasi Shaheed Hospital Karachi, Pakistan This study was done to evaluate the effectiveness of marsupalization in conservative management of large cystic odontogenic tumors. Clinical and histologic examination of 12 cystic large odontogenic tumors were performed before and after surgical management. All the tumors were marsupialized with a standard technique. Clinically and radiographically, the effect of marsupialization was evaluated. Marsupialization was most effective in teenaged patients. In three cases, the tumor disappeared macroscopically, and further surgery was not performed. Histologically, the growth characteristics of the tumor were classified into expansile and invasive types. Premarsupialization, the expansile pattern with the cuboidal cell type was dominant, whereas for postmarsupialization many cases that had been expansile changed to an invasive type showing columnar or basal cell types. Marsupialization was found to be useful as a preliminary treatment of the cystic odontogenic tumors. However, it must be borne in mind that following marsupialization the tumor still has a potential to infiltrate into the surrounding tissues.
038. Orthognathic Surgery IV
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ENHANCING FACIAL HARMONY
S. Benarroch Mahfoda. Aesthetic & Maxillofacial Clinic, Madrid, Spain Determine the type of cosmetic surgery procedures most frequently used to enhance the result of orthognathic surgery Two hundred and fifty two orthognathic surgery patients (180 females and 72 males) that also had plastic procedures over a 7 year period were reviewed retrospectively. The mean age was 26.5 (19-34). All the patients underwent a complete facial analysis. Three groups were evaluated depending on the dentofacial deformity diagnosed. Group I: Maxillar, Group I1: Mandibular, Group II1: Maxillo-mandibular. No distinction was made among patients based on whether the cosmetic surgery was done before, during or after the orthognathic surgery. The facial plastics procedures most frequently associated were: Genioplasty, Rhinoplasty, Malar augmentation, Buccal fat pad removal, Lip-plasties, Submental liposuction, Blepharoplasty. Group I: 110 patients, Genioplasty 63, Rhinoplasty 29, Blepharoplasty (upper lateral canthus, VME) 23, Lip-plasty (lower, reduction) 18, Buccal fat pad removal 15, Malar augmentation 9, Submental liposuction 5. Group I1:88 patients, Genioplasty 43, Rhinoplasty 48, Lip-plasty (lower, reduction) 15, Malar augmentation 14, Queiloplasty (upper, augmentation) 6, Submental liposuction 2. Group II1:54 patients: Genioplasty: 29, Lip-plasty (lower, reduction) 9, Lip-plasty (upper, augmentation) 4. No statistically significant differences in complication rates were found among the groups. The prevalence of morbidity in all groups was practically identical to previous studies. Of the total facial plastic procedures included in this study, 77% were perform at the time of the dentofacial correction. 85% of the patients were satisfied with the final results. Facial harmony is a very complex issue; many studies have been published defining, by mathematical analysis, what constitutes an attractive face. Although there is great variability (sex, race) and subjectivity (eye of the beholder) in appreciation of facial beauty. The results of this retrospective review do not indicate that the combination of cosmetic surgical procedures increases morbidity. The advantages of combined procedures include a single recovery period, reduced surgery costs, and faster patient gratification.
NHS Trust, United Kingdom The aim of this presentation is to discuss a case of a rare tumour (Synovial Sarcoma) of the palate. Review of literature is also discussed. This report is about a 38 year old male with a left palatal lump which proved to be synovial sarcoma. Treatment included left maxillectomy followed by post operative radiotherapy. The tumour was successfully managed with surgery and radiotherapy. The patient has been followed up for the last four years with no local recurrence or metastasis. Synovial sarcoma is an aggressive mesenchymal tumour which is rare in the head and neck region, especially palate. Though this patient has been disease free for the last four years, the overall prognosis of the tumour is poor.
F03~
AESTHETIC CHANGES IN MANDIBULAR MIDLINE OSTEOTOMY FOR CONSTRICTION
R. Lebeda 1,2, M. Baltensperger 1 , R. Alcalde 2, D. Bloomquist 2. 1Center
for Jaw Surgery, Winterthur/Zurich, Switzerland; 2Dept. of OMFS, University of Washington, Seattle, USA Transverse discrepancies in dentofacial deformities can be addressed successfully by constriction with a mandibular midline osteotomy combined with bilateral sagittal split osteotomies (MC-BSSO) and lead to stable and predictive dento-skelettal results. However, soft tissue changes
72 associated with this surgical technique cannot be assessed accurately with cephalograms or photographs. The purpose of this study was to determinate the soft tissue changes of the posterior lower face and the mandibular angle in patients who underwent MC-BSSO. Sixty-four patients underwent bilateral sagittal split osteotomy procedures (BSSO) for treatment of their dentofacial deformity. Thirty of these patients (18 females and 12 males) received a MC-BSSO to address their transverse discrepancy. The mean surgical constriction in the lower 2nd molar region was 5.75±1.45 mm (range 3-9 mm). The patients were interviewed and three dimension surface images were taken preoperatively as well as 3, respectively 6 months after surgery. Facial soft tissue analysis was obtained with the 3dMD Face System that allowed identification of the chosen surface anatomic landmarks (anterior and posterior mandible and gonion) and superimposition of the scans with a minimal accuracy of 0.5 mm. The obtained measurements showed a statistically significant decrease in transverse width at the posterior level of the mandible and the gonion in patients receiving MC-BSSO compared to the group only receiving BSSO (p >0.001). No significant changes between the two groups were obtained at the anterior level of the mandible. The overall soft-tissue response to reduction of transverse width by MC-BSSO was approximately 66.5%. The interviews of the patients demonstrated no aesthetic disadvantages noticed by the patients concerning lower facial width at the posterior face or mandibular angle. In some patients receiving MC-BSSO the changes of the mandibular angle was clearly stated to be an even more favorable aesthetic result, compared to the presurgical situation. MC-BSSO is as previously reported a simple, sable, low cost and low morbidity surgical procedure with minimal soft tissue changes in the lower posterior face and mandibular angle.
[ - O - ' ~ - ] EVALUATION OF THE SOFT AND HARD TISSUE CHANGES AFTER BIMAXILLARY ANTERIOR SEGMENTAL OSTEOTOMY B. Rahsepar, K. Taban, H.R. Pakshir. Shiraz University of Medical
Sciences, Shiraz, Iran Facial changes of 76 adult Iranian, who underwent Wunderer segmental osteotomy on the maxilla and mandible, were analyzed with pre and post operative cephalograms and facial photos. Facial changes of 76 adult Iranian, who underwent Wunderer segmental osteotomy on the maxilla and mandible, were analyzed with pre and post operative cephalograms and facial photos. Significant facial changes were noted as follows: posterior movement of the upper and lower lip at a ratio 3:4 and 1:1 to the upper and lower incisors, the increase of the nasolabial angle, the decrease of the width and thickness of the lip, and accentuation of the labiomental fold. The nasal change could be kept as minimal as possible with Wunderer technique because of the palatal approach and not disturbing alar attachments. Wundere technique is a safe approach for Maxillary Protrusion.
[-0-'~'-~ CONSEQUENCES OF ORTHOGNATHIC SURGERY ON SOFT TISSUE PROFILE M. RLicker1, B. Bastian2, T. Binger3, W.J. Spitzer3. 1Clinic for Oral and Maxillofacial Surgery, Medical University Hannover, 30625 Hannover; 2Dep. of Orthodontics, University of Saarland, Homburg/Saar; 3Dep. of Oral and Maxillofacial Surgery, University of Saarland, 66421 Homburg/Saar, Germany Surgical treatment of maxillofacial dysgnathia results in changes of soft tissue profile. Since the achieved soft tissue profile is essential for patient's pleasure, we studied whether the orthognathic surgery results in a favourable facial esthetic. Maxillofacial dysgnathias were treated surgically either by monomaxillary procedures, in particular by mandibular set back (group 1, n = 18) and maxillary advancement (group 2, n = 17), respectively, or by bimaxillary osteotomy (group 3, n = 10). Using lateral cephalograms taken before and after orthognathic surgery, the soft tissue profile was analyzed according to the methods described by Ricketts and Steiner. After orthognathic surgery a neutral basal relation of jaws was found in group 1 (ANB: 0.5±2.3°), group 2 (ANB: 0.9±2.5 °) and group 3 (ANB: 0.7±2.3°). However, only in some patients the standard values of the Ricketts esthetic line (group 1: lower lip 39/ upper lip 28; group 2: 56/50; group 3: 30/30%patients) and the standard values of the Steiner line (39/59; 50/31; 20/0% patients) could be achieved, although the deviation of upper lip and lower lip from these analytic reference lines was frequently found reduced. After orthognathic surgery
Int. J. Oral Maxillofac. Surg. 2005; 34 (Supplement 1): $ 1 - $ 1 8 1 despite achievement of neutral basal relation of jaws the soft tissue profile was found frequently improved but rarely optimized. Our results that soft tissue profile was found insufficient after both monomaxillary and bimaxillary surgery indicates deviations of facial components not influenced by orthognathic surgery rather than occlusal limitation of jaw movements. Therefore, the request for a perfect soft tissue profile frequently requires additional plastic surgery.
~--~
THREE-DIMENSIONAL SOFT TISSUE CHANGES ASSOCIATED WITH MANDIBULAR ORTHOGNATHIC SURGERY
R.E. Alcalde, Z. Lowe, D. Joondeph, T. Wallen, D. Bloomquist.
University of Washington Department of Oral and Maxillofacial Surgery & Department of Orthodontics, USA To determine the soft tissue changes associated with bilateral sagittal split osteotomy (BSSO) of the mandible, performed with or without a midline osteotomy (MC) Twenty-eight patients were included in this study, after meeting strict inclusion criteria. Thirteen underwent a BSSO with an MC to address transverse discrepancy, while the other fifteen patients only had a BSSO. Twenty-four BSSO procedures were advancements and the rest were setbacks. Pre and post surgical images of the patients' faces were obtained using the 3DMD photo imager, which allowed for the superimposition and manipulation of the 3D data with an accuracy of 0.5 mm. The pre and post surgical images were overlaid, anatomical landmarks identified, and the soft tissue measured for changes. Statistically significant changes in the transverse direction at the mandibular body and gonial angle were measured when a BSSO was combined with MC. In MC patients, the transverse skeletal to soft tissue ratio in the posterior mandible was 1:0.67. Soft tissue changes induced by mandibular advancement and setback were most prominent in the facial midline in 38% of the cases. The skeletal to soft tissue ratio in the anterior and posterior (A-P) direction ranged from 1:0.43 to 1:0.75. In BSSO advancement, the vertical height of the mandible remained relatively constant while the mentolabial fold moved downward following the clockwise rotation associated with mandibular advancement. This study demonstrated that the soft tissue changes occur at a higher degree outside the facial midline, which is where most of the lateral cephalometric measurements are made. 3D analysis of soft tissue changes, using the 3dMD imager allows accurate facial analysis of the A-P, vertical, and transverse changes induced by orthognathic surgery.
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PRESENTATION AND VALIDATION OF A VOXEL-BASED THREE-DIMENSIONAL (3-D) HARD AND SOFT TISSUE CEPHALOMETRIC ANALYSIS
G.R.J. Swennen, E Schutyser, E.-L. Barth, A. Lemaitre, C. Malevez, A. De Mey. 1Dept of Plastic Surgery, University Hospital Brugmann
(ULB), Brussels, Belgium; 2Medical Image Computing (Radiology ESAT/PSI), Faculties of Medicine and Engineering, University Hospital, Gasthuisberg, Leuven, Belgium The purpose of this study is to present and validate a new voxel-based three-dimensional (3-D) hard and soft tissue cephalometric analysis. The CT- data (DICOM 3.0 files) of 20 control patients with normal skeletal relationships were used for this study. To investigate accuracy and reliability of 3-D cephalometry (MaxilimTM, version 1.3.0) a total of 36 angular, 78 linear measurements and 164 (54 horizontal, 54 vertical and 54 transversal) orthogonal measurements were performed on each patient twice by each of two investigators. The intra-observer measurement error was less then 0.85 degrees for angular measurements and less then 0.78 mm, 0.88 mm, 0.76 mm and 0.84 mm for linear, horizontal, vertical and transversal orthogonal measurements, respectively. The inter-observer measurement error was less as 1.03 degrees for angular measurements and less then 0.84 mm, 0.78 mm, 0.86 mm and 1.26 mm for linear, horizontal, vertical and transversal orthogonal measurements, respectively. Squared correlation coefficients showed a high intra-observer and inter-observer reliability. The presented threedimensional cephalometric hard tissue analysis showed to be accurate and reliable and therefore presents a useful tool for objective evaluation of voxel-based virtual planning and surgery.in the future.
RECURRENT AMELOBLASTIC CARCINOMA EX AMELOBLASTOMA OF MAXILLA - A CASE REPORT
L.H. Chi, "~H. Li, B.'~ Pemg. Department of Oral & Maxillofacial Surgery,
Taipei Medical University Hospital 252, Wu-Xing Street, Taipei, Taiwan (ROC) We report the 19th case of a maxillary ameloblastic carcinoma in the English literature. It is a rare odontogenic malignancy. A 23-yearold male presented to us for a recurrent right maxillary tumor. Surgical history of this site was performed 2 years ago, histology diagnosis as ameloblatoma. After a thorough head and neck examination, CT/MRI evaluation, tumor excision surgery was performed via CaldwellLuc approach. Surgical pathology revealed ameloblastic carcinoma ex ameloblastoma, because of focal squamous metaplasia, frequent mitotic figures, apoptosis, tumor necrosis and mild pleomorphism present. Post-operative adjuvant radiotherapy with IMRT mode was performed. Ameloblastoma is 1% of all odontogenic tumor, and 20% in maxilla. The malignant transformation from ameloblatoma is very rare, compared with arising de novo. In the English literature, no report is mentioned about IMRT for this cancer. References
[1] Dhir K, Sciubba JJ, Tufano R. Ameloblastic carcinoma. Oral Oncology 2003; 39:736-741. [ - ~ - - ~ - - 1 S Y N O V I A L SARCOMA OF THE PALATE - CASE REPORT AND REVIEW OF LITERATURE S. Ramachandra, R. Lee, M. Bailey. Ashford and St. Peters Hospitals
71 [-~--~
SURGICAL MANAGEMENT OF LARGE CYSTIC ODONTOGENIC TUMORS; A CONSERVATIVE APPROACH
W. Qadri, S.M. Haider, H.M. Zaidi. Joint departments of oral and
maxillofacial surgery, Karachi Medical and Dental College & Abbasi Shaheed Hospital Karachi, Pakistan This study was done to evaluate the effectiveness of marsupalization in conservative management of large cystic odontogenic tumors. Clinical and histologic examination of 12 cystic large odontogenic tumors were performed before and after surgical management. All the tumors were marsupialized with a standard technique. Clinically and radiographically, the effect of marsupialization was evaluated. Marsupialization was most effective in teenaged patients. In three cases, the tumor disappeared macroscopically, and further surgery was not performed. Histologically, the growth characteristics of the tumor were classified into expansile and invasive types. Premarsupialization, the expansile pattern with the cuboidal cell type was dominant, whereas for postmarsupialization many cases that had been expansile changed to an invasive type showing columnar or basal cell types. Marsupialization was found to be useful as a preliminary treatment of the cystic odontogenic tumors. However, it must be borne in mind that following marsupialization the tumor still has a potential to infiltrate into the surrounding tissues.
038. Orthognathic Surgery IV
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•
]
ENHANCING FACIAL HARMONY
S. Benarroch Mahfoda. Aesthetic & Maxillofacial Clinic, Madrid, Spain Determine the type of cosmetic surgery procedures most frequently used to enhance the result of orthognathic surgery Two hundred and fifty two orthognathic surgery patients (180 females and 72 males) that also had plastic procedures over a 7 year period were reviewed retrospectively. The mean age was 26.5 (19-34). All the patients underwent a complete facial analysis. Three groups were evaluated depending on the dentofacial deformity diagnosed. Group I: Maxillar, Group I1: Mandibular, Group II1: Maxillo-mandibular. No distinction was made among patients based on whether the cosmetic surgery was done before, during or after the orthognathic surgery. The facial plastics procedures most frequently associated were: Genioplasty, Rhinoplasty, Malar augmentation, Buccal fat pad removal, Lip-plasties, Submental liposuction, Blepharoplasty. Group I: 110 patients, Genioplasty 63, Rhinoplasty 29, Blepharoplasty (upper lateral canthus, VME) 23, Lip-plasty (lower, reduction) 18, Buccal fat pad removal 15, Malar augmentation 9, Submental liposuction 5. Group I1:88 patients, Genioplasty 43, Rhinoplasty 48, Lip-plasty (lower, reduction) 15, Malar augmentation 14, Queiloplasty (upper, augmentation) 6, Submental liposuction 2. Group II1:54 patients: Genioplasty: 29, Lip-plasty (lower, reduction) 9, Lip-plasty (upper, augmentation) 4. No statistically significant differences in complication rates were found among the groups. The prevalence of morbidity in all groups was practically identical to previous studies. Of the total facial plastic procedures included in this study, 77% were perform at the time of the dentofacial correction. 85% of the patients were satisfied with the final results. Facial harmony is a very complex issue; many studies have been published defining, by mathematical analysis, what constitutes an attractive face. Although there is great variability (sex, race) and subjectivity (eye of the beholder) in appreciation of facial beauty. The results of this retrospective review do not indicate that the combination of cosmetic surgical procedures increases morbidity. The advantages of combined procedures include a single recovery period, reduced surgery costs, and faster patient gratification.
NHS Trust, United Kingdom The aim of this presentation is to discuss a case of a rare tumour (Synovial Sarcoma) of the palate. Review of literature is also discussed. This report is about a 38 year old male with a left palatal lump which proved to be synovial sarcoma. Treatment included left maxillectomy followed by post operative radiotherapy. The tumour was successfully managed with surgery and radiotherapy. The patient has been followed up for the last four years with no local recurrence or metastasis. Synovial sarcoma is an aggressive mesenchymal tumour which is rare in the head and neck region, especially palate. Though this patient has been disease free for the last four years, the overall prognosis of the tumour is poor.
F03~
AESTHETIC CHANGES IN MANDIBULAR MIDLINE OSTEOTOMY FOR CONSTRICTION
R. Lebeda 1,2, M. Baltensperger 1 , R. Alcalde 2, D. Bloomquist 2. 1Center
for Jaw Surgery, Winterthur/Zurich, Switzerland; 2Dept. of OMFS, University of Washington, Seattle, USA Transverse discrepancies in dentofacial deformities can be addressed successfully by constriction with a mandibular midline osteotomy combined with bilateral sagittal split osteotomies (MC-BSSO) and lead to stable and predictive dento-skelettal results. However, soft tissue changes
72 associated with this surgical technique cannot be assessed accurately with cephalograms or photographs. The purpose of this study was to determinate the soft tissue changes of the posterior lower face and the mandibular angle in patients who underwent MC-BSSO. Sixty-four patients underwent bilateral sagittal split osteotomy procedures (BSSO) for treatment of their dentofacial deformity. Thirty of these patients (18 females and 12 males) received a MC-BSSO to address their transverse discrepancy. The mean surgical constriction in the lower 2nd molar region was 5.75±1.45 mm (range 3-9 mm). The patients were interviewed and three dimension surface images were taken preoperatively as well as 3, respectively 6 months after surgery. Facial soft tissue analysis was obtained with the 3dMD Face System that allowed identification of the chosen surface anatomic landmarks (anterior and posterior mandible and gonion) and superimposition of the scans with a minimal accuracy of 0.5 mm. The obtained measurements showed a statistically significant decrease in transverse width at the posterior level of the mandible and the gonion in patients receiving MC-BSSO compared to the group only receiving BSSO (p >0.001). No significant changes between the two groups were obtained at the anterior level of the mandible. The overall soft-tissue response to reduction of transverse width by MC-BSSO was approximately 66.5%. The interviews of the patients demonstrated no aesthetic disadvantages noticed by the patients concerning lower facial width at the posterior face or mandibular angle. In some patients receiving MC-BSSO the changes of the mandibular angle was clearly stated to be an even more favorable aesthetic result, compared to the presurgical situation. MC-BSSO is as previously reported a simple, sable, low cost and low morbidity surgical procedure with minimal soft tissue changes in the lower posterior face and mandibular angle.
[ - O - ' ~ - ] EVALUATION OF THE SOFT AND HARD TISSUE CHANGES AFTER BIMAXILLARY ANTERIOR SEGMENTAL OSTEOTOMY B. Rahsepar, K. Taban, H.R. Pakshir. Shiraz University of Medical
Sciences, Shiraz, Iran Facial changes of 76 adult Iranian, who underwent Wunderer segmental osteotomy on the maxilla and mandible, were analyzed with pre and post operative cephalograms and facial photos. Facial changes of 76 adult Iranian, who underwent Wunderer segmental osteotomy on the maxilla and mandible, were analyzed with pre and post operative cephalograms and facial photos. Significant facial changes were noted as follows: posterior movement of the upper and lower lip at a ratio 3:4 and 1:1 to the upper and lower incisors, the increase of the nasolabial angle, the decrease of the width and thickness of the lip, and accentuation of the labiomental fold. The nasal change could be kept as minimal as possible with Wunderer technique because of the palatal approach and not disturbing alar attachments. Wundere technique is a safe approach for Maxillary Protrusion.
[-0-'~'-~ CONSEQUENCES OF ORTHOGNATHIC SURGERY ON SOFT TISSUE PROFILE M. RLicker1, B. Bastian2, T. Binger3, W.J. Spitzer3. 1Clinic for Oral and Maxillofacial Surgery, Medical University Hannover, 30625 Hannover; 2Dep. of Orthodontics, University of Saarland, Homburg/Saar; 3Dep. of Oral and Maxillofacial Surgery, University of Saarland, 66421 Homburg/Saar, Germany Surgical treatment of maxillofacial dysgnathia results in changes of soft tissue profile. Since the achieved soft tissue profile is essential for patient's pleasure, we studied whether the orthognathic surgery results in a favourable facial esthetic. Maxillofacial dysgnathias were treated surgically either by monomaxillary procedures, in particular by mandibular set back (group 1, n = 18) and maxillary advancement (group 2, n = 17), respectively, or by bimaxillary osteotomy (group 3, n = 10). Using lateral cephalograms taken before and after orthognathic surgery, the soft tissue profile was analyzed according to the methods described by Ricketts and Steiner. After orthognathic surgery a neutral basal relation of jaws was found in group 1 (ANB: 0.5±2.3°), group 2 (ANB: 0.9±2.5 °) and group 3 (ANB: 0.7±2.3°). However, only in some patients the standard values of the Ricketts esthetic line (group 1: lower lip 39/ upper lip 28; group 2: 56/50; group 3: 30/30%patients) and the standard values of the Steiner line (39/59; 50/31; 20/0% patients) could be achieved, although the deviation of upper lip and lower lip from these analytic reference lines was frequently found reduced. After orthognathic surgery
Int. J. Oral Maxillofac. Surg. 2005; 34 (Supplement 1): $ 1 - $ 1 8 1 despite achievement of neutral basal relation of jaws the soft tissue profile was found frequently improved but rarely optimized. Our results that soft tissue profile was found insufficient after both monomaxillary and bimaxillary surgery indicates deviations of facial components not influenced by orthognathic surgery rather than occlusal limitation of jaw movements. Therefore, the request for a perfect soft tissue profile frequently requires additional plastic surgery.
~--~
THREE-DIMENSIONAL SOFT TISSUE CHANGES ASSOCIATED WITH MANDIBULAR ORTHOGNATHIC SURGERY
R.E. Alcalde, Z. Lowe, D. Joondeph, T. Wallen, D. Bloomquist.
University of Washington Department of Oral and Maxillofacial Surgery & Department of Orthodontics, USA To determine the soft tissue changes associated with bilateral sagittal split osteotomy (BSSO) of the mandible, performed with or without a midline osteotomy (MC) Twenty-eight patients were included in this study, after meeting strict inclusion criteria. Thirteen underwent a BSSO with an MC to address transverse discrepancy, while the other fifteen patients only had a BSSO. Twenty-four BSSO procedures were advancements and the rest were setbacks. Pre and post surgical images of the patients' faces were obtained using the 3DMD photo imager, which allowed for the superimposition and manipulation of the 3D data with an accuracy of 0.5 mm. The pre and post surgical images were overlaid, anatomical landmarks identified, and the soft tissue measured for changes. Statistically significant changes in the transverse direction at the mandibular body and gonial angle were measured when a BSSO was combined with MC. In MC patients, the transverse skeletal to soft tissue ratio in the posterior mandible was 1:0.67. Soft tissue changes induced by mandibular advancement and setback were most prominent in the facial midline in 38% of the cases. The skeletal to soft tissue ratio in the anterior and posterior (A-P) direction ranged from 1:0.43 to 1:0.75. In BSSO advancement, the vertical height of the mandible remained relatively constant while the mentolabial fold moved downward following the clockwise rotation associated with mandibular advancement. This study demonstrated that the soft tissue changes occur at a higher degree outside the facial midline, which is where most of the lateral cephalometric measurements are made. 3D analysis of soft tissue changes, using the 3dMD imager allows accurate facial analysis of the A-P, vertical, and transverse changes induced by orthognathic surgery.
~--~
PRESENTATION AND VALIDATION OF A VOXEL-BASED THREE-DIMENSIONAL (3-D) HARD AND SOFT TISSUE CEPHALOMETRIC ANALYSIS
G.R.J. Swennen, E Schutyser, E.-L. Barth, A. Lemaitre, C. Malevez, A. De Mey. 1Dept of Plastic Surgery, University Hospital Brugmann
(ULB), Brussels, Belgium; 2Medical Image Computing (Radiology ESAT/PSI), Faculties of Medicine and Engineering, University Hospital, Gasthuisberg, Leuven, Belgium The purpose of this study is to present and validate a new voxel-based three-dimensional (3-D) hard and soft tissue cephalometric analysis. The CT- data (DICOM 3.0 files) of 20 control patients with normal skeletal relationships were used for this study. To investigate accuracy and reliability of 3-D cephalometry (MaxilimTM, version 1.3.0) a total of 36 angular, 78 linear measurements and 164 (54 horizontal, 54 vertical and 54 transversal) orthogonal measurements were performed on each patient twice by each of two investigators. The intra-observer measurement error was less then 0.85 degrees for angular measurements and less then 0.78 mm, 0.88 mm, 0.76 mm and 0.84 mm for linear, horizontal, vertical and transversal orthogonal measurements, respectively. The inter-observer measurement error was less as 1.03 degrees for angular measurements and less then 0.84 mm, 0.78 mm, 0.86 mm and 1.26 mm for linear, horizontal, vertical and transversal orthogonal measurements, respectively. Squared correlation coefficients showed a high intra-observer and inter-observer reliability. The presented threedimensional cephalometric hard tissue analysis showed to be accurate and reliable and therefore presents a useful tool for objective evaluation of voxel-based virtual planning and surgery.in the future.