Soft tissue changes associated with double

jaw surgery
Alan C. Jensen, DDS, MS," Peter M. Sinclair, DDS, MSD, b and Larry M. Wolford, DDS c
Dallas, Texas

The purpose of this study was to evaluate the amount, direction, and predictability of the soft tissue
changes associated with simultaneous maxillary impaction and mandibular advancement surgery.
The results suggested that the soft tissue responses were similar to those seen in single jaw
procedures, with the exception of the changes seen in the nasolabial angle and in the area of the
lower lip and chin. The type of soft tissue manipulation employed, in particular the use of the alar
base cinch suture and V-Y closure techniques, were important factors in determining the response of
the upper lip to the surgery, The maxillary soft tissues moved forward 90% of the hard tissue change
and showed 20% shortening of the upper lip, with the changes in the nasolabial angle being due
primarily to the degree of the maxillary rotation. A predictable progressive increase was seen in the
horizontal movement of the mandibular soft tissues ranging from 73% of the hard tissue change at
the lower lip to 100% at pogonion. The vertical movement of the mandibular soft tissue was greater
than that of underlying hard tissues, particularly in the area of the lower lip as it was freed from the
effects of the maxillary incisors. (AM J ORTHOO DENTOFAC 1992;101:266-75.)

T
I n the presurgical workup of any potential
orthogn~fthic case, one of the prime concerns of both
the orthodontist and the oral surgeon must be the final
soft tissue p~ofile and the esthetic appearance of the
patient. The relative anteroposterior positions of the
nOse, lips, and chin must be evaluated, as must the
vertical proportions of the soft tissue as well as the soft
tissue contours, to produce the optimum postoperative
profile.
Initially, facial form was analyzed by various ortho-
dontic investigators in attempts to relate the soft tissue
profile to the underlying dentition. Researchers, who
included Ricketts,1 Steiner,2 B urstone,3 and Holdaway, 4
soon recognized the need for, and therefore developed,
cephalometric techniques to evaluate soft tissue that
were separate from the established skeletal and dental
analyses. Other investigators 51° have clearly demon-
strated that, although the overlying soft tissue does not
always reflect the underlying dentoskeletal pattern,
there were some associations between the amount of
tooth movement and the resultant soft tissue changes.
The first surgical soft tissue studies were associated
primarily with mandibular reduction procedures and at-
Based on a thesis by Alan C. Jensen submitted to the Department of Ortho-
dontics, Baylor College of Dentistry, Baylor University, in partial fulfillment
of the requirements for the degree of Master of Science.
"Orthodontist, Salt Lake City, Utah.
bAssociate Professor, University of North Carolina; formerly Associate Pro-
fessor, Baylor College of Dentistry.
~Clinical Professor, Department of Oral and Maxillofacial Surgery, Baylor
College of Dentistry.
8/1/26244
266
tempted to quantify the noticeable changes that occurred
in the lower lip and chin in conjunction with the sur-
gery. 1115It was reported that for each l mm of posterior
mandibular skeletal movement, the soft tissue lip fell
back 0.6 to 0.75 mm while the soft tissue chin moved
posteriorly 0.9 to 1.0 m m . 16-17
Mandibular advancements have also been evalu-
ated, and investigators have found that although the
soft and hard tissue chins predictably advanced in a
1:1 ratio, the lower lip changes were more variable
with soft/hard tissue ratios ranging from 0.38:1 to
0.75 : 1.17"8
The soft tissue changes associated with maxillary
surgery have also been evaluated, and several investi-
gators noted that as the maxilla was posteriorly dis-
placed, the upper lip moved back, with ratios varying
from 0.33 : 1 to 0.76: 1.19-22The wide range of soft tissue
responses seen has been attributed to the type of soft
tissue surgical manipulation employed. This is evident
in the studies of soft tissue responses to maxillary ad-
vancement in which the early reports, which did not
involve soft tissue manipulation, showed upper lip ad-
vancement ratios of from 0.4:1 to 0 . 8 2 : 1 . 23-27 In
contrast, a more recent group of studies in which the
V-Y closure technique and the alar base cinch suture
procedure were employed demonstrated consistent
soft/hard tissue ratios of approximately 0.9: 1.2~-3o
Initial studies of the soft tissue responses to max-
illary impaction noted that the nasal tip tended to turn
up and that the nasolabial angle response was quite
variable. 24,28 Simultaneously, other investigators 21'26
 Volume 101
Number 3
noted that although the upper lip tended to shorten by
about 40% of the amount of incisor impaction, there
was a tendency for the upper lip to also roll inward,
creating a thinner and less esthetic vermillion border.
More recent studies using the V-Y closure and alar base
suture techniques have found minimal vermillion thin-
ning and only about a 10% shortening of the upper
lip. 28.29
To date, however, all this information has been col-
lected from studies that have evaluated single jaw pro-
cedures carried out independently. When the clinician
now wishes to predict the soft tissue responses to double
jaw surgery, he is forced to use the single jaw data and
attempt to extrapolate and correct them for bimaxillary
surgery. As the data for soft tissue responses in bi-
maxillary surgery are extremely limited, it was the pur-
pose of this study to analyze the soft tissue changes
after simultaneous maxillary impaction and mandibular
advancement with the objective of producing ratios that
will allow for improved predictability of soft tissue
responses in double jaw surgery cases.
MATERIALS AND METHODS
The sample used in this study consisted of 17 consecutive
patients (15 females, 2 males) who were selected from the
records of one surgeon (L. M. W.) and who met the following
criteria:
1. The patients were nongrowing, and each had a di-
agnosis of vertical maxillary excess and mandibular
deficiency.
2. Surgical treatment consisted of simultaneous LeFort I
osteotomy with vertical maxillary impaction and bi-
lateral sagittal split ramus osteotomy to advance the
mandible.
3. No additional surgical procedures, such as genio-
plasty, rhinoplasty, or infraorbital augmentations,
were performed.
4. The alar base cinch suture and the V-Y closure tech-
niques were used in each case.
5. The patients had to have a natural dentition supporting
the lips.
6. Records consisting of standardized lateral cephalo-
grams that met the following criteria were available
on all patients:
(a) A preoperative radiograph taken within 1 week of
surgery.
(b) A postoperative radiograph taken a minimum of
9 months after surgery.
(c) All radiographs taken in centric relation with lips
in repose.
(d) All hard and soft tissue landmarks clearly iden-
tifiable.
The mean age of the sample at the time of surgery was
30 years 9 months, and the average follow-up period before
the final records was 17.9 months. Each patient underwent a
modified LeFort I procedure with the step osteotomy described
Soft tissue changes associated with double jaw surgery 267
Horizontal
Reference
Line (HRL)
Vertical
91
Reference
Line (VRL)
Fig. 1. Cephalometric landmarks digitized.
by Bennet and Wolford. 3~The maxillary segments were sta-
bilized with rigid fixation consisting of Wurzburg or Champy
miniplates and screws. 32The mandibular procedure consisted
of a modified sagittal split osteotomy as described by Wolford
et a1.,33 and fixation was achieved by the use of two or three
bicortical lag screws on each side.
For each patient the pretreatment and posttreatment lateral
cephalometric headfilms were traced, and a total of 31 land-
marks were identified (Fig. 1). These landmarks were then
digitized with a backlit digitizing tablet (Hi-Pad Digitizing
Tablet, Houston Instruments Inc., Austin, Texas) interfaced
to a Data General minicomputer (Data General, Westboro,
Mass.). A standard program (Analog Digital Systems, Al-
buquerque, N.M.) was used to collate the data and translate
the X and Y coordinates into the desired angles and distances
in relation to the horizontal reference line constructed 12°
from the S-N line and the vertical reference line drawn through
sella perpendicular to the horizontal reference line. These
values were then transferred to a microcomputer (Heath/Ze.
nith IBM compatible, Health Co., Benton Harbor, Mich.) for
storage and later analysis by a standard statistical program
(SYSTAT, Systat, Inc., Evanston, Ill.). A total of 47 ceph-
alometric parameters were evaluated, consisting of 29 soft
tissue measurements and 19 hard tissue measurements. Error
analysis revealed that the mean combined error for the linear
measurements was 0.17 mm with a standard deviation of 0.15
ram, whereas the angular measurements had a mean combined
error of 0.28 ° and a 0.16 ° standard deviation.
The overall mean, standard deviation, and range were
calculated for each variable at both time periods. A positive
 Am. J. Orthod. Dentofac. Orthop.
268 Jensen, Sinclair, and Wolford March 1992

Table I. Horizontal changes of maxillary hard

and soft tissue landmarks
Mean +- SD I
I

Landmark (mm) I Range (mm)

Maxillary hard tissue

A point + 1.8 -+ 1.4 + 0 . 2 to + 5 . 5
Supradentale + 2 . 1 -!-- 1.8 - 0 . 4 to + 5 . 9
Maxillary incisor tip + 1.9 +- 3.1 - 2.5 to + 8.7
Maxillary soft tissue
L o w e r nasal tip + 1.2 --- 0.7 -0.4 to +2.4
Subnasale + 1.3 +- 0 . 8 0.0 to +2.6
r 66%* Superior labial sulcus + 2.0 -+ 1.6 -0.3 to +4.7
Labrale superius + 1.5 +- 2.2 - 1.3 to +5.9
~- 1.8mm / _ * U p p e r stomion +1.7 +-- 3.6 -2.4 to +11.2

/mm \ 'oo: + = Anterior or inferior movement.

• ~¢ ~ 78%
1.9mm'~' ' ~ - ~ 89%
* Not Significantly Correlated
Fig. 2. Percent horizontal maxillary soft tissue responses.
value was assigned to changes occurring in the anterior or
inferior directions, whereas a negative value was assigned to
changes occurring in the posterior or superior directions. The
Pearson product' moment correlation coefficient was used to
evaluate associations between parameters, with an r value of
between 0.6 and 0.7 considered to represent a weak corre-
lation, 0.7 to 0.8 a moderate correlation, and greater than 0.8
a strong correlation.
RESULTS
Horizontal maxillary hard and soft tissue changes
(Table I and Fig. 2)
The hard tissue maxillary landmarks (A point, su-
pradentale, upper incisal edge) moved anteriorly an av-
erage of 2.0 mm, with a range of 1.8 to 2.1 mm. The
corresponding soft tissue landmarks (nasal tip, subna-
sale, superior labial sulcus, labrale superius, upper lip
stomion) showed a gradual increase in response from
a minimum of 1.2 m m of advancement at the nasal tip
to a maximum of 1.7 mm at upper lip stomion. The
only exception was at the superior labial sulcus, which
demonstrated 2.0 m m of anterior change.
The strongest correlations (Table II) were found
between the anterior movement of the upper incisal
edge and the three parameters representing the soft tis-
sue upper lip: labrale superius r = 0.81, superior labial
sulcus r = 0.78, and upper lip stomion r = 0.75.
Thus the ratios (Table III) for the upper lip soft tissue
response to maxillary advancement were 1 : 1 at superior
labial sulcus, 0.8:1 at labrale superius, and 0.9:1 at
upper lip stomion.
- Posterior or superior m o v e m e n t s .
It was also noted that the amount of horizontal ad-
vancement of the maxilla correlated to the degree of
upper lip shortening, with 2.0 mm of maxillary ad-
vancement at supradentale producing a 0.6 mm superior
movement of labrale superius with a moderate corre-
lation of r = 0.78 and a resultant 0.38:1 ratio. The
upper lip length (subnasale to upper lip stomion) was
shortened by an average of 0.8 mm and was weakly
correlated (r = - 0 . 6 5 ) to the 1.8 m m of advancement
at A point to produce a 0.44:1 ratio.
Angular maxillary soft-tissue changes (Table IV)
Associations were also found between the amount
of maxillary hard tissue advancement and the changes
that occurred in the nasolabial angle. A mean increase
of 1.2 ° was seen in the nasolabial angle, and this change
was weakly correlated to both the 1.8 mm of advance-
ment at A point (r = 0.61) and the 1.9 m m forward
movement of the upper incisor (r -- 0.62) (Table II).
In fact, the strongest correlations were seen between
the rotational change of the anterior maxilla and the
angulation of the philtrum (r = 0.75) and between the
upper incisor angulation and the changes in nasolabial
angle (r = - 0 . 6 8 ) . Although the nasolabial angle in-
creased by an average of 0.65 ° for every 1 mm of
maxillary advancement, it should be noted that there
was a wide variety in the responses seen (range, - 7 . 9 °
to +9.7°); half of the patients showed increases,
whereas the other half showed reductions after surgery.
The angulation of the nasal dorsum to the horizontal
reference line decreased by a mean of 2.6 ° as the nasal
tip was raised during surgery. This change was weakly
correlated to the amount of forward movement of the
upper incisor (r = - 0 . 6 3 ) and produced a ratio of
1.37 ° of upturn of the nasal dorsum for every 1 mm of
upper incisor advancement.
Volume ]01 Soft tissue changes associated with double jaw surgery 269
Number 3

HORIZONTAL
HARD TISSUE

t A-POiNT o., Io.9, o.,, o.,~ o,, ~i~i 1.0.n .o.~ ii!ii{ o.~, o.o,
2. SUPRAD£NTALE o.,, o.. Io.,, o.. o.. 0.,, ~ii
3. UPPER INCISOR o.~, o.o, o.,, !o.,, o.,, o.,, o.,J ~-il
4. LOWER INCISOR 0.62 0.81 0.M 0.1~ ~ i i
5. INFRADENTALE 0.70 0.8~ 0.94 0.9~ ~ -0.80 ~ii~
0. 6-POINT 0.0~ 0.74 0.90 0.97 0.9~
7. P O G O N ~
VERTICAL
0.71 0.71 0.90 0.97 0.N ~!i ,., i~-i; o.o..
HARD 118SUE

8. A-POfNT !i~!i!o.. o.,, ,.,, o.o, o.09 ~'::."il

9. SUPRA(~NT~.E ~:~o.,, ,., o,,o,, ~iloo7
10. UPPER INCISOR ~iio. -1 ,.o,o,,o,~ ~{o,,
11. MAXILLARY MOLAR

12. POST, NASAL 8PINE

13. LOWER INCISOR ~-i Io.,, ,.0, o.. o.. o.9, I~:'::'~o7,
14. INFRRD~NTAL~

15. B,-PO~NT

16. PO~ONION ~{ o.,, !o.,, o.. o.. o. k~:~::~o.,

ANGULAR
HARD TISSUE

f7. OCCL PLANE/HRL 0.7( 0.3~ "0.01 ,0.73 0.7( 0,~ -0.0~ @ o.. B!! o..
10. MAND. pLANE/HRL 0.64 "0.~ "0.61 0.~ 0.741"0.6~ .0.67 FI~!I o.. o.. o.. o. !~!~:i;o..
~9. ANTERIOR MAX/HRL
I I

Table II. Coefficients of simple correlations between soft tissue and hard tissue changes

HORIZONTAL

I. A-F~NT ~ili 0.09 0.0:

~. SUPRADENTALE o.7~ o.3, ii:~ !o.~ II.!F ~.09
3, UPPER INCISOR 1.0 0.79 0.~ ~ii! 0.42

4, LOWER INCISOR 0.48 0,01 1.26 1.55 ~.":iil

5, INFRADENTALE 0.42 0,72 1.1 1.3~ ~ 0.11

E. B-POINT 0.10 0.37 0.63 0.96 1.2 i~i~! 0.11 ;-~.~.~io.3, o.1,
? POGONION o.,, o.3, o.,,o.. ,.o ;@ o.0 ~i Lo.o,o.,,
VERTICAl.
HARD TISSUE

8. A-POINT ~il 0.2t 0,10 018 0.82 1.12

9, SUPRADENTALE ~i 0.20, 0.17 0.80 1.09

10. UPPER INCISOR i~!o=~ o10 13, 1 . o. 112 ~4~o.01
11, MAXILLARY kK)I_AR ~ 0.27

12. POST. NASAL ~PINE

13. LOWER INCISOR i~~ 016 1,13 1.5 0.73 1.0

14 INFRAD~NTALE 0.19 1.34 t.78 I).091 .19

15. B-POINT 0.27 0.23 1.64 2,19 1,09!I,4~

16. POGONION
ANGUI.AR
~[~i 0.21 1.48 1.07 ~.g~ Jl.31 !~i °."
HARD TISSUE ~!; Fii ~ ~! ~i ~i.............
~il~i ;:~!ii i~!!i
'. i~!~~il ii!i~i~i:iiii~~ii: i !i!i~i~i i i{~:~'~,.~ilf~i
.~ ,i~.~:~!i
17 OCCL PLANE,'HRL 0,g0 ),09 0.77 1,4 ~.40 3.73 4,50 ~!!~ 1.27

13 MAND. PLANE/HRL 0.83 !0.63 0.71 I . ~ ~.21 3.42 4.21 ~:i~{i 1.79 2.3~ 1.10 158 ~iiii1,.09
19. ANTERIOR MAX.IHR(

Table III. Soft/hard tissue ratios of significant correlations

270 Jensen, Sinclair, and Wolford Am. J. Orthod. Dentofac. Orthop.
March 1992

Table V. Vertical changes for maxillary hard

and soft tissue landmarks
Mean +- SD Range
Landmarks (mm) (ram)

Maxillary hard tissue

A point -3.4 --_ 2.1 - 8 . 3 to - 0 . 5
Supradentale - 3 . 5 +- 2.5 - 7 . 8 to - 0 . 2
Upper incisal edge - 3.2 -- 2.7 - 8.9 to + 0.6
First molar tip - 2 . 2 --_ 1.6 - 6 . 1 to + 0 . 1
Posterior nasal spine - 1.1 + 2.3 - 6 . 5 to + 1.5
1% Maxillary soft tissue
L o w e r nasal tip -0.7 ± 0.8 - 2 . 3 to + 0 . 8
3.3mm Subnasale -0.6 _+ 0.6 - 1 . 4 to + 0 . 8
17 Superior labial sulcus -0.6 --_ 0.9 - 2 . 1 to + 0 . 6
Labrale superius - 0 . 8 + 1.1 - 2 . 5 to + 0 . 8
Upper lip stomion - 1.2 _ 1,5 - 3.7 to + 1.6
Upper lip length
(SN-ULS) -0.8 --_ 1.9 -5.0to +1.3

+ = Anterior or inferior movements.

- = Posterior or superior movements.
* - - No Significant Correlations

Fig. 3. Percent vertical maxillary soft tissue responses.

tip (r = 0.84), superior labial sulcus (r = 0.79), and
subnasale (r = 0.74), as well as between supradentale
Table IV. Angular changes for selected hard and and superior labial sulcus (r = 0.82) (Table iI). Thus
soft tissue parameters the ratio of soft tissue change to hard tissue change at
A point was 0.21:1 for lower nasal tip and 0.18:1 for
J Mean ± SD Range
Landmark (degrees) (degrees) both superior labial sulcus and subnasale, whereas the
superior labial sulcus to supradentale ratio was 0.17 : 1
Nasal dorsum to H R L -2.6 ± 1.5 -5.3 to +0.4
(Table lII).
Coiumella to H R L + 1.4 --_ 2.5 - 3.5 to + 4.6
Philtrum to H R L +0.1 _ 7.2 -12.7 to +11.9
Moderate correlations were also noted between the
Nasolabial angle + 1.2 _+ 6.4 -7.9 to +9.7 vertical maxillary impaction and the vertical changes
Occlusal plane to H R L -2.2 ± 6.5 - 19.2 to + 8.1 of the mandibular soft tissues. The upper incisor im-
Mandibular plane to H R L - 2.4 ± 3.1 - 9.0 to + 3.8 paction showed correlations to inferior labial sulcus
Anterior maxilla to H R L -0.1 ± 7.7 - 17.5 to + 14.0
(r = 0.78) and soft tissue pogonion (r = 0.72). Al-
HRL, Horizontal reference line.
though these correlations were an incidental finding
+ = Increase in angulation. occurring as a result of mandibular autorotation, it is
- = Decrease in angulation. interesting to note that the mandibular soft tissue moved
superiorly approximately the same amount as the max-
illary impaction (i.e., a 1:1 ratio).
Vertical maxillary hard and sof tissue changes The 2.6 ° uptum seen in the nasal dorsum was found
(Table V and Fig. 3) to be correlated to the degree of maxillary incisor im-
The vertical impaction of the anterior maxilla (A paction (r = 0.72) producing a ratio of 0.81 ° of nasal
point, supradentale, upper incisal edge) averaged 3.4 dorsum flattening to each 1 mm of incisal edge im-
ram, with a range of 3.2 to 3.5 mm. Most of the cor- paction.
responding maxillary soft tissue landmarks (lower nasal
tip, subnasale, superior labial sulcus, labrale superius) Mandibular hard and soft tissue changes (Table Vl
showed a uniform 0.6 to 0.8 mm of superior change and Fig. 4)
with a mean of 0.7 mm, The only exception was upper The mandibular hard tissue landmarks demonstrated
lip stomion, which moved superiorly by 1.2 ram. a gradual increase in the amount of anterior movement
Therefore upper lip stomion moved superiorly an av- ranging from 6.5 mm at the mandibular incisal tip to
erage of 0.4 mm more than labrale superius, effectively 9.9 mm at pogonion reflecting the upward and forward
reducing the vermilion thickness of the upper lip. rotation of the mandible that occurred as a result of the
The strongest correlations to the vertical maxillary maxillary impaction. The accompanying soft tissue
impaction were seen between A point and lower nasal landmarks also exhibited a gradual increase in their
 Volume 101
Number 3 Soft tissue changes associated with double jaw surgery 271

tt---.-~ 6.5m m ....-..,=__~ 42%*

1 lO%

.I7 %
W -% L9mm 11~

_J t
* -- Not Significantly Correlated

Fig. 4. Percent horizontal mandibular soft tissue responses.

Fig, 5. Percent vertical mandibular soft tissue responses.

Table VI. Horizontal changes of mandibular Table VII. Vertical changes of mandibular hard
hard and soft tissue landmarks and soft tissue landmarks
I Mean ± SD Range I Mean ± SD Range
Landmark (mm ) (mm ) Landmark (mm ) (mm )
Mandibular hard tissue Mandibular hard tissue
Mandibular incisor tip + 6.5 ± 2.6 + 2.0 to + 11.3 L o w e r incisal edge - 3.8 ± 3.0 - 9.7 to + 1.2
Infradentale + 7 . 4 ± 3.4 + 3.9 to + 14.0
Infradentale -3.2 ± 2,6 - 8 . 4 to + 0 . 9
B point + 8 . 4 ± 4.2 + 3 . 6 to + 1 6 . 1
B point -2.6 ± 2.5 - 6 . 6 to + 1 . 0
Pogonion + 9 . 9 ± 5.0 + 3 . 5 to + 1 9 . 1
Pogonion -2.9 ± 2.7 - 7 . 1 to + 1 . 0
Mandibular soft tissue Mandibular soft tissue
L o w e r stomion + 3 . 1 ± 3.7 - 2 . 5 to + 1 0 . 4
L o w e r lip stomion -4.3 ± 3.8 -ll.2to +2.2
Labrale inferius + 5 . 3 ± 3.1 + 1.3 to + 11.7 Labrale inferius -5.7 ± 4.2 - 14.0 to - 0 . 1
Inferior labial sulcus + 8 . 2 ± 4.2 + 3 . 6 to + 16.8
Inferior labial sulcus -2.8 ± 3.8 - 9 . 9 to + 5 . 1
Pogonion soft tissue + 10.1 -*- 4.8 + 5.4 to + 20.4 Pogonion soft tissue -3.8 ± 3.1 - 1 0 . 4 to + 1 . 4

+ = Anterior or inferior m o v e m e n t s .
+ = Anterior or inferior m o v e m e n t s .
- = Posterior or superior m o v e m e n t s .
- = Posterior or superior m o v e m e n t s .

mean anterior movement from 3.1 mm at lower lip
stomion to 10.1 m m at soft tissue pogonion. Strong
correlations were found between virtually all the hard
and soft tissue landmarks ranging from r = 0.81 to
r = 0.98 (Table II). The only exception was for lower
lip stomion that demonstrated weak correlations to
the mandibular hard tissue landmarks ranging from
r = 0.62 to r = 0.74. This difference might be at-
tributed to the freeing of the lower lip previously trapped
by the protrusive upper incisors. Thus the soft/hard
tissue ratios increased from 0.48:1 between lower lip
stomion and lower incisor, through 0.72:1 for labrale
inferius to infradentale, and 0.98:1 for inferior labial
sulcus to B point to 1 : 1 for soft to hard tissue pogonion
(Table III).
Vertical mandibular hard and soft tissue
movements (Table VII and Fig. 5)
The mandibular hard tissue landmarks (lower incisal
edge, infradentale, B point and pogonion) moved su-
periorly an average of 3.1 mm, with a range from 2.6
to 3.8 mm. The lower incisal edge moved vertically
the greatest amount, 3.8 mm, and showed a strong
correlation with the 4.3 mm vertical movement of lower
lip stomion (r = 0.81, ratio = 1.13 to 1) and to the
5.7 mm movement of labrale inferius (r = 0.82,
ratio = 1.5:1) (Tables II and III). Similarly infraden-
tale, which underwent a 3.2 mm vertical move, was
also strongly correlated to the changes at lower stomion
(r = 0.78, ratio = 1.34:1) and to labrale inferius
(r = 0.80, ratio = 1.78:1). These ratios reflecting
greater vertical movement of the soft tissues than the
underlying hard tissues are also probably due to the
previously mentioned upward and backwards rotation
of the lower lip as it was freed from the upper incisor.
The 2.6 mm upward movement at B point was cor-
related (r = 0.79) with the 2.8 mm movement of in-
ferior labial sulcus with a soft/hard tissue ratio of
1.08: 1. Similarly the 2.9 mm upward change in po-
gonion was correlated (r = 0.89) with 3.8 mm ele-
vation of soft tissue pogonion to produce a 1.31 : 1 ratio.
Soft tissue thicknesses (Table VIII)
The upper lip thinned an average of - 0 . 6 mm at
the superior labial sulcus and - 1.5 mm at labrale su-
perius when the maxilla was impacted an average of
272 Jensen, Sinclair, and Wolford
Table VIII. Soft tissue thickness changes
Mean +- SD Range
Measurement (ram) (ram)
Superior labial sulcus - 0 . 6 +_ 1.5 - 3 . 8 to
Labrale superius - 1 . 5 --- 2.0 - 5 . 0 to
Labrale inferius - 3 . 9 +-- 1.9 - 7 . 8 to
Inferior labial sulcus - 0 . 2 +_ 1.0 - 2 . 1 to
Pogonion soft tissue + 0 . 4 _+ 0.9 - 1 . 5 to
Menton soft tissue + 0 . 2 -2-- 1.3 -l.6to
+ = Thickened.
- = Thinned.
3.4 mm and advanced an average of 2.0 mm. The
mandibular soft tissues showed minimal changes with
the exception of labrale inferius, which showed an av-
erage reduction of 3.9 mm and again was reflective
only of the changes in lower lip shape after its release
from under the influence of the maxillary incisors.
No significant correlations were noted between the
changes in soft tissue thickness and any of the surgical
changes (Table II). However, a moderate correlation
(r = 0.77) was noted between the 0.2 mm of reduction
seen in the tissue thicknesses of the lower lip and its
initial presurgical thickness of 11.3 mm. When the sam-
ple was brokendown into subsets with thin lips (n = 7,
x = 10.2 mm, range 9.0 to 11.5 mm) and thick lips
(n = 10, x = 12.2 mm, range 11.6 to 13.0 mm), it
was noted that although the thin-lip group exhibited
insignificant changes, the thick-lip group showed an
average of 1 mm of soft tissue thinning, reflecting a
0.13 mm thinning of the lip for each 1 mm of man-
dibular advancement.
DISCUSSION
Overall, the data from this study suggested that
when simultaneous two jaw surgery was performed to
correct vertical maxillary excess and mandibular defi-
ciency, there was a tendency for the soft tissue re-
sponses to be similar to those seen in single jaw pro-
cedures with the exception of the changes seen in the
nasolabial angle and the vertical movement of the lower
lip and chin.
With an average 2 mm advancement and 3.4 mm
impaction of the maxilla, there was a tendency for the
base of the nose (subnasale and nasal tip) to advance
about two thirds of the amount of anterior movement
of A point, whereas the free end of the upper lip showed
a change that averaged about 90% of the maxillary
advancement (Fig. 2). However, the responses of the
base of the nose and the subnasale area after surgery
have historically been quite unpredictable 26'27'3° and
once again did not show any strong correlations to the
hard tissue changes in this study. This may be due in
Am. J. Orthod. Dentofac. Orthop.
March 1992
part to variations in amount of occlusal plane rotation
that occurred during surgery and the alar base manip-
ulation or surgical handling of the anterior nasal spine.
With regard to the upper lip changes, the maxillary soft
+ 1.6 tissue studies can be divided into two groups: (1) those
+1.3
using surgical soft tissue manipulation (i.e., alar base
-0.2
+1.7 cinch suture and V-Y closure) and (2) those without
+1.7 any soft tissue-altering procedures. The 90% anterior
+2.6 upper lip movement seen in this study was similar to
the findings of other studies in the first group that also
showed a 70% to 90% upper lip response. 29'3° In com-
parison, the second group of older studies in which no
soft tissue manipulation was done found that the an-
terior soft tissue changes ranged from 40% to 60% of
the hard tissue changes. ~7,23'25The difference between
the two groups demonstrates the importance of deter-
mining the surgical technique to be used by the surgeon,
so that an accurate prediction tracing can be produced.
For example, if the surgeon is using an alar base cinch
suture to prevent an increase in alar base width, 34 the
clinician should plan on approximately 80% to 90%
forward movement of the upper lip. However, if the
nose is already narrow, the alar base suture may not be
desirable. In this case a more conservative upper lip
change in the range of 60% should be used in the pre-
diction tracing.
An additional factor complicating the upper lip pre-
diction is the effect of rotational changes in the maxilla.
A strong correlation (r = 0.89) was noted between the
occlusal plane rotation and the horizontal changes in
the maxillary incisor position, which, in combination
with the correlation (r = 0.70) seen directly between
the amount of maxillary rotation and upper lip response,
suggests a significant interaction. It appears that as the
occlusal plane is rotated upward and forward and the
upper incisor is flared, additional support is created for
the upper lip, thereby altering the soft tissue response
ratio. Therefore if an occlusal plane rotation is to be
carried out as part of the surgical treatment plan, the
clinician needs to be aware of the differential horizontal
movements that will occur between A point and the
maxillary incisal edge and should plan the predicted
upper lip movement accordingly.
The data from this study also suggested that changes
in the angulation of the philtrum had the greatest influ-
ence on the nasolabial angle (r = 0.92). Although the
mean change for the philtrum was only 0.1 °, there was
a mean reduction of 5.6 ° in the nasolabial angle in the
cases in which the maxilla and hence the philtrum ro-
tated downward and backward and a mean increase of
6.5 ° in the nasolabial angle where the maxilla was ro-
tated upward and forward (r = 0.75) (Fig. 6).
Overall, it appeared that there was an increase of
0.65 ° in the nasolabial angle for each 1 mm of maxillary
Volume 101 Soft tissue changes associated with double jaw surgery 273
Number 3

advancement. The nasal dorsum demonstrated an ele-

vation (flattening) of 1.3 ° for each 1 mm of maxillary
advancement and an elevation of 0.81 ° for each 1 mm
of maxillary impaction. These changes were consistent
with the findings of other researchers and confirmed
their suggestions that the angular changes in maxillary
hard tissue landmarks had considerable influence on the
final soft tissue responses. 19.21,23,26They also imply that
in future studies upper incisal angulation should be care-
fully evaluated to see whether it can provide correlations
of even greater clinical significance for the upper lip.
The vertical movements of the nose and upper lip
were moderately predictable (r = 0.74 to 0.84) and
exhibited a uniform superior movement of 20% of the
corresponding maxillary hard tissue change (Fig. 3).
The only exception was at upper lip stomion, which
moved superiorly 38% of the amount of upper incisor
impaction and did not appear to be correlated with
the hard tissue change. This additional vertical move-
ment of stomion, which has been reported in other
studies 2°'2j'26'27 and results in thinning of the vermilion
border of the upper lip, has been attributed to the soft
tissue surgical technique employed. 21'~8It was thought
that the use of the V-Y closure and the alar base cinch
suture would minimize this change, but, unlike the find-
ings of Schendel and Williamson, 28 these procedures
Fig. 6. Changes in the nasolabial angle resulting from surgical
appeared to have little effect in this study. anterior maxillary rotation.
Thus a careful assessment of the likely vertical
changes in the upper lip is critical when one is planning
for the correct amount of incisor exposure at rest in and forward in this study, the soft tissue landmarks
vertical maxillary impaction cases. For example, if a overlying the lower incisor, B point, and pogonion
patient has 6 mm of upper incisor exposure and a tooth- moved superiorly more than their underlying hard tis-
to-lip relationship of 3ram is desired, then taking into sues. The slightly greater than 1:1 ratios seen in the
account the expected 20% shortening of the soft tissues, soft tissue movements over B point and the chin
a 4 mm maxillary impaction will be required. If, how- (1.1:1 and 1.2: l, respectively, Fig. 5) were in contrast
ever, a maxillary advancement is also required, then to other studies that have shown soft tissue responses
the likelihood that the upper lip will usually shorten by in the 0.8 to 0.93 range but did not evaluate the par-
0.3 8 mm for each 1 mm of maxillary advancement may ticular surgical combination used in this study. 16'17'21
increase the amount of vertical impaction required. The changes seen in the lower lip can be explained by
The changes seen in the anteroposterior positions its release from the influence of the upper incisor pro-
of mandibular soft tissues showed strong correlations ducing a rotation up and back around the inferior labial
to the underlying hard tissues with the soft/hard tissue sulcus. As a result, lower lip stomion moved superiorly
ratio showing a progressive increase from 42% at lower 110% of the surgical change and labrale inferius moved
lip stomion up to 100% at soft tissue pogonion (Fig. 150% of the surgical change. With the exception of
4). The 1 : 1 ratio of changes seen with the soft tissues some recent data from Proffit and Phillips, 35 which also
of the labiomental fold and chin are similar to reports show lower lip soft tissue ratios greater than 1 : 1, there
by other researchers and probably represent the tight is little information in the literature regarding lower lip
attachment of these tissues to their underlying skeletal changes, and it is not clear whether these findings
bases. ~7,18Although previous reports have stressed the should be confined to cases with lower lip entrapment
unpredictability of the lower lip changes, 16-18this study, or are generally applicable to double jaw surgery cases.
for the first time, showed significant correlations In general, on the basis of the data from this study,
(r = 0.81 to 0.90) at labrale inferius with a 0.72:1 a clinician conducting soft tissue prediction for a com-
soft/hard tissue ratio. bined maxillary impaction and mandibular advance-
As the mandible was advanced and rotated upward ment might find the following guidelines useful. As the
274 Jensen, Sinclair, a n d Wolfe, re1
maxilla is impacted and advanced, _the upper lip will
advance 90% of the underlying hard tissue change and
m o v e superiorly 20% o f the hard tissue m o v e m e n t . In
addition, the nasolabial angle will change by an a m o u n t
equal to about 60% of the rotation of the anterior max-
ilia. As the mandible is advanced, the lower soft tissues
will advance in a graduated fashion, ranging f r o m 72%
at the l o w e r lip to 100% at soft tissue pogonion. Ver-
tically, the mandibular soft tissue will m o v e superiorly
approximately 120% o f the hard tissue changes with
the exception of the l o w e r lip, which may s h o w up to
150% of the hard tissue change.
CONCLUSIONS
l. Overall, the soft tissue responses to simulta-
neous two j a w surgery w e r e similar to those seen in
single j a w procedures with the exception of the changes
in the nasolabial angle and in the area of the l o w e r lip
and chin.
2. The type o f surgical soft tissue manipulation
e m p l o y e d was an important factor in the determination
o f the upper lip r e s p o n s e to the maxillary i m p a c t i o n
and advancement.
3. Ch~inges in the nasolabial angle angle w e r e pri-
marily due to rotational changes of the underlying hard
tissues rather than to their anteroposterior or vertical
movements.
4. The maxillary soft tissues m o v e d forward 90%
o f the hard tissue c h a n g e and showed a 20% shortening
o f the upper lip.
5. There was a predictable progressive increase in
the horizontal m o v e m e n t o f the mandibular soft tissues,
ranging f r o m 72% o f the hard tissue change at the l o w e r
lip to 100% at pogonion,
6. The mandibular soft tissues m o v e d superiorly by
greater amounts than their underlying hard tissues, par-
ticularly in the area o f the l o w e r lip as it was freed f r o m
the effects of the m a x i l l a r y incisors.
REFERENCES
1. Ricketts RM. Planningtreatmentonthebasisofthe facialpattern
and an estimate of its growth. Angle Orthod 1957;27:14-37.
2. Steiner CC. Cephalometrics in clinical practice. Angle Orthod
1959;8-29.
3. Burstone CJ. Lip posture and its significance in treatment plan-
ning. AM J ORTHOD1967;53:262-84.
4, Holdaway RA. A soft tissue cephalometric analysis and its use
in orthodontic treatment planning. Part I. AM J ORTHOD
1983;84:1-28.
5. Downs WB. Analysis of the dentofacial profile. Angle Orthod
1956;26:191-212.
6. Subtelny JD. A longitudinal study of soft tissue facial structures.
AM J ORTHOD1959;45:481-507.
7. Rudee DA. Proportional profile changes concurrent with ortho-
dontic therapy. AM J ORTHOD1964;50:421-33.
Am. J. Orthod. Dentofac. Orthop.
March 1992
8. Bloom LA. Perioral profile changes in orthodontic treatment.
AM J ORTHOD1961;47:371-9.
9. Hershey HG. Incisor tooth retraction and subsequent profile
change in postadolescence female patients. AM J ORTHOO
1972;61:45-54.
10. Jacobs JD. Vertical lip changes from maxillaryincisorretraction.
AM J ORTHOD1978;74:396-404.
11. Knowles CC. Changes in the profile following surgical reduction
of mandibular prognathism. Br J Plast Surg 1965;18:432-4.
12. Aaronson SA. A cephalometric investigation of the surgical cor-
rection of mandibular prognathism. Angle Orthod 1967;37:
251-6.
13. Fromm B, Lundberg M. The soft tissue facial profile before and
after surgical correction of Mandibular Protrusion. Acta Odontol
Scand 1970;28:157-77.
14. Hamula W. Surgical alteration of muscle attachments to enhance
esthetics and denture stability, AM J ORTHOD1970;57:327-67.
15. Bjork N, Eliasson S, Wictorin L. Changes in facial profile after
surgical treatment of mandibular protrusion. Scan J Plast Re-
constr Surg 1971;5:41-6.
16. Hershey HG, Smith LH. Soft tissue profile change associated
with surgical correction of the prognathic mandible. AM J OR-
TROD 1974;65:485-502.
17. Lines PA, Steinhauser WW. Soft tissue changes in relationship
to movement of hard structures in orthognathic surgery: a pre-
liminary report. J Oral Surg 1974;32:891-6.
18. Quast DC, Biggerstaff RH, Haley JV. The short-term and long-
term soft tissue profile changes in accompanying mandibular
advancement surgery. AM J ORTHOD1983;84:29-36.
19. Bell WH, Dann JJ, III. Correction of dentofacial deformities by
surgery in the anterior part of the jaws: a study of stability and
soft tissue changes. AM J ORTHOD1973;64:162-87.
20. Schendel SA, Eisenfeld JH, Bell WH, Epker BN. Superior re-
positioning of the maxilla: stability and soft tissue osseous re-
lations. AM J ORTHOD1976;70:663-74.
21. Radney JR, Jacobs JD. Soft tissue changes associated with sur-
gical total maxillary intrusion. AM J ORTHOD1981 ;80:191-212.
22. Nadkarni PG. Soft tissue profile changes associated with or-
thognathic surgery for bimaxillary protrusion. J Oral Maxillofac
Surg 1986;44:851-4.
23. Dann JJ, III, Fonesca RJ, Bell WH. Soft tissue changes asso-
ciated with total maxillary advancement: a preliminary study.
J Oral Surg 1976;34:19-23.
24. Freihofer HPM. The lip profile after correction of retromaxillism
in cleft and non-cleft patients. J Maxillofac Surg 1976;4:136-
41.
25. Araujo A, Schendel SA, Wolford LM, Epker BN. Total maxillary
advancement with and without bone grafting. J Oral Surg
1978;36:849-58.
26. Mansour S, Burstone C, Legan H. An evaluation of soft tissue
changes resulting from LeFort II maxillary surgery. AMJ ORTHOD
1983;84:37-47.
27. Rosen HM. Lip-nasal aesthetics following LeFort I osteotomy.
Plast Reconstr Surg 1988;81:171-9.
28. Scfiendel SA, Williamson LW. Muscle reorientation following
superior repositioning of the maxilla. J Oral Maxillofac Surg
1983;41:235-40.
29. Wolford LM, Hilliard FW, Dugan DJ. Surgical treatment ob-
jective: a systematic approach to the prediction tracing. St. Louis:
CV Mosby, 1985.
30. Carlotti AE, Aschaffenburg PH, Schendel SA. Facial Changes
Associated with Surgical Advancement of the lip and Maxilla.
J Oral Maxillofac Surg 1986;44:593-6.
Volume 101 Soft tissue changes associated with double jaw surgery 275
Number 3

31. Bennett MA, Wolford LM. The maxillary step osteotomy and 35. Proffit WR, Phillips C. Adaptationsin lip posture and pressure
Steinmanpin stabilization.J Oral MaxillofacSurg 1985;43:307- followingorthognathicsurgery. AMJ ORTHODDENTOFACO~THOP
11. 1988;93:294-302.
32. ChampyM, Lodde JP, Schmitt R, Jaeger JH, Muster D. Man-
dibular osteosynthesisby miniaturescrewed plates via a buccal
approach. J Maxillofac Surg 1978;6:14-21. Reprint requests to:
33. Wolford LM, Bennett MA, Rafferty CG. Modificationof the Dr. Peter M. Sinclair
mandibularramus sagittal split osteotomy. Oral Surg Oral Med Department of Orthodontics
Oral Pathol 1987;64:146-55. School of Dentistry
34. GuymonM, CrosbyDR, WolfordLM. The alar basecinch suture Universityof North Carolina
to control nasal width in maxillary osteotomies. Int J Adult Chapel Hill, NC 27599-7450
Orthod Orthognath Surg 1988;3:89-96.

BOUND VOLUMES AVAILABLE TO SUBSCRIBERS

Bound volumes of the AMERICAN JOURNAL OF ORTHODONTICS AND DENTO-
FACIAL ORTHOPEDICS are available to subscribers (only) for the 1992 issues from
the Publisher, at a cost of $53.00 ($67.71 Canada and $64.00 international) for
Vol. 101 (January-June) and Vol. 102 (July-December). Shipping charges are in-
cluded. Each bound volume contains a subject and author index and all advertising
is removed. Copies are shipped within 60 days after publication of the last issue
in the volume. The binding is durable buckram with the journal name, volume
number, and year stamped in gold on the spine. Payment must accompany all
orders. Contact M o s b y - Y e a r Book, Inc., Subscription Services, 11830 Westline
Industrial Drive, St. Louis, MO 63146-3318, USA; telephone (314)453-4351 or
(800)325-4177.
S u b s c r i p t i o n s m u s t be in force to qualify. B o u n d volumes are not available
in place of a r e g u l a r J o u r n a l s u b s c r i p t i o n .