1. Soft Tissue Changes Associated with Orthognathic Surgery
By David R. Telles
Diplomate of the American Board of Oral and Maxillofacial Surgery

2. Introduction Overview Orthodontic considerations Maxillary Movements
Movement of dentition
Maxillary Movements
Mandibular Movements
Surgical Techniques

3. Introduction
Necessary to include a component of soft tissue changes in the surgical treatment plan while working to achieve a stable, functional dentoskeletal unit
the surgical procedures -- to control the soft tissue changes will be presented and evaluated
help the surgeon understand, control, and maximize the beneficial aspects of the facial soft tissue response to surgery.

4. Historically
Orthognatic surgery -- used to correct skeletofacial deformities and the resultant functional problems, often at the expense of the facial soft tissue esthetics
Early studies produced average ratios – which related hard/soft tissue landmarks
Individual variability noted to be significant
Facial soft tissue response to orthodontics and Sx was MultiFactorial
Prediction equations developed to help preop evaluation for surgical planning and post-op assessment
Recent development of surgical procedures to control soft tissue response to Sx: alar cinch suture and VY closure

5. Orthodontic Considerations
Tooth position and alveolar morphology result from the sum of applied forces during their development
Skeletal imbalances are accompanied by soft tissue imblanaces – result = dental compensation for skeletal malocclusions
Corrections initially result in worsening of the malocclusion preoperatively + jaw-jaw discrepency to appear more severe
Pre-op records to be taken as close to Sx to determine soft- tissue outcome

6. Cephalometric Considerations
Must allow for visualization of the complete soft tissue profile
Instruct pt to keep lips in repose for cephs
Superimpose landmarks that remain unchanged
Presence of ortho hardware changes the lip profile

7. Cephalometric Landmarks

8. Soft Tissue Considerations
To predict soft/hard tissue changes is critical to Tx planning for orthognathic Sx
Changes depending on
surgical procedure
method of wound closure
the new spatial arrangement of the skeletal/dental elements
adaptive qualities of soft tissues
Growth
orthodontic vectors o ftooth movement
lip thickness. tonus, area, contact (competence), strength
interlabial gap
amount of overjet
amount offatty tissue
Musculature
postoperative edema.

9. Soft Tissue Considerations
Stabilize in approx 6 months – some studies suggest 12 months
Surgical Approach
Incision type may play a role – horizontal incision for the Le Fort I osteotomy may cause shortening of the lip
With loss of vermillion
Decrease in lip thickness
Vertical approach with tunneling and palatal flap shows minimal post-op lip changes
Betts et. Al. – investigated soft tissue response to Max Sx – found soft tissue changes may be more related to type/position of incision and method of closure than surgically induced hard tissue change

10. Soft Tissue Considerations
Will mirror changes in the bony foundation should relapse occur
Thin lips move more predictably than thick lips
“dead space” under the lip may absorb the first portion of a bony advancement before soft tissue affected
Horizontal Changes – in soft tissue more predictable than vertical changes
Related to the stability of the hard tissue movements (less stable in vertical dimension)

11. Soft tissue – assoc. Orthodontic tooth movement

12. Maxillary surgical procedures
Most are soft tissue changes manifested in:
Nasal
Labial

13. Maxillary surgical procedures – Nasal
Affects lower aspect of the nasal dorsum
Widening of the alar base regardless of vector of movement
Shortening of the columellar/alar height
shortening of the nasal tip projection
Nasolabial angle decreases or remains constant

14. Maxillary surgical procedures – Nasal
Superior movement
Elevation of the nasal tip
Widening of the alar base
Decreased nasolabial angle
Inferior repositioning
Loss of nasal tip support
Downward movement of columella and alar bases
Thinning of the lip
Increase in NL angle

15. Maxillary surgical procedures – Nasal
Anterior
Advancement in the
upper lip
Subnasale
Pronasale
Thinning of the lip
Widening of the Alar base
Increase in Supratip break if ANS in tact
***Nasal tip advances approx ½ the distance of the subnasale*******
Counter clockwise rotation – raises the nasal tip
Clockwise rotation – decreases superior movement of the nasal tip

16. Maxillary surgical procedures – Nasal

17. Maxillary surgical procedures – Labial
Upper lip is attached to the nose – prevents 1:1 soft tissue change
Widens and lengthens at the philtral columns after Max Sx
w/o VY closure – can cause shortening of the upper lip with loss of exposed vermillion

18. Maxillary Advancement
Greatest effect on the nose/upper lip
Ppts adv of upperlip, subnasale and nose
Shortening of upper lip
Thinning of upper lip (approx. 2 mm)
Widening of Alar base
Deepening of supratip depression if ANS left intact
Progressive increase in horizontal soft tissue displacement seen from tip of nose to free end of upper lip
Decrease in NL angle

19. Maxillary Advancement
Carlotti et. al. – determined that the ratio of horizontal change of upper incision to vermillion border of the upper lip with use of the alar cinch suture and the VY closure
The ratio reduces with larger advancements due to soft tissue stretching: 0.6:1 vs. 0.9:1

20. Maxillary Advancement

21. Maxillary Impaction – superior
Elevation of nasal tip
Widening of alar base (2-4 mm)
Decrease in NL angle
Nasal changes occur w/o changes in angulation of upper lip
Lip follows superiorly approx 40% of the vertical maxillary plane
Lip shortening accentuated with combined anterior/superior max movements
If no VY – amnt of vertical soft tissue change increases progressively from nasal lip to stomion with loss of vermillion

22. Maxillary Impaction

23. Maxillary inferior repositioning
Loss of nasal tip support
Downward repositioning of the columella and alar bases
Thinning of the lip
Increase NL angle

24. Maxillary posterior repositioning
Loss of nasal tip support - due to movement of ANS - movement of bony area around piriform aperture
Lip rotation
Posterior and superiorly about SubNasale
Increased NL angle

25. Maxillary Setback

26. Multi-direction Maxillary movements

27. Mandibular surgical procedures
Generally soft tissues follow hard tissues closely
Exception is lower lip
Types of movements
Anterior
Posterior
Anterior segmental
Autorotation
Genial Segmental procedures

28. Mandibular surgical procedures - anterior
Mandibular Advancement
Limited to the structures below the superior labial sulcus
Little change in the upper lip and none above the ANS
Lower lip advancement is variable and lip often lengthens
Lower labial sulcus and chin adhere to the bony structure and follow underlying osseous structures
Leads to opening of labio-mental fold

29. Mandibular surgical procedures - anterior
Mandibular Advancement
Facial Height
In high angle II cases – results in large increase in FH
Lower lip position
Affected by upper, lower incision and its contact with the upper lip
In class II – lower lip may touch the upper lip/incisor and fold forward – correction of this is necessary to approximate true post-op position

30. Mandibular advancement

31. Mandibular surgical procedures - Posterior
Mandibular Setback
No net effects on subnasale or tissues superior to it
Soft tissues follow mandible posteiorly
Chin most closely
Lower lip
Shortens
More protrusive and curls out
Labiomental fold deepens + becomes more acute

32. Mandibular Setback

33. Mandibular surgical procedures
Anterior Segmental Osteotomy

34. Mandibular Surgical Procedures -- autorotation
Soft tissues follow the osseous landmarks approx 1:1
Except lower lip – falls slightly lingual to the arc of rotation

35. Mandibular Surgical Procedures -- Genioplasty
Anterior

36. Mandibular Surgical Procedures -- Genioplasty
Posterior -- setback

37. Mandibular Surgical procedures – Vertical Augmentation/reduction Genio
Soft tissues follow hard tissues very closely in augmentation genio compared to reduction

38. Controlling Soft Tissue
Poor Surgical Results
Surgical Techniques
VY closure
Cinch Suturing
Figure 8 technique
Dual alar cinch suture
Contouring ANS
Double VY closure
Bilateral alar base wedge resection
Septoplasty
Advancement genioplasty / liposuction – excess submental adipose tissue and/or short cervicomental distance

39. Controlling Soft Tissue

40. Controlling Soft Tissue

41. Controlling Soft Tissue
VY closure

42. Controlling Soft Tissue
Cinch Suture – figure 8

43. Controlling Soft Tissue
Dual Alar cinch Suture

44. Controlling Soft Tissue
Contouring of ANS

45. Controlling Soft Tissue
Double VY

46. Controlling Soft Tissue
Bilateral Alar Base wedge resection

47. Controlling Soft Tissue
Septoplasty
Cartilagenous septum – should be reduced during maxillary impactions of > 3 mm to prevent post-op deviation
Avoid over reduction – as it can cause saddle nose deformity or poly-beak deformity