European Journal of Orthodontics, 2017, 1–10

doi:10.1093/ejo/cjx003

Original article

Short-term hard and soft tissue changes after

mandibular advancement surgery in Class II
patients: a retrospective cephalometric study
A.S. Storms1, A. Miclotte1, L. Grosjean2, M. Cadenas de Llano-Pérula1,
A. Alqerban3, S. Fieuws4, Y. Sun2, C. Politis2, A. Verdonck1, G. Willems1
1
Department of Oral Health Sciences - Orthodontics, KU Leuven and Dentistry, University Hospitals Leuven, Leuven,
Belgium, and 2Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Belgium, 3Department of
Preventive Dental Sciences, College of Dentistry, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia,
4
Interuniversity Institute for Biostatistics and statistical Bioinformatics, KU Leuven and University Hasselt, Belgium

Correspondence to: G.  Willems, Department of Oral Health Sciences—Orthodontics, Katholieke Universiteit Leuven,
Kapucijnenvoer 7, 3000 Leuven, Belgium. E-mail: [email protected]

Summary
Aim:  The aim of this study was to describe hard and soft tissue changes after mandibular
advancement surgery and to investigate the possible differences between Class II facial patterns.
Materials and methods:  Lateral cephalograms of 109 patients who underwent combined orthodontic
treatment and bilateral sagittal split osteotomy (BSSO) were studied. Radiographs were taken within
6 weeks before surgery (T0) and at least 6 months postoperatively (T1). Patients were classified into
3 groups according to the preoperative mandibular plane angle. Hard- and soft-tissue changes were
analysed with an x-y cranial base coordinate system. Measurements were evaluated statistically.
Results:  Soft and hard tissues of the chin moved forward and downward. The position of the upper
lip remained unchanged, while the lower lip moved forward and upward and decreased in thickness.
The soft tissue points of the chin follow their corresponding skeletal points almost completely,
while the change of the lower lip was only 76 per cent of the movement of the underlying hard
tissue. The increase of SNB was more evident in the low-angle group, as well as improvement of
the facial convexity. Stomium superius moved more forward in the low- and medium-angle cases.
Ratios of hard and soft tissue changes showed no differences for different facial patterns.
Limitations:  Limitations derived from the retrospective study design. Only short-term changes
could be addressed. The distinction between surgical changes and changes due to skeletal relapse
is difficult to assess. Also, the difficulty to reproduce a relaxed lip position during imaging may
influence our results.
Conclusion:  Class II characteristics improved after mandibular advancement. Soft tissues of the chin
follow their skeletal structures almost in a 1:1 relationship, while movement of the lower lip was
less predictable. The facial pattern of Class II patients should be considered in treatment planning.

Introduction and appear to have higher self-esteem (2). Nowadays, more and more
adults are seeking treatment to improve dental and facial aesthetics.
Facial appearance is very important in our modern society and plays
Therefore, combined orthodontic-orthognathic correction has become
a crucial role in social interactions (1). Attractive individuals seem
a common treatment plan. The goal of this treatment procedure is to
to be viewed as more successful at work, having better social skills

1
© The Author 2017. Published by Oxford University Press on behalf of the European Orthodontic Society.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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2 European Journal of Orthodontics, 2017

establish a functional occlusion and correct skeletal relationship, as (IQR 3.32–6.19 mm). Only patients with standardized lateral cepha-
well as improve facial aesthetics. Since overall patient’s satisfaction lograms of sufficient quality and resolution were included. Patients
after orthognathic surgery depends on the position of the soft tissues, with congenital malformations and patients who underwent addi-
it is important to comprehend their response to skeletal repositioning tional orthognathic and facial surgery such as maxillary osteotomy,
(3). Proper prediction of the postoperative soft tissue profile is neces- genioplasty and rhinoplasty were excluded. The sample size was thus
sary for accurate diagnosis and treatment planning in combined sur- determined by the number of patients meeting the inclusion crite-
gical-orthodontic treatment. Furthermore, patients expect to obtain ria during the considered time period. The mean age of the patients
detailed information about facial changes after surgery. was 26.6 years (range 14.6–56.2 years). The subjects were catego-
Since 1972, several authors studied the hard to soft tissue rized into 3 groups according to the preoperative mandibular plane
response after mandibular advancement surgery (4–19). In literature, angle of Steiner’s analysis (22). 24 patients represented the low-angle
there seems to be a consensus for the soft tissue chin, varying from group (SnGoGn ≤27 degrees), 63 patients the medium-angle group
90 to 127 per cent of the advancement of pogonion (12). For the (27 degrees < SnGoGn > 37 degrees) and 22 patients the high-angle
response of the lower lip, results are more divergent, ranging from group (SnGoGn ≥37 degrees). Presurgical patient characteristics for
35 to 108 per cent (12). Therefore, the postoperative position of the the different facial patterns are presented in Table 1.
lower lip is still less predictable. Different factors may contribute to
the complexity of soft tissue response such as posture, individual Selection of radiographs
morphology, thickness and tonicity of soft tissues (14, 20). Lateral cephalograms were obtained before surgery after presurgical
Only few articles address the differences in postoperative soft orthodontic decompensation (mean 1.3 months; IQR 25–40 days) at
tissue behaviour among different facial patterns. Until now, the influ- T0 and at T1 at least 6 months after surgery (mean 6.2 months; IQR
ence of the characteristics of high- and low-angle Class II facial pat- 6.0–6.3 months) with brackets in situ. All lateral cephalograms were
terns on postoperative soft tissue changes remains unclear. taken with the subject standing upright, with teeth in centric occlusion
The aims of this study were to: 1.  describe soft tissue changes and the lips in relaxed position. Radiographs were only selected in case
6 months after mandibular advancement surgery in Class II patients, of adequate quality, and standardization and all landmarks had to be
2.  investigate to which extent soft tissue changes correlate to the readily identifiable.
movement of the underlying hard tissue, 3. compare postoperative Preoperative lateral cephalograms were taken after presurgical
changes between different Class II facial patterns. orthodontic decompensation to minimize the effect of orthodon-
tic treatment on the soft tissues. Postsurgical radiographs at least
Materials and methods 6  months after surgery were used to eliminate the effects of tran-
sient soft tissue edema. Patients who had completed orthodontic
This study was registered and approved by the medical ethics com- treatment at T1 were excluded to rule out the effect of the bracket
mittee of the University Hospitals Leuven, with the registration num- removal on the lips.
ber S57380. Of the original data collection of 232 subjects, 9 patients were
rejected due to poor radiograph image quality, 79 patients were
Sample selection excluded due to completion of orthodontic treatment at 6 months
This retrospective cephalometric study consisted of 109 patients (77 after surgery and 35 patients were ruled out because follow-up radi-
females and 32 males) with a Class II malocclusion, who underwent ographs were lacking.
combined orthodontics and bilateral sagittal split osteotomy (BSSO) Radiographs of patients treated between 2009 and 2012 were
advancement between 2009 and 2015. All patients were surgically taken with an Orthophos XG (Sirona Group, Bensheim, Germany).
treated by the same surgeon. In all cases, similar surgical techniques A  Veraviewepocs 2D (J. Morita Co., Kyoto, Japan) was employed
were used and rigid internal fixation according to Tulasne (21) was between 2013 and 2014. Since 2015, lateral cephalograms were
applied. The mean surgical advancement at B-point was 4.88  mm obtained with a Planmeca ProMax® 2D (Planmeca Inc., Helsinki,

Table 1.  Presurgical characteristics of the different Class II facial patterns.

Low-angle Medium-angle 27°  High-angle

SnGoGn ≤27° < SnGoGn > 37° SnGoGn ≥37° P

Variable at T0 Mean SD Mean SD Mean SD

Gender 0.141
 Male 11/24 16/63 5/22
 Female 13/24 47/63 17/22
Age (years) 26.60 12.51 26.50 11.90 26.80 11.49 0.884
SNA (°) 83.90 2.88 80.40 3.73 79.00 4.15 <0.001*
SNB (°) 78.40 2.84 74.60 3.19 71.80 3.72 <0.001*
ANB (°) 5.50 1.92 5.80 1.89 7.10 2.64 0.069
SNGoGn (°) 22.70 3.08 32.10 2.79 41.90 4.52 <0.001*
Overbite (mm) 3.30 1.52 3.20 1.88 2.40 2.23 0.100
Overjet (mm) 8.30 1.92 6.90 1.96 7.10 2.59 0.032
Mlf depth (mm) 7.20 1.89 8.20 1.76 9.10 2.21 0.015
Gl’-Sn-Pog’ (°) −17.90 6.81 −18.6 5.04 −20.00 6.13 0.706
Nasolabial angle (°) 108.80 11.39 110.00 8.77 107.20 12.67 0.713

*P values smaller than 0.01 are considered significant.

A.S. Storms et al. 3

Finland). Magnification for linear measurements was 1.13 for Given the large number of verified relations, P values were only
Planmeca Promax® 2D and 1.10 for both Orthophos XG and considered significant if smaller than 0.01 (instead of the classical
Veraviewepocs 2D. Magnification was accounted for by calibration 0.05) to reduce the probability of false positive results. (23) Still, a
of the cephalograms with an embedded ruler. single significant P value should be interpreted with caution.
All analyses have been performed using SAS software, version
Cephalometric assessment 9.4 of the SAS System for Windows.
All lateral cephalograms were digitally analysed with the
OnyxCeph3TM software (Image Instruments, Chemnitz, Germany). Results
An x-y cranial base coordinate system was constructed on the radi- Inter- and intra-observer reliability is presented in Table  3 and
ographs through nasion. The x-axis was drawn 7  degrees to the Table  4. Mean pre- and postsurgical coordinates and surgical
sella-nasion line, the y-axis passing through nasion perpendicular changes of hard and soft tissue landmarks are presented in Table 5.
to the x-axis. The postoperative tracing was imposed on the first Concerning the mean surgical changes, negative values indicate a
radiograph by structural superimposition on the cribriform plate forward movement and positive values a backward movement of
and the anterior wall of the sella tursica. Figure 1 shows the skel- the landmarks in the horizontal plane. In the vertical direction, nega-
etal, soft tissue and dental landmarks and reference lines used in the tive values indicate a downward movement and positive values an
cephalometric analysis. Definitions of landmarks and measurements
are presented in Table  2. X and Y coordinates for the landmarks
and conventional cephalometric variables were established by the Table  2. Definition of cephalometric landmarks and measure-
OnyxCeph3TM software (Image Instruments, Chemnitz, Germany). ments.

Landmark Definition
Error of the method and statistical analysis
To determine reproducibility of the measurements, 20 subjects were ran- S Sella: center of sella tursica
domly selected and digitized by the same investigator at least 1 month N Nasion: most anterior point of frontonasal suture
apart. Inter-observer reliability was also evaluated on 20 random A Innermost point on contour of maxilla between ante-
subjects, digitized by another investigator at least 1 month apart. The rior nasal spine and incisor tooth
B Innermost point on contour of mandibula between
ICC(A,1) following McGraw KO and Wong SP (1996) has been used.
incisor tooth and bony chin
Changes of measurements between presurgical and postsurgical
Pog Pogonion: most anterior point on osseous contour
situation were evaluated with the Signed rank test. Note that dif- of chin
ferences were calculated as postsurgical value (T1) minus presurgi- Me Menton: most inferior midline point on mandibular
cal value (T0). Kruskal Wallis tests were used to compare changes symphysis
between groups. Associations amongst ordinal/continuous variables Gn Gnathion: most inferior anterior point on the outline
were verified with Spearman correlations. The slope (and 95% CI) of the bony chin
from a linear regression model was reported to verify if the changes Go Gonion: point at the angle of the mandible
(T1–T0) in hard and soft tissue were of similar magnitude. Isup Incision superior: midpoint of incisal edge of most
prominent maxillary central incisor
Iinf Incision inferior: midpoint of incisal edge of most
prominent mandibular central incisor
Pn Pronasale: most anterior and prominent point of nose
(tip of nose)
Cm Columella point: midpoint of columella of nose
Sn Subnasale: point at which columella (nasal septum)
merges with upper lip in midsagittal plane
Ls Labrale superius: most anterior point of upper lip
Li Labrale inferius: most anterior point of lower lip
Stms Stomion superius: most inferior point of upper lip
Stmi Stomion inferius: most upper point of lower lip
B’ Soft tissue B point: point of greatest concavity in
midline of lower lip between labrale inferius
and soft tissue pogonion
Pog’ Soft tissue pogonion: most prominent or anterior
point on chin in midsagittal plane
Me’ Soft tissue menton: lowest point on contour of soft
tissue chin
Gn’ Soft tissue gnathion: most inferior anterior point of
the soft tissue chin
Max1-NF U1 angle: upper central incisor to palatal plane angle
Mand1-MP L1 angle: lower incisor to mandibular plane angle
II Interincisal angle
G’-Sn-Pog’ Facial convexity: angle between soft tissue glabella,
subnasale and soft tissue pogonion
Cm-Sn-Ls Nasolabial angle: angle between columella and
labrale superius
Mlf depth Mentolabial fold depth: horizontal distance from B’
to Li
Figure 1.  Landmarks and reference planes used in cephalometric analysis.
4 European Journal of Orthodontics, 2017

Table 3.  Inter-observer reliability based on 20 subjects. Table 4.  Intra-observer reliability based on 20 subjects.

Inter-observer reliability Intra-observer reliability

Measurement ICC SEM RC Measurement ICC SEM RC

Pog(x) 0.932 2.239 6.201 N(x) 0.308 0.456 1.262

B(x) 0.921 2.100 5.818
A(x) 0.910 1.278 3.541 Me(x) 0.987 1.033 2.861
Isup(x) 0.910 1.669 4.623 Pog(x) 0.987 0.991 2.746
Ls(x) 0.903 1.658 4.592 Gn(x) 0.987 1.032 2.860
Pog’(x) 0.917 2.498 6.921 B(x) 0.984 0.959 2.656
N(y) −0.494 0.344 0.953 A(x) 0.973 0.709 1.964
Pog(y) 0.966 1.523 4.219 Isup(x) 0.976 0.865 2.397
B(y) 0.775 3.322 9.201 Iinf(x) 0.955 1.250 3.463
A(y) 0.783 1.956 5.419 Sn(x) 0.963 0.891 2.468
Isup(y) 0.949 1.123 3.111 Ls(x) 0.974 0.871 2.413
Ls(y) 0.920 1.316 3.646 Stm-s(x) 0.964 1.023 2.835
Pog’(y) 0.932 2.072 5.740 Stm-i(x) 0.970 0.988 2.737
II(°) 0.858 3.200 8.863 Li(x) 0.980 0.910 2.520
B’(x) 0.984 0.922 2.555
Pog’(x) 0.987 0.985 2.729
ICC, intra-class correlation; SEM, Standard error of measurement; RC, Re-
Gn’(x) 0.978 1.417 3.924
producibility coefficient (calculated as 2.77*SEM) which expresses the range
Me’(x) 0.974 1.542 4.270
of plausible differences between two repeated measures (i.e. the half width of
N(y) 0.099 0.378 1.048
the 95%CI for differences between two repeated measurements).
Me(y) 0.988 0.871 2.412
Pog(y) 0.954 1.781 4.934
upward movement. Mean changes for the high-angle, medium-angle
Gn(y) 0.986 0.969 2.685
and low-angle group are given in Table 6. B(y) 0.974 1.110 3.074
A(y) 0.964 0.792 2.193
Changes of landmarks after mandibular Isup(y) 0.976 0.769 2.131
advancement surgery Iinf(y) 0.978 0.777 2.152
Skeletal changes Sn(y) 0.966 0.730 2.021
Horizontal Ls(y) 0.970 0.800 2.215
Stm-s(y) 0.969 0.782 2.166
The anterior movement of the bony chin was significant and similar
Stm-i(y) 0.979 0.727 2.014
for all landmarks (P  <  0.0001). The mean advancement (T1–T0)
Li(y) 0.981 0.829 2.298
was 5.01 mm at pogonion, 5.06 mm at gnathion, 5.11 mm at men- B’(y) 0.984 0.810 2.245
ton, and 4.88 mm at B-point. The position of A-point showed no Pog’(y) 0.947 1.829 5.066
significant changes. Gn’(y) 0.978 1.187 3.288
Me’(y) 0.984 1.013 2.806
Vertical SNA(°) 0.982 0.544 1.506
The skeletal landmarks of the chin also showed an even absolute SNB(°) 0.988 0.467 1.293
ANB(°) 0.983 0.337 0.934
downward movement: 2.16 mm at pogonion, 2.18 mm at gnathion,
OB(mm) 0.875 0.599 1.659
2.30 mm at menton, and 2.23 mm at B-point. (P < 0.0001) Again,
OJ(mm) 0.990 0.270 0.749
there was no significant change at A-point. Max1-NF(°) 0.965 1.391 3.853
For horizontal and vertical changes, there were no significant dif- Mand1-MP(°) 0.940 1.822 5.048
ferences found between high- and low-angle subjects. II(°) 0.962 1.645 4.557
Gl’SnPog’(°) 0.969 1.108 3.068
Angular CotgSnLs(°) 0.943 2.429 6.729
After surgery, the skeletal distal relationship significantly improved. SNGoGn(°) 0.969 1.258 3.485
The mean ANB-angle changed from 6.01  degrees to 2.98  degrees [Sn-A] 0.915 0.749 2.075
due to forward movement of the mandible, of which the position [Ls-Isup] 0.994 0.187 0.519
[Li-Iinf] 0.988 0.243 0.672
(SNB) improved from 74.88 degrees to 77.81 degrees (P < 0.0001).
[B-B’] 0.981 0.284 0.788
Increase of the SNB-angle was more evident (P = 0.007) in the low-
[Pog-Pog’] 0.827 1.110 3.074
angle group with on average 3.50 degrees ± 1.07, while high- angle
patients showed a lower increase of 2.7 degrees ± 1.52 (P = 0.015).
ICC, intra-class correlation; SEM, Standard error of measurement; RC, Re-
Also, ANB decreased more in the low-angle group with 3.60 degrees producibility coefficient (calculated as 2.77 × SEM) which expresses the range
± 0.99 (P = 0.019). The mandibular plane angle (SN-GoGn) showed of plausible differences between two repeated measures (i.e. the half width of
a mean significant increase of 1.21 degrees ± 1.89 (P < 0.0001). the 95%CI for differences between two repeated measurements).

Dental changes
Horizontal slightly forward by 0.41 mm (P < 0.001). Incision superior moved
Incision inferior translated forward by 4.49 mm (P < 0.0001). The slightly forward in the low-angle group, while it moved backward
mean overjet changed from 7.27  mm to 3.01  mm, with a mean in the high-angle cases (P  =  0.01). However, changes for incision
decrease of 4.23  mm (P  <  0.0001). Also, incision superior moved superior were very small and clinically irrelevant.
A.S. Storms et al. 5

Vertical and Iinf-Li. Vertically, correlation was strongest for Me-Me’, Pog-
A significant downward movement of 1.94  mm was seen for inci- Pog’, B-B’, and Iinf-Li, respectively.
sion inferior (P < 0.0001). Overbite decreased with 1.46 mm, from A weak negative correlation was found between presurgical
3.03 mm at T0 to 1.57 mm at T1 (P < 0.0001). Changes for incision thickness of the lip and postsurgical vertical change of soft tissue
superior were not significant. B-point. This implies a more downward movement of soft tissue
B-point when the presurgical thickness of the lower lip is higher.
Angular No significant correlation was found for the horizontal change of
Angulation of the upper incisor (Max1-NF) and the interincisal angle soft tissue B-point and vertical and horizontal change of Li with the
(II) showed no significant changes after surgery. Angulation of the lower presurgical thickness of the lip.
incisor (Mand1-MP) decreased significantly with 2.42° (P < 0.0001). No significant correlation was found for the presurgical thick-
For vertical and angular changes, there were no significant differ- ness of the soft tissue chin at Me-Me’ and Pog-Pog’ and changes of
ences found between high- and low-angle patients. soft tissue pogonion and soft tissue menton landmarks.

Soft tissue changes Ratio of hard and soft tissue changes

Horizontal To evaluate if hard and soft tissue changes were equal in magnitude,
No significant changes were observed for labrale superius. However, changes of some soft tissue landmarks and their underlying hard tis-
there were differences between the growth patterns (P = 0.009) for sto- sue structures are presented in Figure 2 as scatterplots. If for every
mium superius, which moved more forward in the low- and medium- subject the changes of hard and soft tissue points are equal, all points
angle subjects (P = 0.018 and P = 0.003, respectively) Concerning the would fall on the identity line. The slope from the linear regression is
lower lip, labrale inferius showed a very significant forward move- reported to show the average value, i.e. equal to 1 if changes in hard
ment of 3.76  mm (P  <  0.0001). All soft tissue landmarks of the chin and soft tissues are on average equal in magnitude. The slope (95%
moved forward: 4.81 mm at soft tissue pogonion, 4.92 mm at soft tissue CI) was found to be 0.981 for Pog’:Pog, 0.928 for B’:B, Me’:Me
gnathion, 4.94 mm at soft tissue menton, and 4.75 mm at soft tissue 0.923, and lowest for Li:Iinf with 0.756. All changes are in the hori-
B-point (P < 0.0001). For the changes of the lower lip and soft tissue zontal plane with exception of Me’:Me. The soft tissue landmarks of
chin, no differences were found between the different facial patterns. the chin follow the change of the corresponding hard tissue points
almost completely (>90 per cent). On the other hand, change in soft
Vertical tissue of the lower lip is only 75.6 per cent of the change in hard
No significant postsurgical changes were noticed for the upper lip. tissue. No significant differences were found between between low-
Regarding the lower lip, labrale inferius and stomium inferius moved angle and high-angle subjects.
upward by 1.17  mm (P  <  0.0001) and 0.58  mm (P  =  0.0003) cor-
respondingly. Soft tissue landmarks of the chin were relocated down- Discussion
ward after mandibular advancement (P < 0.0001). Soft tissue pogonion
In our study, we evaluated short-term hard and soft tissue changes
moved downward by 1.59 mm, soft tissue gnathion by 1.85 mm, soft
after mandibular advancement surgery in 109 patients. Our sample
tissue menton by 2.03 mm, and soft tissue B-point by 1.87 mm.
consisted of more than twice as many females than males, which
implies that mostly females are seeking treatment. This was also
Thickness
found in previous studies (11, 12, 24).
Soft tissue thickness of the upper lip at Ls-Isup showed no significant
Postsurgical lateral cephalograms of at least 6 months after sur-
change. Decrease of thickness of the lower lip by 1.89 mm was evident
gery were selected to rule out the effect of soft tissue edema imme-
(P < 0.0001). Also, depth of the mentolabial fold decreased by 0.99 mm
diately after surgery. According to literature, postoperative swelling
(P < 0.0001). Concerning soft tissue thickness of the chin, the only sig-
is fully resolved after 6  months (10). Another criterion for X-ray
nificant change was a decrease of Me-Me’ by 0.34 mm (P = 0.0011).
selection was that brackets still had to be in situ to eliminate posi-
tional changes on upper and lower lip due to bracket removal. As a
Angular result of these strict selection criteria, we were only able to evaluate
There was no important change in nasolabial angle after surgery. On short-term changes in a range of 6 to 8.5 months after mandibular
the other hand, reduction of facial convexity was highly significant advancement surgery.
(5.29 degrees ± 2.76; P < 0.0001). P =  Facial convexity had a ten- Concerning dental changes, we found a very small but statisti-
dency to improve more in the low-angle group (6.70 degrees ± 2.57) cal significant forward movement of incision superior of 0.41 mm.
than in high-angle cases (5.60 degrees ± 3.21) (P = 0.011). This change is probably due to the finishing phase of orthodontic
treatment. However, this small movement is clinically irrelevant. We
Relationship between landmarks also noticed a mean decrease in angulation of the lower incisor of
Correlations 2.42 degrees. This finding might be a result of establishing frontal
Spearman correlation coefficients between hard and soft tissue changes contact between lower and upper incisors by mandibular advance-
are presented in Table 7. There was a strong correlation of the hori- ment surgery and orthodontic finishing.
zontal change of Li, B’, Pog’, Gn’, and Me’ with the horizontal change Our results suggest no significant effect of surgery on the position
of pogonion. Landmarks closer to pogonion showed a stronger cor- of the upper lip in vertical and horizontal direction. This seems to be
relation. For these points there was also a good correlation in vertical in agreement with previous authors, who either found no effect (5,
direction, although correlation of Li was somewhat weaker. 7) or only clinically irrelevant changes (11, 24, 25). In literature, an
Furthermore, changes of all soft tissue points of the mandible initial anterior movement of the upper lip was reported immediately
showed a significant positive correlation with the movement of their after surgery due to postoperative swelling, which gradually faded
corresponding skeletal structures. In horizontal direction, correla- (7, 11, 12, 24). In the long-term, a posterior relocation of labrale
tion was highly significant for Pog-Pog’, followed by B-B’, Me-Me’, superius has been reported especially in low-angle patients (24).
6 European Journal of Orthodontics, 2017

Table 5.  Pre- and postsurgical coordinates (T0 and T1) and surgical changes (T1-T0) of hard and soft tissue landmarks.

Coordinate at T0 Coordinate at T1 Change T1-T0 P

Landmark Mean SD Mean SD Mean SD

Skeletal
  Horizontal (mm)
  Me(x) 16.93 8.69 11.82 8.70 −5.11 2.40 <0.0001*
  Pog(x) 11.98 8.20 6.97 8.27 −5.01 2.23 <0.0001*
  Gn(x) 13.48 8.56 8.42 8.60 −5.06* 2.30 <0.0001*
  B(x) 13.10 7.11 8.22 7.24 −4.88* 1.99 <0.0001*
  A(x) 1.86 4.28 1.82 4.32 −0.04 0.65 0.9964
  Vertical (mm)
  Me(y) −112 7.70 −114 7.96 −2.30 2.02 <0.0001*
  Pog(y) −106 8.06 −108 8.37 −2.16 2.29 <0.0001*
  Gn(y) −110 7.92 −112 8.18 −2.18 2.10 <0.0001*
  B(y) −94.4 6.73 −96.7 7.05 −2.23 2.67 <0.0001*
  A(y) −57.1 4.19 −57.3 4.24 −0.15 0.67 0.0274
  Angular (°)
  SNA 80.89 4.00 80.79 4.09 −0.09 0.60 0.1148
  SNB 74.88 3.87 77.81 4.01 2.93 1.18 <0.0001*
  ANB 6.01 2.13 2.98 2.04 −3.03 1.21 <0.0001*
  SN-GoGn 31.88 7.17 33.09 6.90 1.21 1.89 <0.0001*
Dental
  Horizontal (mm)
  Isup(x) −1.08 5.59 −1.49 5.60 −0.41 1.24 0.0010*
  Iinf(x) 5.94 5.36 1.45 5.42 −4.49 2.12 <0.0001*
  Overjet 7.27 2.14 3.01 0.78 −4.23 2.19 <0.0001*
  Vertical (mm)
  Isup (y) −78.2 5.02 −78.3 5.00 −0.09 1.31 0.5620
  Iinf(y) −74.7 5.12 −76.6 5.20 −1.94 1.88 <0.0001*
  Overbite 3.03 1.90 1.57 1.09 −1.46 1.98 <0.0001*
  Angular (°)
  Max1-NF 111.7 7.91 112.6 7.09 0.89 3.61 0.0118
  Mand1-MP 96.12 7.53 93.70 7.11 −2.42 4.13 <0.0001*
  II 126.7 9.18 127.7 7.76 0.94 6.76 0.1514
Soft tissue
  Horizontal (mm)
  Ls(x) −13.2 5.35 −13.5 5.42 −0.28 1.50 0.0978
  Stms(x) −5.54 5.29 −6.59 5.47 −1.05 1.58 <0.0001*
  Stmi(x) −4.44 5.64 −6.32 5.55 −1.88 2.11 <0.0001*
  Li(x) −6.15 6.15 −9.91 6.09 −3.76 2.24 <0.0001*
  B’(x) 2.03 6.74 −2.72 6.87 −4.75 2.09 <0.0001*
  Pog’(x) 0.45 8.48 −4.36 8.31 −4.81 2.41 <0.0001*
  Me’(x) 18.18 9.14 13.24 9.33 −4.94 3.31 <<0.0001*
  Gn’(x) 5.89 9.35 0.97 9.23 −4.92 3.06 <0.0001*
  Vertical (mm)
  Ls(y) −69.2 4.56 −69.0 4.76 0.12 1.57 0.5280
  Stms(y) −75.2 4.36 −75.1 4.59 0.11 1.47 0.4754
  Stmi(y) −77.3 4.98 −76.7 5.17 0.58 1.61 0.0003*
  Li(y) −87.0 5.86 −85.9 6.25 1.17 2.02 <0.0001*
  B’(y) −91.5 6.31 −93.3 6.52 −1.87 2.29 <<0.0001*
  Pog’(y) −105 7.73 −107 8.12 −1.59 2.89 <0.0001*
  Me’(y) −119 7.79 −121 8.02 −2.03 2.08 <0.0001*
  Gn’(y) −114 7.88 −116 8.20 −1.85 2.70 <0.0001*
  Thickness (mm)
  Ls-Isup 11.89 2.45 11.94 2.48 0.05 1.02 0.6159
  Li-Iinf 14.72 2.18 12.83 1.78 −1.89 1.37 <<0.0001*
  B-B’ 11.78 2.12 11.67 2.06 −0.11 1.31 0.2332
  Pog-Pog’ 11.92 2.73 11.70 2.68 −0.22 1.16 0.0177
  Me-Me’ 7.60 2.05 7.26 1.91 −0.34 1.09 0.0011*
  Mlf depth 8.19 1.96 7.19 2.06 −0.99 1.13 <0.0001*
  Angular (°)
  Nasolabial angle 109.2 10.21 108.9 10.37 −0.30 5.15 0.9258
  G’-Sn-Pog’ −18.7 5.68 −13.4 5.67 5.29 2.76 <0.0001*

T0, before surgery; T1, at least 6 months after surgery; horizontal changes, negative value implies anterior movement, positive value implies posterior movement; vertical
changes, negative value implies inferior movement, positive value indicates superior movement; angular changes, negative value implies decrease, positive value implies increase.
P values are obtained from Signed rank tests.
*P values smaller than 0.01 are considered significant.
A.S. Storms et al. 7

Table 6.  Mean changes (T1-T0), SD, and P value for low-angle, medium-angle and low-angle group.

Low-angle Medium-angle High-angle P

Landmark Mean SD Mean SD Mean SD

Skeletal
  Horizontal (mm)
  Me(x) −5.6 2.12 −4.8 2.29 −5.4 2.94 0.368
  Pog(x) −5.6 1.89 −4.8 2.17 −5.1 2.69 0.299
  Gn(x) −5.7 2.01 −4.8 2.20 −5.2 2.78 0.219
  B(x) −5.6 1.70 −4.6 1.81 −4.8 2.60 0.083
  A(x) −0.1 0.69 −0.1 0.65 0.2 0.58 0.173
  Vertical (mm)
  Me(y) −2.3 2.61 −2.3 1.95 −2.3 1.52 0.989
  Pog(y) −2.1 2.64 −2.1 2.27 −2.4 2.01 0.820
  Gn(y) −2.3 2.64 −2.1 2.03 −2.3 1.71 0.930
  B(y) −2.0 2.80 −2.3 2.79 −2.2 2.25 0.870
  A(y) 0.1 0.78 −0.2 0.58 −0.2 0.78 0.164
  Angular (°)
  SNA −0.0 0.69 −0.0 0.56 −0.4 0.52 0.023
  SNB 3.5 1.07 2.8 1.01 2.7 1.52 0.007*
  ANB −3.6 0.99 −2.8 1.09 −3.1 1.55 0.019
  SN-GoGn 1.6 1.98 1.3 1.80 0.5 1.94 0.117
Dental
  Horizontal (mm)
  Isup(x) −0.5 1.01 −0.6 1.32 0.3 0.99 0.010
  Iinf(x) −5.1 2.11 −4.3 1.99 −4.2 2.42 0.170
  Overjet −4.9 2.08 −3.8 1.99 −4.6 2.66 0.137
  Vertical (mm)
  Isup (y) −0.1 1.52 0.0 1.14 −0.4 1.51 0.505
  Iinf(y) −2.1 2.08 −2.0 1.80 −1.6 1.92 0.646
  Overbite −1.6 1.89 −1.6 1.84 −0.9 2.38 0.215
  Angular (°)
  Max1-NF 0.3 3.40 1.6 3.74 −0.6 2.97 0.015
  Mand1-MP −3.3 4.49 −2.4 4.34 −1.55 2.92 0.241
  II 1.1 5.36 0.2 7.87 2.8 3.92 0.068
Soft tissue
  Horizontal (mm)
  Ls(x) −0.4 1.35 −0.4 1.68 0.2 1.04 0.261
  Stms(x) −1.2 1.61 −1.3 1.61 −0.2 1.26 0.009*
  Stmi(x) −1.9 1.82 −2.0 2.18 −1.6 2.23 0.512
  Li(x) −4.0 1.73 −3.8 2.33 −3.3 2.50 0.363
  B’(x) −5.3 1.57 −4.7 1.90 −4.5 2.94 0.146
  Pog’(x) −5.6 1.90 −4.5 2.41 −4.8 2.79 0.164
  Me’(x) −6.2 3.19 −4.8 2.90 −4.0 4.19 0.066
  Gn’(x) −5.7 3.12 −4.8 2.82 −4.4 3.58 0.456
  Vertical (mm)
  Ls(y) 0.7 1.76 0.1 1.40 −0.3 1.72 0.187
  Stms(y) 0.7 1.69 0.0 1.31 −0.3 1.53 0.074
  Stmi(y) 0.4 1.87 0.7 1.57 0.5 1.46 0.800
  Li(y) 1.2 2.17 1.1 2.00 1.3 2.02 0.962
  B’(y) −2.1 2.77 −1.8 2.12 −1.9 2.27 0.886
  Pog’(y) −1.3 3.64 −1.4 2.66 −2.5 2.56 0.223
  Me’(y) −2.0 2.65 −1.9 2.03 −2.4 1.50 0.496
  Gn’(y) −1.9 3.32 −1.5 2.58 −2.8 2.06 0.107
  Thickness (mm)
  Ls-Isup 0.1 1.06 0.0 1.07 0.1 0.87 0.822
  Li-Iinf −2.1 1.14 −1.8 1.44 −2.1 1.40 0.383
  B-B’ −0.4 0.80 0.1 1.29 −0.4 1.69 0.135
  Pog-Pog’ −0.0 0.66 −0.2 1.32 −0.4 1.11 0.481
  Me-Me’ −0.5 0.67 −0.4 1.22 0.1 0.97 0.114
  Mlf depth −1.3 0.92 −0.8 1.05 −1.1 1.48 0.144
  Angular (°)
  Nasolabial angle −0.9 5.56 −0.8 4.99 1.7 4.87 0.227
  G’-Sn-Pog’ 6.7 2.57 4.7 2.48 5.6 3.21 0.011

Horizontal changes, negative value implies anterior movement, positive value implies posterior movement; vertical changes, negative value implies inferior movement, posi-
tive value indicates superior movement; angular changes, negative value implies decrease, positive value implies increase. P values are from Kruskal–Wallis tests.
*P values smaller than 0.01 are considered significant.
8 European Journal of Orthodontics, 2017

Table 7.  Spearman correlation coefficients between hard and soft surgery, and profile improvement was more evident for the low-
tissue changes. angle group. Also, the SNB-angle increased more for the low-angle
subjects. This is a remarkable finding, since the mean pre-operative
Change in Relation with Spearman (95% CI) P
SNB-angle was significantly higher (P  <  0.001) for the low-angle
Horizontal group (78.4 degrees) than for the high-angle group (71.8 degrees) .
This can be explained by the fact that advancement of the mandible
Pog Li 0.647 (0.520;0.743) <0.0001* in these patients can be performed more straightforward than in
B’ 0.829 (0.758;0.879) <0.0001*
high-angle cases, where more clockwise rotation of the mandible
Pog’ 0.881 (0.830;0.917) <0.0001*
occurs during advancement. As far as we observed, only two other
Gn’ 0.799 (0.717;0.857) <<0.0001*
studies analysed surgical changes according to growth pattern.(11,
Me’ 0.788 (0.702;0.849) <0.0001*
B B’ 0.874 (0.820;0.912) <0.0001* 24) No differences were found for the facial convexity between
Me Me’ 0.808 (0.730;0.864) <0.0001* the groups in these studies. However, we need to treat these results
Iinf Li 0.687 (0.571;0.774) <<0.0001* with some degree of caution due to weak significance (P = 0.011).
Vertical According to the Class II growth patterns, we only found few dif-
Pog Li 0.486 (0.326;0.616) <0.0001* ferences in our examined variables. This is somewhat surprising,
B’ 0.694 (0.580;0.779) <0.0001* since high-angle and low-angle Class II patients are considered to
Pog’ 0.769 (0.677;0.835) <0.0001* be two distinct entities with a different treatment approach. Low-
Gn’ 0.784 (0.697;0.846) <<0.0001*
angle cases typically have a reduced anterior facial height, a deep
Me’ 0.836 (0.767;0.884) <0.0001*
bite and a deep mentolabial fold. In these patients, more clockwise
B B’ 0.613 (0.478;0.717) <0.0001*
Me Me’ 0.898 (0.854;0.929) <0.0001*
rotation of the mandible is desired to improve vertical dimensions.
Iinf Li 0.451 (0.285;0.588) <0.0001* High-angle patients are characterized by an increased anterior facial
B’ Li-IinfatT0 −0.306 (−0.466;−0.124) 0.0011* height, a convex profile with a weak chin, reduced overbite, incom-
petent lips, and an increased nasolabial angle. Surgical increase in
*P values smaller than 0.01 are considered significant. lower anterior facial height is not desirable in this facial pattern. In
our retrospective sample however, we only found a significant dif-
ference in presurgical patient characteristics between the different
Continuous lowering of labrale superius in the long term may be due facial patterns for SNA and SNB. Variables were evaluated with
to lack of soft tissue strength with age (25). We found no significant average values of the subgroups. This may explain why we found
changes in the nasolabial angle, which is in contrast with the findings no significant differences for horizontal and vertical changes of the
of Mobarak et al. (24), who reported an increase of this variable in lower jaw between high- and low-angle patients.
the low-angle group. Also other authors found an increase of the In our study, we were not able to take skeletal relapse after man-
nasolabial angle (11, 15). dibular advancement surgery into account. It is important to keep
There seems to be some discussion in literature about the behav- in mind that changes between T0 and T1 represent a combination
iour of the lower lip after BSSO advancement. Our results show a sig- of surgical changes and skeletal relapse. There seems to be some dis-
nificant forward and upward movement, a decrease in thickness and cussion about the timing and amount of skeletal relapse after man-
a small decrease of the depth of the mentolabial fold. These findings dibular advancement surgery. Several authors reported that relapse
are also reported in previous studies (5, 7, 9, 12, 24). The decrease 6 months after surgery is minimal, ranging from 5.3 per cent – 15
in thickness is probably the reason why the anterior movement of per cent at point B. Keeling et al. (7) found no relapse at the hard
labrale inferius is smaller than the landmarks of the soft tissue chin. tissues of the chin 6  months after surgery, but only a horizontal
However, some studies found a correlation between the pre-operative relapse of the lower lip due to edema in the first 8 weeks. Blomqvist
soft tissue thickness and the post-operative response of the lower lip et al. (26) found a somewhat higher amount of short-term relapse
(24). We only reported a correlation between the pre-operative thick- of 18.4 per cent. On the other hand, Mobarak et al.(8) reported 33
ness of the lower lip and the vertical movement of the soft tissue per cent of relapse at Pog 3 years postoperative, of which most part
B-point. The thicker the lower lip before surgery, the more soft tissue occurred between 1 week and 2 months and between 1 and 3 years
B-point will move downward after mandibular advancement surgery, after surgery. High-angle patients showed more skeletal relapse (36
which implies smoothening of the mentolabial fold. Furthermore, the per cent) than low-angle cases (27.6 per cent). For the low-angle
relationship between the movement of the lower incisor and that of group, almost all horizontal relapse (95 per cent) at pogonion took
the lower lip shows most variation in literature. In a recent systematic place during the first two months after surgery. Horizontal changes
review of Joss et al. (25) long-term ratios are reported ranging from were more progressive in the high-angle group, with 29 per cent of
35 to 108 per cent. In our study, we also found that the lower lip the total relapse occurring within two months, 25.3 per cent between
followed the lower incisor in lesser extent than Pog’:Pog, B’:B, and 2 months and 1 year, and 38 per cent between 1 and 3 years after
Me’:Me, more specific with 76 per cent. Many factors, such as the surgery. Low-angle patients seem to have an increased tendency to
difficulty to reproduce a relaxed lip position during imaging, bracket vertical relapse, while high-angle patients show more horizontal
removal and individual differences in tonicity, posture and soft tis- relapse. A recent literature review (27) also reported skeletal relapse
sue morphology account for this variation in results. Also, the lower in the long-term, with 2–31.4 per cent after 1 year and 60 per cent
lip position is mostly supported by the maxillary incisors and thus after 12.7  years. Skeletal relapse is a complex multifactorial pro-
already maintained in a more forward position. cess and may be influenced by seating of the condyles, amount of
For the chin, the relationship between hard and soft tissue move- advancement, type of fixation, mandibular plane angle, distal seg-
ments were far more consistent and approached a 1:1 relationship ment rotation, soft tissue and muscle stretch, remaining growth and
for Pog’:Pog, B’:B, and Me’:Me. Our results were comparable to remodelling and surgeon skills.
previous stated ratios, ranging from 88 to 127 per cent. (25) Facial Since all surgeries were performed by the same surgeon, no vari-
convexity reduced significantly after mandibular advancement ability in hard or soft tissue changes after mandibular advancement
A.S. Storms et al. 9

Figure 2.  Scatterplots presenting changes of soft tissue landmarks and their underlying hard tissue structures.

surgery can be attributed to the number of surgeons involved. • The bony chin changed to a more forward and downward
Different surgeons can use different surgical protocols, can differ in position.
experience or manual dexterity, influencing surgical variables as type • There was no influence on the upper lip position, while the lower
of sagittal split, occurrence of bad splits or nerve damage, but once lip moved upward and forward and decreased in thickness. Also
the correction of the overjet is reached, the tooth bearing mandibular a small smoothening of the mentolabial fold was noticed.
fragment is in place, independently of the technique used (28). • The change of the soft tissue of the lower lip was smaller than the
movement of underlying hard tissue, while the soft tissue land-
Limitations marks of the chin follow the change of the corresponding skeletal
points almost completely.
The study was marked by some limitations derived from its retro-
• We also reported some differences between Class II facial pat-
spective nature. We were only able to evaluate short-term changes
terns:
6  months after mandibular advancement surgery. The distinction
between surgical changes and changes due to skeletal relapse is dif-   o SNB increased more in low-angle cases, despite a signifi-
ficult to assess. Also, the difficulty to reproduce a relaxed lip position cantly higher mean preoperative value for this group.
during imaging may influence our results.   o The facial convexity had the tendency to improve more in
low-angle patients. This can be due to the possibility of a
Conclusion more straightforward surgical advancement in low-angle
In Class II patients who received mandibular advancement surgery, patients, while in high-angle cases also a clockwise rotation
the following changes could be observed: of the mandible occurs during advancement.
10 European Journal of Orthodontics, 2017

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  o For the ratio of hard and soft tissue changes, we found no an average of 12 years postoperatively. Journal of oral and maxillofacial
surgery, 65, 2301–2310.
differences between Class II facial patterns.
14. Kneafsey L.C., Cunningham S.J., Petrie A. and Hutton T.J. (2008) Pre-
diction of soft-tissue changes after mandibular advancement surgery with
an equation developed with multivariable regression. American journal of
Conflict of interest
orthodontics and dentofacial orthopedics, 134, 657–664.
None to declare. 15. Dermaut L.R. and De Smit A.A. (1989) Effects of sagittal split advance-
ment osteotomy on facial profiles. European journal of orthodontics, 11,
366–374.
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