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YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
Clinical Paper
Orthognathic Surgery
Maxillary advancement versus
mandibular setback in class III
dentofacial deformity: are there
any differences in aesthetic
outcomes?
M. Ghassemi, R.-D. Hilgers, U. Fritz, A. Modabber, A. Ghassemi: Maxillary
advancement versus mandibular setback in class III dentofacial deformity: are there
any differences in aesthetic outcomes?. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–
xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published
by Elsevier Ltd. All rights reserved.
M. Ghassemi1
, R.-D. Hilgers2
,
U. Fritz1
, A. Modabber3
,
A. Ghassemi4
1
Department of Orthodontics, RWTH Aachen
University, Aachen, Germany; 2
Department of
Medical Statistics, RWTH Aachen University,
Aachen, Germany; 3
Department of Oral and
Maxillofacial Surgery, RWTH Aachen
University, Aachen, Germany; 4
Oral and
Maxillofacial Surgery, Klinikum-Lippe,
Detmold, Germany
Abstract. A retrospective evaluation of maxillary advancement and mandibular
setback in class III patients was performed and their aesthetic outcomes compared.
Patients with a sella–nasion–A-point angle (SNA) of 80–848 were selected. Pre- and
postoperative lateral cephalograms were obtained for 34 class III patients; these
were divided into two groups according to the surgical procedure performed:
mandibular setback group (n = 17) and maxillary advancement group (n = 17). The
pre- and postoperative cervical length, lip–chin–throat angle, lower/upper lip
thickness, distance from the lower/upper lip to the aesthetic line, soft tissue angle,
facial contour angle, and nasolabial angle of the two groups were compared.
Significant differences were observed for cervical length (P = 0.0003) and sex
(P = 0.003) when comparing maxillary advancement with mandibular setback.
Although the preoperative cervical length was similar in the two groups, it increased
significantly after maxillary advancement and decreased after mandibular setback.
In this study, the differences in aesthetic outcomes depending on the surgical
procedure performed were considered. Some aesthetically important parameters
proved to be superior after maxillary advancement when compared to mandibular
setback, even with the maxilla in the normal position.
Key words: Class III deformity; maxillary ad-
vancement versus mandibular setback; soft
tissue outcome.
Accepted for publication 29 November 2016
Class III malocclusion is considered one of
the most complex conditions in terms of
diagnosis and treatment planning, and an
increasing demand for surgical correction
has been observed in recent years.1–3
Treat-
ment should include the following goals:
function, aesthetics, long-term stability,
and the selection of the procedure with
the lowest complication rate. The anatomi-
cal feasibility should also be considered.
The level of patient satisfaction is an
important factor that has a significant
Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx
http://dx.doi.org/10.1016/j.ijom.2016.11.017, available online at http://www.sciencedirect.com
0901-5027/000001+07 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
impact on oral health-related quality of
life.4
The facial profile comprises five
main prominences: the forehead, nose,
lips, chin, and the submental–cervical re-
gion.5
Additionally, lip thickness, lip to-
nicity, initial incisor inclination, and lip
height affect the resulting soft tissue
changes and consequently the aesthetic
outcome.6
The final aesthetic outcome,
however, is determined by the procedure
performed, individual soft tissue adapta-
tion, and achievable possible tendency.7,8
The lip and the chin are the two regions
influenced by mandibular setback and
maxillary advancement.
Historically, Class III malocclusions
were treated by isolated mandibular set-
back; however, bimaxillary procedures
have become increasingly frequent.9–12
One important reason for the increase in
bimaxillary procedures is the achievement
of stable long-term results.2,3
However,
one-jaw surgery is often sufficient to cor-
rect most of the dentofacial deformity, and
two-jaw surgery can increase the risk of
complications. The selection of which jaw
to operate on is generally based on the
position of the maxilla and the mandible.
Mandibular setback is generally the pro-
cedure of choice if the mandible is posi-
tioned anteriorly with the maxilla in the
normal position.13
Many studies have compared the aes-
thetic outcomes of mandibular setback
surgery, maxillary advancement surgery,
and combined surgery.9–13
In this study,
the aesthetic outcomes of mandibular
setback surgery were compared to those
of maxillary advancement surgery in
patients suffering from class III dento-
facial deformities with the maxilla in the
normal position. The hypothesis was that
in patients with a class III deformity
with the maxilla in the normal position,
the aesthetic outcome differs between
maxillary advancement and mandibular
setback.
Materials and methods
The study was performed in accordance
with the Declaration of Helsinki statement
for medical research involving human
subjects.16
The study protocol was
reviewed and approved by the Ethics
Committee of RWTH Aachen University
prior to study commencement. As the
patients in this study remained anony-
mous, the consent process was not com-
pulsory.
A retrospective cohort study was con-
ducted based on the clinic medical
records. The patients (n = 34) underwent
combined orthodontic and orthognathic
surgery and were assigned to either the
mandibular setback group (n = 17) or the
maxillary advancement group (n = 17)
according to the surgical procedure per-
formed. Although different orthodontists
performed the orthodontic treatment, one
surgeon performed all of the mandibular
setback procedures and another performed
all of the maxillary advancement proce-
dures. The examiner in this study was
blinded to the surgeon names. The study
inclusion criteria were as follows: (1) non-
syndromic patient with a class III dento-
facial deformity and a preoperative sella–
nasion–A-point angle (SNA) of 80–848
and Wits value of <0 (the Wits value is
the distance between AO (perpendicular
from A-point to occlusal plane) and BO
(perpendicular from B-point to occlusal
plane))16
; (2) the patient had completed
skeletal growth; (3) the surgical treatment
performed was either mandibular setback
or maxillary advancement; (4) the patient
had not undergone previous surgery in-
volving the middle or lower face.
A lateral cephalogram was taken at the
beginning of orthodontic treatment (T1)
and at least 6–10 months postoperatively
(T2), after the postoperative swelling had
subsided. Patients were asked to have their
teeth in occlusion and their lips in an
unstrained and relaxed position to avoid
muscular compensation. The changes in
outcome (pre- and postoperative) were
compared by means of continuous out-
come distances and angles (sagittal, verti-
cal), cervical length (Gn0
–H: the distance
between the soft tissue gnathion (Gn0
)
point and the neck point (H)),17,18
nose
position, and dental, upper lip, and lower
lip changes (Fig. 1).
Statistical analysis
To assess the differences between the two
groups – mandibular setback vs. maxillary
advancement – the analysis of covariance
(ANCOVA) models were adjusted to the
data of the 14 outcome parameters sepa-
rately (Table 1). Specifically, cervical
length served as a dependent variable;
age, sex, and treatment, as well as the
(two-way) interaction between age and
treatment and the (two-way) interaction
between sex and treatment served as inde-
pendent variables (fixed-effects). Normal
errors were assumed and the validity was
checked by residual and influence diag-
nostics. Similar models were used for the
other outcome variables.
Using a backward selection process, the
model was first reduced by removing
the non-important interaction terms
(P > 0.05) and was then continued in
the same way with the main effectors of
sex and age. Of primary interest was the
effect on the main effect treatment group
in the ANCOVA models. The type 1 error
rate for the multiple testing of the 14
outcome variable endpoints was con-
trolled using Hochberg’s multiple testing
procedure.19
The results of the adjusted
effects of the different treatments (adjust-
ed for age and sex and the interaction
term) on the respective outcome variables
are given in Table 2, along with the 95%
confidence intervals for the mean differ-
ence, the P-values, and the (adjusted)
Hochberg significance levels. The overall
significance level was set to 5%. All com-
putations were performed using SAS ver-
sion 9.4 (TS1M1) (SAS Institute, Cary,
NC, USA) in Windows X64 7 Pro (Micro-
soft, Redmond, WA, USA).
Results
This study included 34 patients with a class
III dentofacial deformity and an SNA of
80–848; 14 were male and 20 were female,
and they ranged in age from 16 to 51 years
(mean age 25 years). These patients under-
went combined orthodontic–surgical treat-
ment, and cephalograms were taken pre-
and postoperatively. The mean age of
the maxillary advancement group was
31 years, and the mean age of the mandib-
ular setback group was 25 years
(t = À1.86, df = 35.7, P = 0.070). The
mean mandibular setback was À7.1 mm
(maximum À12.9 mm, minimum À2 mm)
and the mean maxillary advancement was
4.6 mm (maximum 8.5 mm, minimum
2.4 mm).
The sella–nasion–B point angle (SNB),
SNA, and Wits appraisal changed signifi-
cantly depending on the procedure per-
formed (SNB: t = À6.61, df = 27.05,
P = 0.0001; SNA: t = À5.84, df = 25.97,
P = 0.001; Wits: t = À1.75, df = 25.66,
P = 0.008).
There was a significant difference be-
tween the maxillary advancement and
mandibular setback groups with regard
to sex (P = 0.003).
The cervical length differed significant-
ly depending on whether mandibular set-
back or maxillary advancement was
performed (P = 0.0003). The mean preop-
erative cervical length was 55.00 mm
(standard deviation (SD) 7.95) in the man-
dibular setback group and 54.00 mm (SD
11.49) in the maxillary advancement
group. The mean postoperative cervical
length was 46.00 mm (SD 11.28) in the
mandibular setback group and 56.00 mm
(SD 10.97) in the maxillary advancement
group.
2 Ghassemi et al.
YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
The mean change in the lip–chin–throat
angle was 10.478 (SD 6.5) in the mandib-
ular setback group and À0.648 (SD 9.1) in
the maxillary advancement group; the
change in the lip–chin–throat angle in
the mandibular setback group appeared
to be significantly different to that in
the maxillary advancement group
(P = 0.024), but this difference was not
significant using the Hochberg procedure.
The change in upper lip thickness in
the mandibular setback group was not
significantly different to that in the
maxillary advancement group when
using the Hochberg significance level
(P = 0.029).
The distance between the lower lip and
the aesthetic line in the mandibular set-
back group was not significantly different
to that in the maxillary advancement
group (P = 0.549).
The postoperative change in the soft
tissue facial angle in the maxillary ad-
vancement group (mean À0.888, SD
2.61) was similar to that in the mandibular
setback group (P = 0.128).
The postoperative facial contour angle
did not differ significantly between the
groups using the Hochberg significance
level (P = 0.205).
The postoperative anterior movement
of the upper lip in the mandibular setback
group (mean 0.88 mm, SD 2.75) was sim-
ilar to that in the maxillary advancement
group (mean 1.58 mm, SD 2.93)
(P = 0.549).
Maxillary advancement vs. mandibular setback 3
YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
Fig. 1. Graphic showing the mean tracing of the hard and soft tissues (gonion angle, mandible inclination, lower lip to E-line, nasolabial angle, soft
tissue facial angle, nose prominence, upper lip thickness, upper lip length, lower lip length, cervical length, lip–chin–throat angle, facial contour,
upper lip to E-line).
The postoperative change in the upper
incisor inclination in the mandibular set-
back group (mean 1.98, SD 7.1) was simi-
lar to that in the maxillary advancement
group (SD 8.2) (P = 0.549).
The nasolabial angle increased after
mandibular setback (SD 7.53) and de-
creased after maxillary advancement
(SD 6.5), but the difference between the
groups was not significant (P = 0.772).
There was no significant difference be-
tween the two groups in mandible inclina-
tion (P = 0.819) or length of the lower lip
(P = 0.820).
Although the nose prominence tended
to decrease more in the mandibular set-
back group (mean À0.94 mm, SD 2.4)
compared with the maxillary advancement
group (mean À1.58 mm, SD 2.9), this
difference was not significant (P = 0.820).
The postoperative change in gonion
angle of the mandibular setback group
(SD 3.6) was similar to that in the maxil-
lary advancement group (P = 0.800).
Discussion
The purpose of this study was to compare
the aesthetic outcomes of maxillary ad-
vancement with those of mandibular set-
back in patients with a class III dentofacial
deformity but with the maxilla in the
normal position (SNA of 80–848). This
should help in selecting the appropriate
jaw if one-jaw surgery is planned, or in
choosing the appropriate amount of
movement for each jaw if two-jaw surgery
is considered.
The facial appearance after maxillary
advancement was more favourable than
that after mandibular setback. It was ob-
served that the cervical length increased
after maxillary advancement in contrast to
mandibular setback. Additionally, man-
dibular setback resulted in a straightening
of the upper lip with a concomitant unde-
sirable increase in the nasolabial angle.
To reduce the selection bias, the sur-
geons were asked for their reasons for
choosing maxillary advancement or man-
dibular setback. The surgical procedure
was chosen based on personal preference
in relation to clinical findings or the posi-
tion of the jaw. Mandibular setback was
the main procedure performed before
2005, but maxillary advancement became
the main procedure thereafter.9–11,14,20
To
reduce measurement bias, all cephalo-
grams were traced and digitized by the
same examiner. The surgical approaches
applied were the one-piece Le Fort I
osteotomy for maxillary advancement
and the bilateral sagittal split osteotomy
for mandibular setback. The preoperative
cervical length was similar in the two
groups, but increased significantly after
maxillary advancement and decreased af-
ter mandibular setback.
No increase in the incidence of double
chin was observed following maxillary
advancement (Fig. 2) when compared to
mandibular setback (Fig. 3). This may
explain the more favourable facial appear-
ance in the maxillary advancement group
and its impact on the chin region. There
was considerable variation in the change
4 Ghassemi et al.
YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
Table 1. Values of selected cephalometric variables before and after surgery (mean Æ standard
deviation), with Dahlberg’s standard deviation of error for each variable.
Variables Before surgery After surgery Accidental error
SNA (8) 81 Æ 4.15 81 Æ 4.13 0.8
SNB (8) 83.9 Æ 4.71 80.5 Æ 4.21 0.79
Wits appraisal (mm) À10 Æ 4.08 À4.1 Æ 3.52 0.75
Gonion angle (8) 128.5 Æ 6.32 128.17 Æ 6.87 0.69
Mandible inclination (8) 34.61 Æ 6.83 34.76 Æ 6.44 0.78
Upper 1 inclination (8) 105.61 Æ 7.61 104.88 Æ 5.80 0.81
Lower lip to E-line (mm) À8.3 Æ 3.31 À5.7 Æ 3.71 0.51
Nasolabial angle (8) À2.5 Æ 3.24 À3.4 Æ 3.03 0.78
Soft tissue facial angle (8) 110 Æ 12.53 100.6 Æ 12.2 0.8
Upper lip thickness (mm) 18.2 Æ 3.53 16.5 Æ 3.32 0.51
Pg0
(mm) 13 Æ 3.23 13 Æ 4.23 0.7
Upper lip length (mm) 21.9 Æ 3.34 23.7 Æ 4.43 0.4
Lower lip length (mm) 46.5 Æ 7.52 48.1 Æ 6.13 0.6
Cervical length (mm) 50.6 Æ 10.04 47.9 Æ 10.42 0.72
Lip–chin–throat angle (8) 50.6 Æ 10.14 47.9 Æ 10.32 0.77
Upper lip to E-line (mm) À8.3 Æ 3.32 À5.7 Æ 3.72 0.74
SNA, sella–nasion–A-point angle; SNB, sella–nasion–B-point angle; E-line, aesthetic line; Pg0
,
soft tissue pogonion.
Table 2. Values of the soft tissue cephalometric index in relation to mandibular setback/maxillary advancement.
Source
Least square mean 95% CI for
difference P-value
Hochberg significance
level Commentsa
Mandibular
setback
Maxillary
advancement
Cervical length (mm) 44.439 54.618 À15.343 to À5.014 0.0003 0.0036 (1)b
Lip–chin–throat angle (8) 113.706 106.470 0.977 to 13.495 0.024 0.0071 (1)
Upper lip thickness (mm) 17.010 14.872 0.231 to 4.044 0.029 0.0107 (1)
Lower lip to E-line (mm) À5.784 À3.862 À3.716 to À0.128 0.036 0.0143 (1)
Soft tissue facial angle (8) 93.925 95.133 À3.043 to 0.6295 0.189 0.0179 (1)
Facial contour angle (8) À9.119 À11.174 À1.184 to 5.295 0.205 0.0214 (1)
Upper lip to E-line (mm) À6.414 À5.934 À2.098 to 1.138 0.549 0.0250 (2)
Upper 1 inclination (8) 106.348 105.122 À3.176 to 5.628 0.574 0.0286 (1)
Nasolabial angle (8) 106.585 102.075 À10.335 to 7.752 0.772 0.0321 (1)
Upper lip length (mm) 22.750 23.014 À2.141 to 1.6128 0.775 0.0357 (1)
Mandible inclination (8) 32.154 31.904 À1.964 to 2.463 0.819 0.0393 (1)
Lower lip length (mm) 44.387 43.965 À3.334 to 4.178 0.820 0.0429 (1)
Nose prominence (mm) 15.808 15.603 À1.627 to 2.038 0.820 0.0464 (1)
Gonion angle (8) 126.968 127.149 À3.681 to 3.319 0.916 0.0500 (1)
CI, confidence interval; E-line, aesthetic line; ANCOVA, analysis of covariance.
a
(1) ANCOVA model with baseline value and treatment; (2) ANCOVA model with significant sex.
b
Treatment interaction.
in cervical length, which was greater in
patients who had maxillary advancement,
and maxilla impaction due to the autoro-
tation of the mandible. As reported in
previous studies, a straightening of the
upper lip was also found after mandibular
setback, with a concomitant increase in
the nasolabial angle. Increasing the naso-
labial angle has a negative effect on the
aesthetic outcome.22,23
Although the nose
prominence was decreased in the maxil-
lary advancement group, this amount of
decrease was similar to that found in the
mandibular setback group (Table 2).
A consciousness and perception of the
attractiveness of different facial parame-
ters may be useful in compiling the opti-
mal treatment option.23
Generally, the
amount of sagittal discrepancy and the
position of the mandible and the maxilla
vis-a`-vis the skull base are decisive factors
for selecting the surgical procedure. If
there is a small discrepancy, one-jaw sur-
gery will generally be sufficient to correct
the deformity; in such cases, two-jaw sur-
gery will inevitably increase the risk of
complications without additional benefits.
Maxillary advancement vs. mandibular setback 5
YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
Fig. 2. Photographs of a patient who underwent maxillary advancement: (a) pre-treatment, (b) post-treatment.
Fig. 3. Photographs of a patient who underwent mandibular setback: (a) pre-treatment, (b) post-treatment.
Many studies have shown that mandibular
setback has a negative impact on function
and can lead to a negative aesthetic
outcome in the submental region.4,10,24
In addition, maxillary advancement
increases the width of airways and
improves the aesthetics of the nasolabial
and submental regions.6
The vertical
change was similar in the two groups
(Table 2). A minimal vertical change fol-
lowing maxillary advancement caused a
forward movement of the mandible and
increased the cervical length positively, as
also reported by Proffit et al.3
As recommended in a previous study,
surgeons performing this operation should
limit the amount of mandibular setback to
less than 5 mm and correct the remaining
distance by advancing the maxilla, irre-
spective of the SNA or SNB.15
This has a
positive aesthetic impact on the submental
region, improves the functional outcome,
and shows stable, long-term results, as
reported in other studies.9,25
Some authors
have also reported that isolated mandibu-
lar setback is less predictable and less
stable,22,26–28
and others have shown that
maxillary advancement is a more stable
component and causes larger mandible
autorotation.9,12
The nose, facial contour angle, cervical
length, and facial angle are the main
components of facial aesthetics, and
should all be considered when planning
and predicting the outcome of orthog-
nathic surgery.5,15,22
Vasudavan et al.
showed that the Le Fort I advancement
produces an elevation of the nasal tip, as
evidenced by a reduction in nasal length
and nasofrontal angle, along with an in-
crease in the nasal tip protrusion.29
In the
present study, it was found that advancing
the maxilla had a great effect on the nose
(nasolabial angle and nose prominence),
the cervical length, and the upper lip, as
reported previously.1,19,25,28,30
The dis-
tance from the upper lip to the aesthetic
line – depending on the patient’s sex – was
significantly different after maxillary ad-
vancement when compared with mandib-
ular setback. In female patients, maxillary
advancement was performed more often
than mandibular setback, whereas the op-
posite was the case for male patients. A
possible reason for this is related to the
surgeon’s consideration of the double
chin deformity which can result from
mandibular setback. This requires further
investigation.
In conclusion, maxillary advancement
achieved a significantly more favourable
outcome when considering the cervical
length in class III patients, regardless of
the maxilla position. These findings
should be considered when selecting the
appropriate jaw for osteotomy.
Funding
No funding.
Competing interests
No conflicts of interest.
Ethical approval
The Ethics Committee of the Medical
University of RWTH Aachen E approved
the study (EK 150/30).
Patient consent
Written patient consent was obtained to
publish the clinical photographs.
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surgical–orthodontic treatment. Am J Orthod
Dentofacial Orthop 2013;143:793–8.
22. Brock RA, Taylor RW, Buschang PH, Behr-
ents RG. Ethnic differences in upper lip
response to incisor retraction. Am J Orthod
Dentofacial Orthop 2005;127:683–91.
23. Peck H, Peck S. A concept of facial esthetics.
Angle Orthod 1970;40:284–318.
24. Ghassemi M, Hilgers RD, Jamilian A, Ho¨l-
zle F, Fritz U, Gerressen M, et al. Consid-
eration of effect of the amount of mandibular
setback on the submental region in the plan-
ning of orthodontic–orthognathic treatment.
Br J Oral Maxillofac Surg 2014;52:334–9.
25. Cho HJ. Long-term stability of surgical man-
dibular setback. Angle Orthod 2007;77:
851–6.
6 Ghassemi et al.
YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
26. Jakobsone G, Stenvik A, Sandvik L, Espe-
land L. Three-year follow-up of bimaxillary
surgery to correct skeletal class III maloc-
clusion: stability and risk factors for relapse.
Am J Orthod Dentofacial Orthop 2011;139:
80–9.
27. Rosen HM. Lip–nasal aesthetics following
Le Fort I osteotomy. Plast Reconstr Surg
1988;81:171–82.
28. Czarnecki ST, Nanda RS, Currier GF. Per-
ceptions of a balanced facial profile. Am J
Orthod Dentofacial Orthop 1993;104:
180–7.
29. Vasudavan S, Jayaratne YS, Padwa BL.
Nasolabial soft tissue changes after Le Fort
I advancement. J Oral Maxillofac Surg
2012;70:e270–7.
30. Naini FB, Donaldson AN, Cobourne MT,
McDonald F. Assessing the influence of man-
dibular prominence on perceived attractive-
ness in the orthognathic patient, clinician, and
layperson. Eur J Orthod 2012;34:738–46.
Address:
Mehrangiz Ghassemi
Department of Orthodontics
RWTH Aachen University
Pauwelsstrasse 30
52074 Aachen
Germany
Tel: +49 241 8035796; Fax: +49 241 8082459
E-mail: mghassemi@ukaachen.de
Maxillary advancement vs. mandibular setback 7
YIJOM-3562; No of Pages 7
Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial
deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/

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2016 ghassemi-maxillary advancement versus man

  • 1. YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/ Clinical Paper Orthognathic Surgery Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes? M. Ghassemi, R.-D. Hilgers, U. Fritz, A. Modabber, A. Ghassemi: Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?. Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx– xxx. # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. M. Ghassemi1 , R.-D. Hilgers2 , U. Fritz1 , A. Modabber3 , A. Ghassemi4 1 Department of Orthodontics, RWTH Aachen University, Aachen, Germany; 2 Department of Medical Statistics, RWTH Aachen University, Aachen, Germany; 3 Department of Oral and Maxillofacial Surgery, RWTH Aachen University, Aachen, Germany; 4 Oral and Maxillofacial Surgery, Klinikum-Lippe, Detmold, Germany Abstract. A retrospective evaluation of maxillary advancement and mandibular setback in class III patients was performed and their aesthetic outcomes compared. Patients with a sella–nasion–A-point angle (SNA) of 80–848 were selected. Pre- and postoperative lateral cephalograms were obtained for 34 class III patients; these were divided into two groups according to the surgical procedure performed: mandibular setback group (n = 17) and maxillary advancement group (n = 17). The pre- and postoperative cervical length, lip–chin–throat angle, lower/upper lip thickness, distance from the lower/upper lip to the aesthetic line, soft tissue angle, facial contour angle, and nasolabial angle of the two groups were compared. Significant differences were observed for cervical length (P = 0.0003) and sex (P = 0.003) when comparing maxillary advancement with mandibular setback. Although the preoperative cervical length was similar in the two groups, it increased significantly after maxillary advancement and decreased after mandibular setback. In this study, the differences in aesthetic outcomes depending on the surgical procedure performed were considered. Some aesthetically important parameters proved to be superior after maxillary advancement when compared to mandibular setback, even with the maxilla in the normal position. Key words: Class III deformity; maxillary ad- vancement versus mandibular setback; soft tissue outcome. Accepted for publication 29 November 2016 Class III malocclusion is considered one of the most complex conditions in terms of diagnosis and treatment planning, and an increasing demand for surgical correction has been observed in recent years.1–3 Treat- ment should include the following goals: function, aesthetics, long-term stability, and the selection of the procedure with the lowest complication rate. The anatomi- cal feasibility should also be considered. The level of patient satisfaction is an important factor that has a significant Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2016.11.017, available online at http://www.sciencedirect.com 0901-5027/000001+07 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
  • 2. impact on oral health-related quality of life.4 The facial profile comprises five main prominences: the forehead, nose, lips, chin, and the submental–cervical re- gion.5 Additionally, lip thickness, lip to- nicity, initial incisor inclination, and lip height affect the resulting soft tissue changes and consequently the aesthetic outcome.6 The final aesthetic outcome, however, is determined by the procedure performed, individual soft tissue adapta- tion, and achievable possible tendency.7,8 The lip and the chin are the two regions influenced by mandibular setback and maxillary advancement. Historically, Class III malocclusions were treated by isolated mandibular set- back; however, bimaxillary procedures have become increasingly frequent.9–12 One important reason for the increase in bimaxillary procedures is the achievement of stable long-term results.2,3 However, one-jaw surgery is often sufficient to cor- rect most of the dentofacial deformity, and two-jaw surgery can increase the risk of complications. The selection of which jaw to operate on is generally based on the position of the maxilla and the mandible. Mandibular setback is generally the pro- cedure of choice if the mandible is posi- tioned anteriorly with the maxilla in the normal position.13 Many studies have compared the aes- thetic outcomes of mandibular setback surgery, maxillary advancement surgery, and combined surgery.9–13 In this study, the aesthetic outcomes of mandibular setback surgery were compared to those of maxillary advancement surgery in patients suffering from class III dento- facial deformities with the maxilla in the normal position. The hypothesis was that in patients with a class III deformity with the maxilla in the normal position, the aesthetic outcome differs between maxillary advancement and mandibular setback. Materials and methods The study was performed in accordance with the Declaration of Helsinki statement for medical research involving human subjects.16 The study protocol was reviewed and approved by the Ethics Committee of RWTH Aachen University prior to study commencement. As the patients in this study remained anony- mous, the consent process was not com- pulsory. A retrospective cohort study was con- ducted based on the clinic medical records. The patients (n = 34) underwent combined orthodontic and orthognathic surgery and were assigned to either the mandibular setback group (n = 17) or the maxillary advancement group (n = 17) according to the surgical procedure per- formed. Although different orthodontists performed the orthodontic treatment, one surgeon performed all of the mandibular setback procedures and another performed all of the maxillary advancement proce- dures. The examiner in this study was blinded to the surgeon names. The study inclusion criteria were as follows: (1) non- syndromic patient with a class III dento- facial deformity and a preoperative sella– nasion–A-point angle (SNA) of 80–848 and Wits value of <0 (the Wits value is the distance between AO (perpendicular from A-point to occlusal plane) and BO (perpendicular from B-point to occlusal plane))16 ; (2) the patient had completed skeletal growth; (3) the surgical treatment performed was either mandibular setback or maxillary advancement; (4) the patient had not undergone previous surgery in- volving the middle or lower face. A lateral cephalogram was taken at the beginning of orthodontic treatment (T1) and at least 6–10 months postoperatively (T2), after the postoperative swelling had subsided. Patients were asked to have their teeth in occlusion and their lips in an unstrained and relaxed position to avoid muscular compensation. The changes in outcome (pre- and postoperative) were compared by means of continuous out- come distances and angles (sagittal, verti- cal), cervical length (Gn0 –H: the distance between the soft tissue gnathion (Gn0 ) point and the neck point (H)),17,18 nose position, and dental, upper lip, and lower lip changes (Fig. 1). Statistical analysis To assess the differences between the two groups – mandibular setback vs. maxillary advancement – the analysis of covariance (ANCOVA) models were adjusted to the data of the 14 outcome parameters sepa- rately (Table 1). Specifically, cervical length served as a dependent variable; age, sex, and treatment, as well as the (two-way) interaction between age and treatment and the (two-way) interaction between sex and treatment served as inde- pendent variables (fixed-effects). Normal errors were assumed and the validity was checked by residual and influence diag- nostics. Similar models were used for the other outcome variables. Using a backward selection process, the model was first reduced by removing the non-important interaction terms (P > 0.05) and was then continued in the same way with the main effectors of sex and age. Of primary interest was the effect on the main effect treatment group in the ANCOVA models. The type 1 error rate for the multiple testing of the 14 outcome variable endpoints was con- trolled using Hochberg’s multiple testing procedure.19 The results of the adjusted effects of the different treatments (adjust- ed for age and sex and the interaction term) on the respective outcome variables are given in Table 2, along with the 95% confidence intervals for the mean differ- ence, the P-values, and the (adjusted) Hochberg significance levels. The overall significance level was set to 5%. All com- putations were performed using SAS ver- sion 9.4 (TS1M1) (SAS Institute, Cary, NC, USA) in Windows X64 7 Pro (Micro- soft, Redmond, WA, USA). Results This study included 34 patients with a class III dentofacial deformity and an SNA of 80–848; 14 were male and 20 were female, and they ranged in age from 16 to 51 years (mean age 25 years). These patients under- went combined orthodontic–surgical treat- ment, and cephalograms were taken pre- and postoperatively. The mean age of the maxillary advancement group was 31 years, and the mean age of the mandib- ular setback group was 25 years (t = À1.86, df = 35.7, P = 0.070). The mean mandibular setback was À7.1 mm (maximum À12.9 mm, minimum À2 mm) and the mean maxillary advancement was 4.6 mm (maximum 8.5 mm, minimum 2.4 mm). The sella–nasion–B point angle (SNB), SNA, and Wits appraisal changed signifi- cantly depending on the procedure per- formed (SNB: t = À6.61, df = 27.05, P = 0.0001; SNA: t = À5.84, df = 25.97, P = 0.001; Wits: t = À1.75, df = 25.66, P = 0.008). There was a significant difference be- tween the maxillary advancement and mandibular setback groups with regard to sex (P = 0.003). The cervical length differed significant- ly depending on whether mandibular set- back or maxillary advancement was performed (P = 0.0003). The mean preop- erative cervical length was 55.00 mm (standard deviation (SD) 7.95) in the man- dibular setback group and 54.00 mm (SD 11.49) in the maxillary advancement group. The mean postoperative cervical length was 46.00 mm (SD 11.28) in the mandibular setback group and 56.00 mm (SD 10.97) in the maxillary advancement group. 2 Ghassemi et al. YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
  • 3. The mean change in the lip–chin–throat angle was 10.478 (SD 6.5) in the mandib- ular setback group and À0.648 (SD 9.1) in the maxillary advancement group; the change in the lip–chin–throat angle in the mandibular setback group appeared to be significantly different to that in the maxillary advancement group (P = 0.024), but this difference was not significant using the Hochberg procedure. The change in upper lip thickness in the mandibular setback group was not significantly different to that in the maxillary advancement group when using the Hochberg significance level (P = 0.029). The distance between the lower lip and the aesthetic line in the mandibular set- back group was not significantly different to that in the maxillary advancement group (P = 0.549). The postoperative change in the soft tissue facial angle in the maxillary ad- vancement group (mean À0.888, SD 2.61) was similar to that in the mandibular setback group (P = 0.128). The postoperative facial contour angle did not differ significantly between the groups using the Hochberg significance level (P = 0.205). The postoperative anterior movement of the upper lip in the mandibular setback group (mean 0.88 mm, SD 2.75) was sim- ilar to that in the maxillary advancement group (mean 1.58 mm, SD 2.93) (P = 0.549). Maxillary advancement vs. mandibular setback 3 YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/ Fig. 1. Graphic showing the mean tracing of the hard and soft tissues (gonion angle, mandible inclination, lower lip to E-line, nasolabial angle, soft tissue facial angle, nose prominence, upper lip thickness, upper lip length, lower lip length, cervical length, lip–chin–throat angle, facial contour, upper lip to E-line).
  • 4. The postoperative change in the upper incisor inclination in the mandibular set- back group (mean 1.98, SD 7.1) was simi- lar to that in the maxillary advancement group (SD 8.2) (P = 0.549). The nasolabial angle increased after mandibular setback (SD 7.53) and de- creased after maxillary advancement (SD 6.5), but the difference between the groups was not significant (P = 0.772). There was no significant difference be- tween the two groups in mandible inclina- tion (P = 0.819) or length of the lower lip (P = 0.820). Although the nose prominence tended to decrease more in the mandibular set- back group (mean À0.94 mm, SD 2.4) compared with the maxillary advancement group (mean À1.58 mm, SD 2.9), this difference was not significant (P = 0.820). The postoperative change in gonion angle of the mandibular setback group (SD 3.6) was similar to that in the maxil- lary advancement group (P = 0.800). Discussion The purpose of this study was to compare the aesthetic outcomes of maxillary ad- vancement with those of mandibular set- back in patients with a class III dentofacial deformity but with the maxilla in the normal position (SNA of 80–848). This should help in selecting the appropriate jaw if one-jaw surgery is planned, or in choosing the appropriate amount of movement for each jaw if two-jaw surgery is considered. The facial appearance after maxillary advancement was more favourable than that after mandibular setback. It was ob- served that the cervical length increased after maxillary advancement in contrast to mandibular setback. Additionally, man- dibular setback resulted in a straightening of the upper lip with a concomitant unde- sirable increase in the nasolabial angle. To reduce the selection bias, the sur- geons were asked for their reasons for choosing maxillary advancement or man- dibular setback. The surgical procedure was chosen based on personal preference in relation to clinical findings or the posi- tion of the jaw. Mandibular setback was the main procedure performed before 2005, but maxillary advancement became the main procedure thereafter.9–11,14,20 To reduce measurement bias, all cephalo- grams were traced and digitized by the same examiner. The surgical approaches applied were the one-piece Le Fort I osteotomy for maxillary advancement and the bilateral sagittal split osteotomy for mandibular setback. The preoperative cervical length was similar in the two groups, but increased significantly after maxillary advancement and decreased af- ter mandibular setback. No increase in the incidence of double chin was observed following maxillary advancement (Fig. 2) when compared to mandibular setback (Fig. 3). This may explain the more favourable facial appear- ance in the maxillary advancement group and its impact on the chin region. There was considerable variation in the change 4 Ghassemi et al. YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/ Table 1. Values of selected cephalometric variables before and after surgery (mean Æ standard deviation), with Dahlberg’s standard deviation of error for each variable. Variables Before surgery After surgery Accidental error SNA (8) 81 Æ 4.15 81 Æ 4.13 0.8 SNB (8) 83.9 Æ 4.71 80.5 Æ 4.21 0.79 Wits appraisal (mm) À10 Æ 4.08 À4.1 Æ 3.52 0.75 Gonion angle (8) 128.5 Æ 6.32 128.17 Æ 6.87 0.69 Mandible inclination (8) 34.61 Æ 6.83 34.76 Æ 6.44 0.78 Upper 1 inclination (8) 105.61 Æ 7.61 104.88 Æ 5.80 0.81 Lower lip to E-line (mm) À8.3 Æ 3.31 À5.7 Æ 3.71 0.51 Nasolabial angle (8) À2.5 Æ 3.24 À3.4 Æ 3.03 0.78 Soft tissue facial angle (8) 110 Æ 12.53 100.6 Æ 12.2 0.8 Upper lip thickness (mm) 18.2 Æ 3.53 16.5 Æ 3.32 0.51 Pg0 (mm) 13 Æ 3.23 13 Æ 4.23 0.7 Upper lip length (mm) 21.9 Æ 3.34 23.7 Æ 4.43 0.4 Lower lip length (mm) 46.5 Æ 7.52 48.1 Æ 6.13 0.6 Cervical length (mm) 50.6 Æ 10.04 47.9 Æ 10.42 0.72 Lip–chin–throat angle (8) 50.6 Æ 10.14 47.9 Æ 10.32 0.77 Upper lip to E-line (mm) À8.3 Æ 3.32 À5.7 Æ 3.72 0.74 SNA, sella–nasion–A-point angle; SNB, sella–nasion–B-point angle; E-line, aesthetic line; Pg0 , soft tissue pogonion. Table 2. Values of the soft tissue cephalometric index in relation to mandibular setback/maxillary advancement. Source Least square mean 95% CI for difference P-value Hochberg significance level Commentsa Mandibular setback Maxillary advancement Cervical length (mm) 44.439 54.618 À15.343 to À5.014 0.0003 0.0036 (1)b Lip–chin–throat angle (8) 113.706 106.470 0.977 to 13.495 0.024 0.0071 (1) Upper lip thickness (mm) 17.010 14.872 0.231 to 4.044 0.029 0.0107 (1) Lower lip to E-line (mm) À5.784 À3.862 À3.716 to À0.128 0.036 0.0143 (1) Soft tissue facial angle (8) 93.925 95.133 À3.043 to 0.6295 0.189 0.0179 (1) Facial contour angle (8) À9.119 À11.174 À1.184 to 5.295 0.205 0.0214 (1) Upper lip to E-line (mm) À6.414 À5.934 À2.098 to 1.138 0.549 0.0250 (2) Upper 1 inclination (8) 106.348 105.122 À3.176 to 5.628 0.574 0.0286 (1) Nasolabial angle (8) 106.585 102.075 À10.335 to 7.752 0.772 0.0321 (1) Upper lip length (mm) 22.750 23.014 À2.141 to 1.6128 0.775 0.0357 (1) Mandible inclination (8) 32.154 31.904 À1.964 to 2.463 0.819 0.0393 (1) Lower lip length (mm) 44.387 43.965 À3.334 to 4.178 0.820 0.0429 (1) Nose prominence (mm) 15.808 15.603 À1.627 to 2.038 0.820 0.0464 (1) Gonion angle (8) 126.968 127.149 À3.681 to 3.319 0.916 0.0500 (1) CI, confidence interval; E-line, aesthetic line; ANCOVA, analysis of covariance. a (1) ANCOVA model with baseline value and treatment; (2) ANCOVA model with significant sex. b Treatment interaction.
  • 5. in cervical length, which was greater in patients who had maxillary advancement, and maxilla impaction due to the autoro- tation of the mandible. As reported in previous studies, a straightening of the upper lip was also found after mandibular setback, with a concomitant increase in the nasolabial angle. Increasing the naso- labial angle has a negative effect on the aesthetic outcome.22,23 Although the nose prominence was decreased in the maxil- lary advancement group, this amount of decrease was similar to that found in the mandibular setback group (Table 2). A consciousness and perception of the attractiveness of different facial parame- ters may be useful in compiling the opti- mal treatment option.23 Generally, the amount of sagittal discrepancy and the position of the mandible and the maxilla vis-a`-vis the skull base are decisive factors for selecting the surgical procedure. If there is a small discrepancy, one-jaw sur- gery will generally be sufficient to correct the deformity; in such cases, two-jaw sur- gery will inevitably increase the risk of complications without additional benefits. Maxillary advancement vs. mandibular setback 5 YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/ Fig. 2. Photographs of a patient who underwent maxillary advancement: (a) pre-treatment, (b) post-treatment. Fig. 3. Photographs of a patient who underwent mandibular setback: (a) pre-treatment, (b) post-treatment.
  • 6. Many studies have shown that mandibular setback has a negative impact on function and can lead to a negative aesthetic outcome in the submental region.4,10,24 In addition, maxillary advancement increases the width of airways and improves the aesthetics of the nasolabial and submental regions.6 The vertical change was similar in the two groups (Table 2). A minimal vertical change fol- lowing maxillary advancement caused a forward movement of the mandible and increased the cervical length positively, as also reported by Proffit et al.3 As recommended in a previous study, surgeons performing this operation should limit the amount of mandibular setback to less than 5 mm and correct the remaining distance by advancing the maxilla, irre- spective of the SNA or SNB.15 This has a positive aesthetic impact on the submental region, improves the functional outcome, and shows stable, long-term results, as reported in other studies.9,25 Some authors have also reported that isolated mandibu- lar setback is less predictable and less stable,22,26–28 and others have shown that maxillary advancement is a more stable component and causes larger mandible autorotation.9,12 The nose, facial contour angle, cervical length, and facial angle are the main components of facial aesthetics, and should all be considered when planning and predicting the outcome of orthog- nathic surgery.5,15,22 Vasudavan et al. showed that the Le Fort I advancement produces an elevation of the nasal tip, as evidenced by a reduction in nasal length and nasofrontal angle, along with an in- crease in the nasal tip protrusion.29 In the present study, it was found that advancing the maxilla had a great effect on the nose (nasolabial angle and nose prominence), the cervical length, and the upper lip, as reported previously.1,19,25,28,30 The dis- tance from the upper lip to the aesthetic line – depending on the patient’s sex – was significantly different after maxillary ad- vancement when compared with mandib- ular setback. In female patients, maxillary advancement was performed more often than mandibular setback, whereas the op- posite was the case for male patients. A possible reason for this is related to the surgeon’s consideration of the double chin deformity which can result from mandibular setback. This requires further investigation. In conclusion, maxillary advancement achieved a significantly more favourable outcome when considering the cervical length in class III patients, regardless of the maxilla position. These findings should be considered when selecting the appropriate jaw for osteotomy. Funding No funding. Competing interests No conflicts of interest. Ethical approval The Ethics Committee of the Medical University of RWTH Aachen E approved the study (EK 150/30). Patient consent Written patient consent was obtained to publish the clinical photographs. References 1. Janson G, De Souza JE, Barros SE, Andrade Junior P, Nakamura AY. Orthodontic treat- ment alternative to a class III subdivision malocclusion. J Appl Oral Sci 2009;17: 354–63. 2. Harrington C, Gallagher JR, Borzabadi-Far- ahani A. A retrospective analysis of dento- facial deformities and orthognathic surgeries using the index of orthognathic functional treatment need (IOFTN). Int J Pediatr Otor- hinolaryngol 2015;79:1063–6. 3. Proffit WR, Phillips C, Turvey TA. Stability after mandibular setback: mandible only vs. two jaw surgery. J Oral Maxillofac Surg 2012;70:e408–14. 4. Arad I, Jandu J, Bassett P, Fleming PS. Influence of single-jaw surgery vs bimaxil- lary surgery on the outcome and duration of combined orthodontic–surgical treatment. Angle Orthod 2011;281:983–7. 5. Moles DR, Cunningham SJ. A national re- view of mandibular orthognathic surgery activity in the National Health Service in England over a nine-year period: Part 1— service factors. Br J Oral Maxillofac Surg 2009;47:268–73. 6. Proffit WR, Phillips C, Turvey TA. Stability after surgical–orthodontic correction of skel- etal class III malocclusion. III. Combined maxillary and mandibular procedures. Int J Adult Orthodon Orthognath Surg 1991;6:211–25. 7. Mobarak KA, Krogstad O, Espeland L, Lyberg T. Factors influencing the predict- ability of soft tissue profile changes follow- ing mandibular setback surgery. Angle Orthod 2001;71:216–27. 8. Mucedero M, Coviello A, Baccetti T, Fran- chi L, Cozza P. Stability factors after double- jaw surgery in class III malocclusion. A systematic review. Angle Orthod 2008;78: 1141–52. 9. Abeltins A, Jakobsone G, Urtane I, Bige- stans A. The stability of bilateral sagittal ramus osteotomy and vertical ramus osteot- omy after bimaxillary correction of class III malocclusion. J Craniomaxillofac Surg 2011;39:583–7. 10. Abdelrahman TE, Takahashi K, Tamura K, Nakao K, Hassanein KM, Alsuity A, et al. Impact of different surgery modalities to correct class III jaw deformities on the pha- ryngeal airway space. J Craniofac Surg 2011;22:1598–601. 11. Dahlberg G. Statistical methods for medical and biological students. London: George Allen & Unwin Ltd; 1940: 122–32. 12. Modarai F, Donaldson JC, Naini FB. The influence of lower lip position on the per- ceived attractiveness of chin prominence. Angle Orthod 2013;83:795–800. 13. McNeill RW, Proffit WR, White RP. Cepha- lometric prediction for orthodontic surgery. Angle Orthod 1972;42:154–64. 14. Costa F, Robiony M, Sembronio S, Polini F, Politi M. Stability of skeletal class III mal- occlusion after combined maxillary and mandibular procedures. Int J Adult Orthodon Orthognath Surg 2001;16:179–92. 15. Sonego CL, Bobrowski AN, Chagas Jr OL, Torriani MA. Aesthetic and functional impli- cations following rotation of the maxillo- mandibular complex in orthognathic surgery: a systematic review. Int J Oral Maxillofac Surg 2014;43:40–5. 16. World Medical Association. World Medi- cal Association Declaration of Helsinki: ethical principles for medical research in- volving human subjects. JAMA 2013;310: 2191–4. 17. Jacobson A. The ‘‘Wits’’ appraisal of jaw disharmony. Am J Orthod 1975;67:125–38. 18. Legan HL, Burstone CJ. Soft tissue cepha- lometric analysis for orthognathic surgery. J Oral Surg 1980;38:744–51. 19. Hochberg Y. A sharper Bonferroni procedure for multiple tests of significance. Biometrika 1988;75:800–2. 20. Proffit WR, Jackson TH, Turvey TA. Changes in the pattern of patients receiving surgical–orthodontic treatment. Am J Orthod Dentofacial Orthop 2013;143:793–8. 22. Brock RA, Taylor RW, Buschang PH, Behr- ents RG. Ethnic differences in upper lip response to incisor retraction. Am J Orthod Dentofacial Orthop 2005;127:683–91. 23. Peck H, Peck S. A concept of facial esthetics. Angle Orthod 1970;40:284–318. 24. Ghassemi M, Hilgers RD, Jamilian A, Ho¨l- zle F, Fritz U, Gerressen M, et al. Consid- eration of effect of the amount of mandibular setback on the submental region in the plan- ning of orthodontic–orthognathic treatment. Br J Oral Maxillofac Surg 2014;52:334–9. 25. Cho HJ. Long-term stability of surgical man- dibular setback. Angle Orthod 2007;77: 851–6. 6 Ghassemi et al. YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/
  • 7. 26. Jakobsone G, Stenvik A, Sandvik L, Espe- land L. Three-year follow-up of bimaxillary surgery to correct skeletal class III maloc- clusion: stability and risk factors for relapse. Am J Orthod Dentofacial Orthop 2011;139: 80–9. 27. Rosen HM. Lip–nasal aesthetics following Le Fort I osteotomy. Plast Reconstr Surg 1988;81:171–82. 28. Czarnecki ST, Nanda RS, Currier GF. Per- ceptions of a balanced facial profile. Am J Orthod Dentofacial Orthop 1993;104: 180–7. 29. Vasudavan S, Jayaratne YS, Padwa BL. Nasolabial soft tissue changes after Le Fort I advancement. J Oral Maxillofac Surg 2012;70:e270–7. 30. Naini FB, Donaldson AN, Cobourne MT, McDonald F. Assessing the influence of man- dibular prominence on perceived attractive- ness in the orthognathic patient, clinician, and layperson. Eur J Orthod 2012;34:738–46. Address: Mehrangiz Ghassemi Department of Orthodontics RWTH Aachen University Pauwelsstrasse 30 52074 Aachen Germany Tel: +49 241 8035796; Fax: +49 241 8082459 E-mail: mghassemi@ukaachen.de Maxillary advancement vs. mandibular setback 7 YIJOM-3562; No of Pages 7 Please cite this article in press as: Ghassemi M, et al. Maxillary advancement versus mandibular setback in class III dentofacial deformity: are there any differences in aesthetic outcomes?, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/