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1. EVALUATION OF SOFT TISSUE CHANGES
FOLLOWING LEFORT-I SURGERY USING
SOFT TISSUE MARKERS: A SIX MONTH
PROSPECTIVE STUDY
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2. INDIAN DENTAL ACADEMY
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3. INTRODUCTION
The two prime objectives of orthognathic surgery are
normal occlusion and improved facial esthetics.
There are great variations in the amount and distribution
of the soft tissue elements
soft tissues exhibit more consistent changes, while the
unattached tissues show less consistent change.
Even an excellent osteotomy of maxilla and mandible
may create an unpleasant effect because of changes in
soft tissues which is difficult to control.
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4. AIM
To study the soft tissue changes in patient’s who had
undergone Lefort 1 osteotomy by utilizing Arnett and
bregman’s soft tissue markers.
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5. Objectives
To determine the soft tissue structural changes of the
middle third of face.
To determine the facial length changes.
To determine the antero – posterior measurements of
soft tissues overlying the hard tissue landmarks.
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6. Materials and methods
Total no. of patients
- 8.

Males
- 5.

Females
- 3.
Patients who required Lefort I were taken for the study.
The maxilla was always kept in one piece. When indicated, considerable
effort was made to prevent undesirable nasal changes, including resection
of the anterior nasal spine, flattening of the pyriform rim, and reduction of
nasal septum.
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7. Lateral cephalograms were taken one week
preoperatively and 1, 3 and 6 months post operatively to
evaluate the soft tissue changes as a result of surgery.
Persons for whom additional procedures were indicated
except Genioplasty.
persons with underlying systemic disease and persons
with cleft Deformities and syndromes were excluded
from the study.
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8. Soft tissue markers
For soft tissue cephalometric analysis, metallic markers
were placed on the right side of face to mark the key mid
face structures. The key structures are the orbital rim,
cheek bone, alar- base contour and sub- pupil which
indicate the anero – posterior position of maxilla.
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9. Soft tissue markers
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10. ORBITAL MARKER
The Orbital marker is placed
directly over the osseous
orbital rim and directly under
the pupil with the eye in the
straight gaze.
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11. CHEEK BONE MARKER
The Cheek bone required two
perspectives. First, examined
from ¾ view, the right malar
height of contour was marked
with ink. Then, with the
examiner standing directly in
front of the patient a metal
bead was placed at the
intersection of right malar
height of contour ink mark and
a vertical line through the outer
canthus.
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12. ALAR BASE MARKER
A Metallic bead was placed at
the deepest depression at the
alar base of the nose.
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13. SUB – PUPIL MARKER
The Sub – pupil marker was
placed one half the vertical
distance between the alar –
base marker and the orbital
rim marker directly below the
straight ahead gaze of the
pupil.
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14. Lateral ceph with markers
1
2
3
4
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15. METHODOLOGY
With the marked mid – face structures using markers,
lateral cephalograms were obtained with the patient
positioned in the lateral head position, seated condyle
and with passive lips.
All tracings were drawn by a single operator. Each
tracing of a radiograph was made on 0.003 inch acetate
paper with a 0.5mm pencil.
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16. PRE OPERATIVE
LATERAL PROFILE
FRONTAL PROFILE
LATERAL CEPHALOGRAM
CEPHALOGRAM TRACING
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17. 1 MONTH POST OPERATIVE
FRONTAL PROFILE
LATERAL CEPHALOGRAM
LATERAL PROFILE
CEPHALOGRAM TRACING
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18. 3 MONTH POST OPERATIVE
LATERAL PROFILE
FRONTAL PROFILE
LATERAL CEPHALOGRAM
CEPHALOGRAM TRACING
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19. 6 MONTH POST OPERATIVE
FRONTAL PROFILE
LATERAL PROFILE
LATERAL CEPHALOGRAM
CEPHALOGRAM TRACING
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20. LATERAL CEPH WITH SUPERIMPOSITION
Black
-
Pre-operative
Blue
-
1 Month Post-operative
Red
-
3 Month Post-operative
Green
-
6 Month Post-operative
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21. The tracings included the anterior cranial base, the soft
tissue profile, the key mid face structures marked with
metallic beads and the outlines of maxilla and mandible.
A reference system was developed to measure the
displacement of the points considered in both the X and
Y directions.
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22. The X-axis of this coordinate system consisted of the
constructed Frankfort horizontal (a line 70 below the S-N
line).
The Y-axis was established by drawing a line
perpendicular to the X-axis with it’s origin at sella.
For each cephalogram 2 hard tissue landmarks and 15
soft tissue landmarks were identified.
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23. HARD TISSUE LANDMARKS
1. MAXILLARY INCISAL EXPOSURE – It is the vertical
distance measured between the upper lip inferior and the
incisal tip of maxillary central incisor.
2. MAXILLARY HEIGHT – It is the distance from Sn to
the maxillary incisal tip.
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24. Maxillary height & Incisal exposure
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25. SOFT TISSUE LANDMARKS
1. UPPER LIP THICKNESS – It is the distance
measured from the upper lip inside to the upper lip
anterior.
2. NASOLABIAL ANGLE – It is formed by the
intersection of a columella tangent and an upper lip
tangent.
3. UPPER LIP LENGTH – It is the distance measured
from Sn to the upper lip inferior.
4. INTERLABIAL GAP – It is the distance measured
from the upper lip inferior to the lower lip superior.
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26. SOFT TISSUE STRUCTURES
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NASOLABIAL ANGLE

27. MIDFACE LANDMARKS
Orbital rim
Cheek bone
Subpupil
Alar base
Nasal projection
Subnasal
‘A’ point
Upper lip antreior
Maxillary incisal tip
Soft tissue ‘A’ point.
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28. Standardisation of Radiograph
Steps to correct the magnification of the lateral
cephalogram were not considered necessary because
absolute measurements were made and all
cephalograms were taken at a fixed object – source
distance.
Ten tracings were selected at random. These were
selected to estimate the accuracy of the linear
measurements, which did not exceed less than or more
than 0.6mm.
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29. Result
Table 1 : Midface soft tissue structures
PRE OP 1 MONTH
PRE OP 3 MONTH
PRE OP - 6
MONTH
1 MONTH - 3
MONTH
1MONTH - 6
MONTH
3 MONTH 6 MONTH
X
Y
X
Y
X
Y
X
Y
X
Y
X
Y
Orbital rim
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Cheek
Bone
NS
NS
NS
NS
NS
NS
S
NS
NS
NS
NS
NS
Sub Pupil
S
NS
S
NS
S
NS
NS
NS
S
NS
NS
NS
Alar Base
S
NS
NS
NS
NS
NS
S
NS
S
S
NS
NS
Nasal
projection
S
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Sub Nasal
S
NS
NS
NS
S
NS
S
NS
S
NS
NS
NS
A' Point
NS
S
NS
S
NS
S
NS
NS
NS
S
NS
NS
Upper Lip
Anterior
NS
NS
NS
NS
NS
NS
NS
NS
S
NS
S
NS
Maxillary
Incsal Tip
NS
S
NS
S
NS
S
NS
NS
NS
NS
NS
NS
S
S
NS
NS
NS
NS
S
NS
S
NS
S
NS
Soft Tissue
'A' Point
S - Significant;
NS - Non Significant; P Value <0.05.
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30. Table 2 : Hard Tissue Structures
PRE OP 1 MONTH
PRE OP 3 MONTH
PRE OP - 6
MONTH
1 MONTH 3 MONTH
1MONTH 6 MONTH
3 MONTH
-6
MONTH
Maxillary Incisal EXP
S
S
S
NS
NS
S
Maxillary Height
S
S
S
NS
NS
NS
PRE OP 1 MONTH
PRE OP 3 MONTH
PRE OP –
6 MONTH
1 MONTH 3 MONTH
1MONTH 6 MONTH
3 MONTH 6 MONTH
NS
NS
S
S
S
NS
Nasolabial Angle
S
NS
NS
S
S
S
Upper lip Angle
S
S
S
NS
NS
NS
Upper lip Length
NS
NS
NS
NS
NS
NS
Inner Labial Gap
S
S
S
NS
NS
NS
Table 3 : Soft tissue structures
Upper Lip Thickness
S - Significant;
NS - Non Significant; P Value <0.05.
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31. Discussion
Prediction of soft tissue response to surgical correction
of maxillary deformities is more uncertain than that of
mandible.
The nose, lips and the mid face are subjected to
dimensional changes subsequent to maxillary surgeries.
Despite many methods that have been introduced for
objective evaluation of the hard and soft tissue profile,
none of them is totally satisfactory because they aim at
making the face conform to a specific predetermined
standard.
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32. In this study, a novel approach of assessing the soft
tissue changes following Le Fort I surgery was carried
out.
In a total number of six patients for whom Le Fort I
impaction with superior repositioning was done, the
mean ,standard deviation, level of significance with
mean change was calculated.
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33. HORIZONTAL HARD AND SOFT TISSUE CHANGES

The Orbital marker did not show any statistical change at any
time interval either in the horizontal or vertical direction. This is
attributed to the location of the marker away from the area of
surgical exposure.

The Cheek bone was displaced horizontally by 2 mm from preop to 1 month post-op. This is due to the edema in mid face
which reduced within the six month period.
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34. 
The Sub- pupil in the same way showed significant changes in
the horizontal direction between the pre-op and the 1, 3, 6 month
post-op

The horizontal values decreased over a period of time between
1 month to 3 month post-op and from 3 month to 6 month postop.

This aptly agrees with the early literature that many of the soft
tissue characteristics return to their pre-operative measurements
in the long term
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35. 
The changes in the Alar base were similar in which their was an
increase in the horizontal direction in the first and third post-op
month after which the changes came back to the original pre-op
values at the end of sixth post-op month.

The nasal projection along the horizontal axis was increased by
3 mm between pre-op and the first post-op month. The
horizontal movement of the subnasal in the first and third postop month came back to the pre-op values at the sixth post –op
month and so remained stable.
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36. 
‘Upper lip anterior’ showed significant changes by a posterior
movement of -2.3mm and -0.8 mm in the third and sixth post-op
month. This reduction is due to the postero-superior positioning
of the maxilla by Le Fort I osteotomy.

The Soft tissue ‘A’ point showed significant increase at the first
post-op month which reduced over the next three month and at
the sixth post-op month the values were quite similar to the preoperative values.
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37. VERTICAL HARD AND SOFT TISSUE CHANGES

The ‘A’ Point showed significant changes of 8 mm reduction
along the vertical direction which is due to the superior
repositioning of the maxilla which agrees with the earlier
literature that ‘A’ Point showed the greatest amount of changes
in the study.

Maxillary incisal tip demonstrated a 6mm reduction along the ‘y’
axis which is constant from the third post –op month.
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38. 
Soft tissue ‘A’ Point showed a decrease of 2mm which is the
adaptive changes of the upper lip to the underlying hard tissue.
The maxillary Incisal Exposure showed the most significant
change by a reduction of 8 mm which is the main ideal of Le Fort
I surgery in which the maxilla is repositioned superiorly.

The maxillary Height showed significant change by a reduction
4mm uniformly between the pre-op and 1, 3 and 6 month postoperatively. This ratio of maxillary soft to hard tissue is therefore
1:2 which very well agrees with earlier literature.
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39. 
The Upper Lip Thickness showed an initial increase in thickness
in the first month post-op which reduced significantly by the third
and sixth post-operative months. This very well correlates with
the earlier literature in which a reduction of 1 – 2mm is noted.

The Nasolabial angle showed significant changes by an
immediate post- operative change of + 160 which reduced in the
third and sixth month to +60 which agrees with the earlier
literature that a mild increase in the nasolabial angle following Le
Fort I surger
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40. 
The Upper Lip Angle showed a decrease of – 100 which
remained stable until the sixth post-operative month. The upper
lip angle has so far not been studied in any of the earlier
literature and that it shows a significant change following Le Fort
I surgery is quite evident in this study.

The Interlabial gap showed a decrease of – 8.7 mm in which the
interlabial gap reduced from 10.3 to 1.6mm.
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41. CONCLUSION
The result shows:

The Hard Tissue ‘A’ Point showed the greatest change of 8 mm
in the vertical direction due to Le Fort I impaction.

Maxillary incisal exposure was significantly reduced by 7mm
and so also the maxillary height in the vertical direction.

The Upper Lip Thickness showed a reduction of 2 mm postoperatively. The Lip Length was not affected due to change in
the movement of maxilla.
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42. 
In maxillary Advancement, the hard tissue ‘A’ point and the
maxillary height showed significant increase of 7 mm.

The Upper Lip Anterior showed a decrease of 3mm along the
horizontal direction which stabilized in the third post-operative
month. In the vertical direction it was increased by 4mm and
remained stable after the third post-operative month.
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