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Perceptions of Orthognathic Surgery Patients' Change in Profile: A Five Year Follow-up


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PERCEPTIONS OF ORTHOGNATHIC SURGERY PATIENTS CHANGE IN PROFILE: A FIVE YEAR FOLLOW-UP By REID W. MONTINI A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2005

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ACKNOWLEDGMENTS I thank my wife Karin for all of her love, support, understanding and sacrifice. I cannot wait to see what the future holds for us. I thank my son Austin who has inspired to me to do my best, and when I fail, always, Try again. I thank my parents and family for the solid foundation they created for me and their emotional and financial support. I thank the Southern Association of Orthodontists for their financial support of this study. I thank my committee members--Dr. Wheeler, Dr. Dolce, and Dr. McGorray. I thank all of the patients and evaluators for their contributions to this study. I also thank Marie Taylor for all of her time and effort. ii

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TABLE OF CONTENTS page ACKNOWLEDGMENTS..................................................................................................ii LIST OF TABLES...............................................................................................................v LIST OF FIGURES...........................................................................................................vi ABSTRACT......................................................................................................................vii CHAPTER 1 INTRODUCTION........................................................................................................1 2 MATERIALS AND METHODS.................................................................................3 Surgical Subjects..........................................................................................................3 Evaluator Subjects........................................................................................................4 Evaluator Demographics..............................................................................................5 Experimental Design....................................................................................................5 Statistical Method.........................................................................................................5 3 RESULTS.....................................................................................................................7 Demographics...............................................................................................................7 Overall Perceptions of Profile Change.........................................................................7 Orthodontists Perceptions of Profile Change..............................................................7 Oral Surgeons Perceptions of Profile Change.............................................................8 Lay Persons Perceptions of Profile Change................................................................8 Evaluator Differences...................................................................................................9 4 DISCUSSION.............................................................................................................14 Differences between Hard and Soft Tissue Arrangement of VAS.............................14 Perceptions of Change in Soft Tissue Profile.............................................................15 Evaluator Differences.................................................................................................16 Guidelines for Decision Making Regarding Surgical Advancement.........................17 5 CONCLUSIONS........................................................................................................19 iii

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LIST OF REFERENCES...................................................................................................20 BIOGRAPHICAL SKETCH.............................................................................................22 iv

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LIST OF TABLES Table page 2-1. Amount of mandibular advancement, page number, facial convexity, and time point orientation of surgical patients..........................................................................6 3-1.Evaluator demographic information............................................................................10 3-2. Perceived differences in profile (% of Orthodontists/ % of Oral Surgeons/ % of Lay Persons)..............................................................................................................10 3-3. Perceived differences and the significance of evaluator group differences in individual features (% of Orthodontists/ % of Oral Surgeons/ % of Lay Persons)....................................................................................................................11 v

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LIST OF FIGURES Figure page 2-1. Example of a survey page.............................................................................................6 3-1. Mean changes in VAS arranged by advancement of hard tissue pogonion...............12 3-2. Mean changes in VAS arranged by change in soft tissue Gb-Sn-Pg..........................12 3-3. Significant differences in VAS between evaluator groups.........................................13 vi

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Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science PERCEPTIONS OF ORTHOGNATHIC SURGERY PATIENTS CHANGE IN PROFILE: A FIVE YEAR FOLLOW-UP By Reid W. Montini May 2005 Chair: Timothy Wheeler Major Department: Orthodontics The purpose of this study was to compare pairs of silhouettes generated from pre-surgical and 5-year post-surgical cephalometric radiographs to evaluate whether orthodontists, oral surgeons, and lay persons can perceive changes in profile after orthodontic and mandibular advancement surgical treatment. A survey-based method of data collection was used. A mailing was conducted to recruit orthodontist and oral surgeon evaluators. Lay persons were recruited from the atrium of Shands hospital, the lobby of the University of Florida College of Dentistry student clinic, neighbors of the researcher in Jacksonville, Florida, and parents of elementary school children in Palm Beach Gardens, Florida. Orthodontists and oral surgeons were randomly chosen from professional directories, while lay persons were chosen via a convenience sample. The survey was conducted during the summer and fall of 2004. Fifteen pairs of silhouettes were evaluated. These included 1 control pair and 14 surgical pairs ranging from 0.11 mm of mandibular advancement to 10.13 mm of mandibular advancement. vii

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Collected data were analyzed to detect whether changes can be perceived and if these changes were esthetically pleasing. The vast majority of evaluators (n=127, 53 orthodontists, 32 oral surgeons, 42 lay persons) were able to identify changes in profile and individual features. At least one group of evaluators was able to perceive significant (p<0.05) improvements in visual analogue scale (VAS) for all silhouette pairs, except the pair with 10.13 mm of mandibular advancement. The silhouette pair that represented the patient with 10.13 mm of mandibular advancement was perceived to have a significant (p<0.05) worsening in VAS by the lay person group. The control pair of silhouettes was identified by 104 of 127 evaluators. There were significant differences between groups of evaluators. The pairwise Wilcoxon rank sum test showed significant VAS differences between evaluator groups for silhouette pairs with 3.27 mm, 3.20 mm, 4.74 mm, and 10.13 mm of mandibular advancement. Esthetic improvement in profile was perceived in 13 of 14 surgically treated silhouette pairs. The control was identified by 104 of 127 evaluators. In some cases, orthodontists, oral surgeons, and lay persons perceived changes in profile differently. viii

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CHAPTER 1 INTRODUCTION Combined orthodontic and orthognathic surgical treatment has become a common and stable treatment modality for the correction of facial deformities and occlusal disharmonies. In a review of the literature concerning psychological aspects of orthognathic surgery, Cunningham et al. 4 sites multiple studies stating that esthetic improvement was the major motivating factor for patients undergoing surgery. Research has been conducted to assess perceptions of surgical outcomes. 2,3,13,16,18,19 In general, studies have looked at pre-treatment and post-treatment photographs, digitally altered photographs simulating surgical outcomes, and silhouettes. Studies have found that surgical patients perceive their own profile changes differently than lay persons and dental professionals. Kiyak et al. 13 showed that patients may not always be able to appreciate changes in profile even after successful surgical correction. Phillips et al. 16 used patient records and showed a 7.8mm visual analogue scale (VAS) improvement in surgically treated Class II skeletal cases while camouflaged patients showed no significant improvement in VAS. However, the results and retrospective nature of this study suggest that more attractive patients were camouflaged while less attractive patients were treated surgically. Shelly et al. 18 evaluated the silhouettes of 34 surgically treated Class II patients and found a significant negative correlation between initial esthetic score and esthetic change for lay evaluators and orthodontist evaluators. Burcal et al. 3 used digitally altered photographs to show that lay persons and patients recognized a 2 mm change at pogonion in 22% of retrognathic subjects. A 4 mm change was recognized in 1

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2 44% of retrognathic subjects. A 6 mm change was recognized in 67% of retrognathic subjects. Dental professionals were 5%, 6%, and 15% more accurate at the three levels of advancement. Romani et al. 19 also used digitally altered photographs and showed that Orthodontists detected 1mm of horizontal change in mandibles in 65.9% of cases. The detection rate improved significantly to 93. 9% at 3 mm of change and further improved to 97% for a 5 mm change. Controlled research is needed to assess whether dental professionals can recommend orthognathic surgery as an option for observable esthetic improvement. Several factors will play a part in such a recommendation. Dental professionals must understand a patients goals and perceptions of normal and how these differ from his or her own goals and perceptions. A positive and perceivable result depends upon the soft tissue effect and stability of the surgical correction as well as achieving a large enough surgical movement for patients, dental professionals, and lay persons to recognize. This study compared pairs of silhouettes generated from pre-surgical and 5-year post-surgical cephalometric radiographs and utilized a control pair of silhouettes, a feature which was absent in many other studies. The purpose of this study of orthodontically and surgically treated patients was to evaluate whether profile changes that occur following treatment are detectable 5 years after surgery, compare differences in perception of profile change between orthodontists, oral surgeons, and lay persons, evaluate how much hard tissue pogonion advancement and soft tissue profile change is needed to cause perceivable profile changes, and establish a guideline for when esthetics can be recommended as a reason for surgery.

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CHAPTER 2 MATERIALS AND METHODS Surgical Subjects Records obtained from a group of 127 surgical subjects were used in this study. These records included pre-operative (T2) and 5 year post-operative (T8) cephalometric radiographs. These radiographs were also used in a prospective randomized clinical trial 5 looking at hard and soft tissue stability following surgery using rigid or wire fixation. All patients underwent bilateral sagittal split osteotomy (BSSO). Seventy-eight subjects underwent rigid fixation and 49 subjects underwent wire fixation. Thirty-five of the BSSO subjects underwent genioplasty with rigid fixation while 24 subjects underwent genioplasty with wire fixation. Surgeries were performed at three different surgical centers. Inclusion criteria for this study were the presence of pre-surgical and 5 year post-surgical lateral cephalometric radiographs. Exclusion criteria included incomplete or poor quality records. Patients that underwent genioplasty were not included. Fourteen surgical subjects were used in this study. Their mandibular advancements ranged from 0.11 mm to 10.13 mm. Measurements were made using an x-y coordinate system and templates as described by Dolce et al.. 5,6 Surgical subjects were selected based on the quality of the records and an effort was made to assure that the majority of surgical subjects had advancements between 1 mm and 6 mm. Previous studies have shown that this range of advancement is critical in the recognition of esthetic change in profile following surgical advancement of the mandible. 3,18 Surgical subjects had their profiles traced from cephalometric radiographs. The tracings were then scanned, set to a 3

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4 standard size, converted into a silhouettes, and oriented using Frankfort horizontal. These silhouettes were then used to create a survey. Pre-surgical and post-surgical silhouettes were placed beside each other. Seven pages of the survey had silhouettes from T2 on the left side of the page and silhouettes from T8 on the right side of the page. Seven other pages of the survey had silhouettes from T8 on the left side of the page and silhouettes from T2 on the right side of the page. The control pair of silhouettes had T8 silhouettes from the patient with a 4.74 mm advancement on the right and left side of the page. The questions, Is there a difference between the two silhouettes? and, What is different? were printed above the pairs of silhouettes. A 100 mm VAS was used to assess the level of esthetic improvement, if any. VAS has been found to be valid, reproducible, and reliable way of evaluating esthetics. 10,21 An example of a survey page is presented in Figure 2-1. The amount of mandibular advancement, page number, soft tissue Gb-Sn-Pg angle, and time point orientation of surgical subjects is shown on Table 2-1. Linear measurements (amount of hard tissue pogonion advancement) were obtained from data used in a previously published study. 5 Angular measurements (soft tissue Gb-Sn-Pg) were made by one researcher for this study. Evaluator Subjects Pre-surgical and post-surgical profile silhouettes were assessed by 53 orthodontists, 32 oral surgeons, and 42 lay persons. The orthodontists and oral surgeons were randomly chosen from professional directories. Randomization was achieved by generating a list of random numbers and using these numbers to pick professionals from their directories. Surveys were mailed to 421 orthodontists and 460 oral surgeons. Survey packets included an informed consent letter, a self addressed and stamped envelope, and a copy of the survey. Orthodontists and oral surgeons received no compensation.

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5 A convenience sample of lay persons was obtained in the Shands Hospital lobby, The University of Florida College of Dentistry student clinic lobby, a neighborhood in Jacksonville, Florida, and an elementary school in North Palm Beach, Florida. Lay person evaluators received a coupon for a free movie rental from Blockbuster Video as compensation for their participation. The inclusion criterion was the acceptance of the informed consent. Exclusion criteria included rejection of informed consent, inability to follow survey instructions, and failure to return the survey. Evaluator Demographics Demographic information was collected from all evaluators. This information included age, education, gender, and race. Experimental Design This study was a controlled survey based study. Surgical subjects were stratified by the amount of hard tissue pogonion surgical advancement. Statistical Method The number of evaluators that saw differences between silhouette pairs and features of silhouette pairs were calculated. These totals were then separated into their respective evaluator groups. To assess group differences, the Chi-square and Fisher exact tests were used. The level of significance used was p<0.05 (*). The arithmetic means and standard deviations for the VAS were calculated for each silhouette. The arithmetic means and standard deviations for the VAS differences (post-surgical minus pre-surgical) were also calculated. These means and standard deviations were then separated by evaluator groupings to evaluate group differences. To assess differences in post-surgical minus pre-surgical VAS, paired t tests were used. Evaluator group differences in post-surgical minus pre-surgical VAS were assessed

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6 by Kruskal Wallis and pairwise Wilcoxon rank sum tests. Age differences between evaluator groups were assessed using Kruskal Wallis tests. The level of significance used was p<0.05 (*). Is there a difference between the two silhouettes?__YES __NO What is different? (Mark all that apply)__Forehead __Nose __Upper Lip __Lower Lip __Chin __Nothing Silhouette 1 Silhouette 2 On the following scale, please mark with an X the level of attractiveness you attribute to each silhouette. Less More Less More Attractive Attractive Attractive Attractive Figure 2-1. Example of a survey page. Table 2-1. Amount of mandibular advancement, page number, facial convexity, and time point orientation of surgical patients. Surgical Advancement Page Number Soft Tissue Gb-Sn-Pg (degrees) T2/T8/Difference Time Point Orientation Control (4.74 mm patient) 8 164/164/0 T8/T8 0.11 mm 12 164/164/0 T2/T8 1.09 mm 2 159. 5/160. 5/1 T8/T2 2.27 mm 10 174. 5/175/0. 5 T2/T8 2.43 mm 4 162. 5/171/8. 5 T8/T2 3.20 mm 7 158/166. 5/8. 5 T2/T8 3.80 mm 6 162/170/8 T8/T2 4.74 mm 14 160/164/4 T2/T8 5.24 mm 15 169/174/5 T8/T2 5.90 mm 5 161/164/3 T2/T8 6.81 mm 9 162/169/7 T8/T2 7.38 mm 13 167. 5/173. 5/6 T8/T2 8.69 mm 11 172/176. 5/4. 5 T8/T2 9.56 mm 3 164/172/8 T2/T8 10.13 mm 1 166/177b/11 T2/T8

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CHAPTER 3 RESULTS Demographics The demographic information obtained from the evaluators is presented in Table 3-1. Differences in the mean ages of the evaluator groups were not significant (p>0. 05). Statistical analysis of education, gender, and race were not considered due to expected differences between the groups. Overall Perceptions of Profile Change The vast majority of evaluators were able to perceive changes in all surgical silhouette pairs (Table 3-2). The control pair of silhouettes was correctly identified as unchanged by 104 out of 127 evaluators. Many evaluators were able to perceive changes to individual features. The majority of these changes took place at the chin, the lower lip, and the upper lip. However, many evaluators perceived changes to the nose and the forehead. (Table 3-3). Overall VAS means arranged by the amount of hard tissue pogonion advancement are presented in Figure 3-1, while overall means arranged by change in soft tissue Gb-Sn-Pg are presented in Figure 3-2. However, the largest improvements in VAS occurred in the patients with 3.20mm, 7.38 and 8.69mm of advancement. The patient with 10.13mm of advancement experienced a worsening in VAS. Orthodontists Perceptions of Profile Change The majority of orthodontists detected changes in profile and individual features 7 (Table 3-2, Table 3-3). The control pair of silhouettes was correctly identified as

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8 unchanged by 47 out of 53 orthodontist evaluators. Orthodontist evaluators perceived significant improvements in all surgical silhouette pairs except for the pairs with 9.56mm and 10.13mm of advancement. The worsening of VAS in the 10.13 mm silhouette pair and the improvement in the 9.56 mm silhouette pair did not reach statistical significance. Orthodontist evaluators perceived no significant change in VAS for the control pair of silhouol pair of silhouettes was correctly identified as unchanged by 25 out of valuators perceived signif3mm, e pairs with 2.27mm, 2.43mm, 4.74mm, 5 with 2.43mm, 4.74mve a ettes. Oral Surgeons Perceptions of Profile Change The majority of oral surgeons detected changes in profile and individual features (Table 3-2, Table 3-3). The contr 32 oral surgeon evaluators. Oral surgeon e icant improvements in all surgical silhouette pairs except for the pairs with 2.45.24, and 10.13mm of advancement. The pairs with 2.43mm and 5.24mm of advancement were perceived to have non-significant improvement in VAS. The pair with 10.13mm of advancement was perceived to have a non-significant worsening in VAS. Oral surgeon evaluators perceived no significant change in VAS for the control pair of silhouettes Lay Persons Perceptions of Profile Change The majority of lay persons also detected changes in profile and individual features (Table 3-2, Table 3-3). The control pair of silhouettes was correctly identified as unchanged by 32 out of 42 lay person evaluators. Lay person evaluators perceived significant improvements in all surgical silhouette pairs except for th .24mm, and 10.13mm of advancement. The pairs m, and 5.24mm of advancement were perceived to have non-significant improvement in VAS. The pair with 2.27mm of advancement was perceived to ha

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9 non-significant worsening in VAS. The pair with 10.13mm of advancement was perceived to have a significant worsening in VAS. Lay person evaluators perceived no significant change in VAS for the control pair of silhouettes. Evaluator Differences No evaluator group differences were seen when evaluating the detection of changto the silhou es ettes as a whole. However, there were multiple evaluator group differences when individual facette pairs had at least uette e ant evaluator differences in VAS for these silhouette pairs. Lay persons perceived sigth 2.27 mm and 4.74 mly less ial feature evaluations were considered. All silhou one significant group difference for one feature except the control and the surgical pairs with 0.11 mm, 3.80 mm, 6.81 mm, and 6.81 mm of advancement. The silhopairs with 4.74mm, 5.25mm, 7.38mm, and 8.69mm all had three features reach significance with regard to evaluator groups differences. These results and significant group differences are presented on Table 3-3. Evaluator groups were significantly different in their perception of profile changfor silhouette pairs representing 2.27 mm, 3.20 mm, 4.74 mm, and 10.13 mm of mandibular advancement when evaluating silhouette pairs using the VAS. Figure 3-3 depicts the signific nificantly less improvement in VAS for pairs wi m of advancement than did their orthodontist and oral surgeon counterparts. For the silhouette pair with 3.20 mm of advancement, lay person perceived significantimprovement than oral surgeons but were similar to orthodontists. Lay persons alsoperceived a significantly greater amount of worsening in VAS for the silhouette pair with 10.13mm of advancement than the orthodontist evaluator group.

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10 Group Age (years) Education Level Gender Race 45 m Table 3-1.Evaluator demographic information. Orthodontists 53 +/13.23 8 female ale 2 Asian 1 Black 1 Hispanic 0 Other 49 White Oral S30 male 0 Black 0 Other urgeons 49 +/12.60 2 female 2 Asian 0 Hispanic 30 White 8 Some college 7 Beyond college 15 male 5 Black 1 Other Table 3-2. Perceived differences in profile (% of Orthodontists/ % of Oral Surgeons/ %no evaluator group differences. Lay Persons 46 +/14.82 11 Highschool 16 College graduate 27 female 0 Asian 2 Hispanic 34 White of Lay Persons. An (*) indicates evaluator group differences. (N.S.) indicates SurgicalAdvancement/ Soft Tchange Differences Group Differences issue Gb-Sn-Pg Detected Profile Significant Evaluator Control 23.8/21.9/11.3 N.S. 0.11 mm/0 degrees 100/100/94.3 N.S. 2.27mm/0.5 degrees 100/100/94.3 N.S. 3.20mm/8.5 degrees 100/100/100 N.S. 3.80 mm/8 degrees 95.2/96.9/94.3 N.S. 5.24 mm/5 degrees 95.24/96.9/88.7 N.S. 5.90 mm/3 degrees 95.2/100/94.3 N.S. 7.38 mm/6 degrees 100/96.9/98.1 N.S. 8.69mm/4.5 degrees 100/96.9/98.1 N.S. 1.09 mm/1 degree 97.6/93.8/92.5 N.S. 2.43mm/8.5 degrees 97.6/96.9/100 N.S. 4.74 mm/4 degrees 88.1/96.9/98.1 N.S. 6.81 mm/7 degrees 97.6/100/96.2 N.S. 9.56 mm/8 degrees 100/96.9/100 N.S. 1 0.13 mm/11 degrees 100/100/100 N.S.

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11 Table 3 -3. Perceivs and evaup nces in vid of Orthodontists/ % of Oral Surgeons/ % of Lay Persons). An (*) indicates evaluator group differences. (N.S.) indicates no evaluator group differences. Surgical Advancement/Gb-Sn-Pg change Detected Difference Detected Difference Detected Upper Lip Difference Detected LDce ed difference the significance of luator gro differe indi ual features (% Soft Tissue Forehead Nose ower Lip ifference Detected Chin Differen 7/1/18.8 3.8 (N.S.) 0.11 mm/ 0 degrees 41.5(N.S). 5.7/437.7(/ .) 890.6 (N.S.) / S.) 52.4/34.4/ 3 0.6/ 81.0/81.3 N.S.) 67.9 (N.S 8.1/84.4/ 45.2/62.5 39.6 (N. 4.4/ *) 28.6/43.8/ 35.9 (N.S.) 81.0/90. 6/ 83.0 (N.S. Control 9.5/3.1/ 3.8(N.S.) 9.5/12.5/ 9.4 (N.S.) 2.4/6.3/ 1.9 (N.S.) 2.4/6.3/ 3.8 (N.S.) / 1.09 mm/ 1 degree 23.8/6.2/ 3.8 (*) 59.5/326.4 (64.3/75.0/ 75.5 (N.S.) ) 2 .27mm/ .5 degrees 61.9/16.1/ 30.2(*) 45.2/25.8/ 20.8 (*) 64.3/45.2/ 41.5 (N.S.) 81.0/81.0/ 81.1 (N.S.) 83.3/93.6/ 86.8 (N.S.) 0 2.43mm/ 14.3/6.2/ 5.6 (N.S.) 31.0/40.6/ 11.3 (*) 90.5/93.8/ 92.5 (N.S.) 52.4/62.5/ 52.8 (N.S.) 35.7/53.1/ 56.6 (N.S.) 78.6/40.6/ 66.7/68.8/ 8.5 degrees 3.20mm/ ) 64.3/53.1/ .7 (76.2/84.4/ 85.7/96.9/ 94.3 (N.S.) 8.5 degrees 45.3 (* 60.4(N.S.) 54 N.S.) 88.7 (N.S.) 3.80 mm/ 8 degree66.7/ s 40.6/ 50.9(N.S.) .9/426.4 ( 52.4/75.0/ 60.4 (N.S.) 59.5/65.6/ 52.8(N.S.) 42 6.9/ N.S.) 69.1/65.6/ 66.0 (N.S.) 4.74 mm / 21.4/3.1/ (*) 4.8/435.9 (N.S.) 59.5/65.3/ 71.7 (N.S.) 57.1/100/ 88.7 (*) 4 degrees 5.7 30.1/12.5/ 5 9.4 (*) 0.6/ 5.24 mm/ 2 5 degrees 1.9 4.4/6.3/ (*) 8.1/652.8 (70.7/78.1/ 66.0 (N.S.) 39.0/56.3/ 39.6 (N.S.) 51.2/25.0/ 7 13.2 (*) 5.6/ *) 5.90 mm/ 3 degrees 28.85.7 /9.4/ (*) 9.1/964.3/84.4/ 73.6 (N.S.) 54.8/75.0/ 71.7 (N.S.) 45.2/46.9/ 37.7(N.S.) 673.6 (N.S.) 0.6/ 6.81 mm/ 35.7 7 degrees 26 /28.1/ .4(N.S.) 90.5/73.0 (73.8/75.0/ 77.4 (N.S.) 50.0/59.4/ 41.5 (N.S.) 21.4/25.0/ 11.3(N.S.) 8 8.1/ N.S.) 7.38 mm/ 66 6 degrees 43 .7/25.0/ .4 (*) 2.4/5.2 (83.3/87.5/ 92.5 (N.S.) 57.1/84.4/ 77.4 (*) 64.3/56.3/ 5 56.6(N.S.) 30 3.1/ *) 4.5 degrees 24 26.4 (*) 4 *) 9.56 mm/ 21 8 degrees 9.4 .4/21.9/ (N.S.) 8.6/54.7(*71.4/84.4/ 86.8 (N.S.) 50.0/81.2/ 67.9 (*) 38.1/31.2/ 7 20.8(N.S.) 5 0.0/ ) 10.13 mm/ 31.0 11 degrees /15.6/ 13.2(N.S.) 17.0 (*) 6.2/866.0 (N.S.) 85.7/90.6/ 90.6 (N.S.) 78.6/96.9/ 98.1 (*) 42.9/37.5/ 7 4.4/ 8.69mm/ 47.6/18.8/ .5 (*) 64.3/34.4/ 73.8/50.0/ 7.2 (85.7/87.5/ 92.5 (N.S.) 38.1/59.4/ 47.2 (N.S.)

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12 -1530s AS cm1.09 mm3mm35.90 mm69.56 mm1 A Ad Tiss *** 2025 10 -5 0 5 10 Post-Surgical VAS minuPreSurgical V ontr0.11 m ol 2.27 m2.43 m.20 mm .80 4.74 m5.24 m mmmm .81 7.38 m8.69 m mmmm 0.1 3 mm mount of Surgical dvancement at Har ue Pogonion Figure 3-1. M eanVgedesuAn (*) indaff changes in AS arran by advancem nt of hard tis e pogonion. icates evalu tor group di erences. P ost-Surgical min Surgical VA control00.5 134 5567 8 8 8.58.5 ge 6page 3page 7page 11 Amount of Change Soft Tissue Gb-Sndegrees) * * Figure 3-2. Mean changes in VAS arranged by change in soft tissue Gb-Sn-Pg. An (*) indicates evaluator group differences. -10-5051015202530 us Pre S 4.pa4 inPg (

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13 -20-10010203040Post-Surgical VAS minus Pre-Surgical VAS 2.27 mm3.20 mm4.74 mm10.13 mm Amount of Advancement of Hard Tissue Pogonion Orthodontists Oral Surgeon s Lay Persons **** Figure 3-3. Significant differences in VAS between evaluator groups. An (*) indicates evaluator group differences.

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CHAPTER 4 DISCUSSION This study shows changes in soft tissue profile can be perceived five years after surgery by groups of evaluators including orthodontists, oral surgeons and lay persons in a patient population with a wide array of mandibular advancements. The results show that the three groups had differing preferences and sensitivities to horizontal change of mandibular position and the majority of evaluators were able to identify a lack of significant change in the control silhouette pair. Differences between Hard and Soft Tissue Arrangement of VAS Multiple studies have evaluated various aspects of the hard and soft tissue change b rought about by orthognathic surgery. 5,6,8,9,12,14,17 Several Studies have found a 1:1 20. owever, results from this study indicate that a predictable 1:1 ratio of hard tissue to soft tissue movement may not be occurring five years after surgery. This is demonstrated by differences in the distribution of VAS changes when comparing data arranged by hard tissue and soft tissue change values. Previously published data supports the ideas that the amount of advancement and time can play a role in the ratio of hard tissue to soft tissue change. A study by Van Sickels et al. suggested that a 1:1 ratio of movement may not be occurring when the hard tissue advancement exceeds 8mm. 20 Mobarak et al. showed that significant relapse occurred three years after surgery and felt that a 1:1 ratio may be too optimistic a prediction for treatment planning purposes. Other factors that may be at relationship between hard tissue surgical advancement and soft tissue change7,11,15, H 14

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15 work include the impact of individual features, small changes due to head position or lip posture, and significant differences between evaluator groups. Perceptions of Change in Soft Tissue Profile e al atures, there appears to be a trend toward recognizinrity of changntour by m e resuf suggest that the significant change in VAS for the patient with 0.11 mm in hard tissue This study agrees with previously published reports3,16,18,19 in that evaluators werable to detect even the smallest changes in profile when evaluating silhouettes generated from cephalometric radiographs. However, this study shows that all evaluators were potentially more sensitive to overall changes in profile than previously reported as the vast majority of evaluators recognized as least some amount of change in all surgicsilhouette pairs. When considering individual fe g changes in features such as upper lip, lower lip and chin as the majo es detected lie in these three areas. These results appear to be logical as the chances of affecting forehead or nasal comandibular advancement would seeto be rather small at best. It is likely that changes in forehead contour were thlt ochanges in head positioning, while changes in nasal contour could have resulted from a change in lip support brought about by a new relationship between the nose, lips, teeth, and jaws. It should also be noted that the majority of evaluators successfully identifiedthe control pair of silhouettes. Previous studies have not examined changes less than 1mm and no comparison of control data can be done because previous studies have not used controls. Multiple significant improvements in VAS were also found. Significant improvements in VAS were found for every surgical silhouette pair by at least one groupof evaluators. However, VAS did not change significantly for the control. This would

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16 pogonion advancement is truly being detected. This study also shows that there may be alimit as to how far the mandible can be advanced before a partic ular patient experiences a worsening in profile as perceived by various groups of evaluators. The other studies did not show any worsenl.3 rt nces e only found for the upper lip and chin when the advancement was 4.74 mm oitive to ing in profile following surgical correction Evaluator Differences Significant differences between evaluator groups were found in this study. Previous studies have not found such differences. 16,18,19 Another study by Burcal et ashowed a trend toward dental professionals being more accurate and sensitive in their identification of changes in profile, however, no statistical analysis was done to suppothese observations. Arpino et al.1 showed that orthodontists were significantly more accepting of deviations than oral surgeons, surgical patients, and acquaintances of surgical patients. This study found that there were multiple evaluator group differewhen detecting changes in individual features but no group differences when detecting overall changes in profile. The forehead (8 significant differences) and nose (7 significant differences) were the most common places to see differences in the detectionof change. This could be a result of different esthetic priorities in the various evaluator groups, or one or more groups may not have focused as heavily on areas that were not directly involved in jaw surgery. It is also interesting to note that no significant differences between evaluator groups were found for the lower lip and significant differences wer r greater. There appears to be a trend toward lay persons being more senschanges in the upper lip while orthodontists were more sensitive to changes in chin contour or position.

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17 This study also showed that orthodontists perceived a greater number of significant improvements in VAS than oral surgeons and oral surgeons perceived a greater number of significant improvements in VAS than lay persons. This would seem to agree with Burcal et al.3 as the professional groups were able to perceive im provements in patients with small surgical advancementanges. However, it could also be suents eptan lay o le provement when compared to soft and hard tissue change and the large standard deviations would leave such a guideline weakly supported at best. The s and small soft tissue ch ggested that orthodontists were merely more willing to accept small improvemand their evaluations were inflated due to their accce of greater deviations from normal. This idea would tend to agree with the results presented by Arpino et al.1. In general, when significant differences were present, lay persons saw significantlyless improvement in VAS than their professional counterparts. This could mean that persons could not perceive the changes that were occurring or they did not view an improvement in facial convexity as being important. It is possible that lay persons may have focused on individual features such as nose, forehead, or chin when evaluating improvements in esthetics or that these features had an overriding effect on theirevaluation. Guidelines for Decision Making Regarding Surgical Advancement One of the objectives of this study was to establish a guideline for when estheticscan be recommended as a reason for surgery. However, it may not be possible testablish a guideline for decision making regarding surgical advancement using theresults of this study. While this study showed that nearly everyone recognized that somechange had taken place, improvements in esthetics and VAS may have been dependent on factors other than the amount of change in mandibular position. The unpredictabamount of esthetic im

PAGE 26

18 only g by usinge uidelines that can be given are that there may be a limit as to how far the mandible can be advanced before a particular patient experiences a worsening in profile and changes in profile can be detected five years after surgery. The use of living patients with varying amounts of surgical advancements was a strength of this study from the standpoint of soft tissue response to surgical change, however, the variation in attractiveness of other facial features may have turned out to bethe weakness that prevented us from achieving our final objective. We attempted to control for as many features as possible and differences based on sex of the patie nt silhouettes. However, it would seem that digitally altered photographs offer the best way to create such a guideline but the lack of a true soft tissue response may undo this methodology as well. The results of such a study would only be as reliable as thartists ability to mimic true soft tissue responses at varying amounts of hard tissue advancement. In the end, surgical decisions should be based on thorough study and accurate diagnosis of individual cases.

PAGE 27

CHAPTER 5 CONCLUSIONS Surgical changes were perceivable five years after surgery. There were significant differences between groups of evaluators. The control pair of silhouettes was correctly identified as unchanged by 104 ou127 evaluators. However, the patient with the smallest mandibular advancemen(0.11 mm) showed significant improvements in VAS when evaluated by orthodontists, oral surgeons, and lay person. Guidelines on surgical decision making should be determined based on thorough study and accurate diagnosis of the patient. However, this study suggests that excessively large changes in hard tissue pogonion and soft tissue Gb-Sn-Pg may lead to less esthetic improvement or a worsening in profile esthetics. t of t 19

PAGE 28

LISES 1l profile preferences of patients and clinicians. Am J Orthod Dentofacial Orthop 1998 Dec; 114 (6):631-7 2. Bell R, Kiyak A, Joondeph DR, McNeill RW, Wallen TR. Perceptions of facial 3. ion of profile change after simulated orthognathis surgery. J Oral Maxillofac Surg 1987;45:666-670 4. 5. olce C, Hatch JP, Van Sickels JE, Rugh JD. Rigid versus wire fixation for mandibular advancement: Skeletal and dental changes after 5 years. Am J Orthod Dentofacial Orthop 2002;121:610-9 6. Dolce C, Johnson PD, Van Sickels JE, Bays RA, Rugh JD. Maintenance of soft tissue changes after rigid versus wire fixation for mandibular advancement, with and without genioplasty. Oral Surg Oral Med Oral Pathol Oral Radio Endod 2001;92:142-9 7. Ewing M, Ross RB. Soft tissue response to mandibular advancement and genioplasty. Am J Orthod Dentofacial Orthop 1992;101:550-5 8. Hoffman GR, Staples G, Moloney FB. Cephalometric alterations following facial advancement surgery:1. Statistical evaluation. A review of aesthetic evaluation of the face and an attempt to assess treatment validity. J Craniomaxillofac Surg 1994 Aug;22(4):214-9 9. Hoffman GR, Staples G, Moloney FB. Cephalometric alterations following facial advancement surgery. W. Clinical and computerized evaluation. J Craniomaxillofac Surg 1994 Dec;22(6):371-5 10. Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiologic use. Am J Orthod 1995 Nov; 88: 402-408 11. Jensen AC, Sinclair PM, Wolford LM. Soft tissues associated with double jaw surgery. Am J Orthod Dentofacial Orthop 1992: 101(3): 266-275 T OF REFERENC Arpino VJ, Giddon, DB, BeGole EA, Evans CA. Presurgica profile and their influence on the decision to undergo orthognathic surgery. Am J Orthod 1985 Oct; 88(4):323-32 Burcal RG, Laskin DM, Sperry TP. Recognit Cunningham SJ, Hunt NP, Feinmann C. Psychological aspects of orthognathicsurgery: A review of the literature. Int J Adult Orthod Orthognath Surg. 1995;10(3):159-172 D 20

PAGE 29

21 12. Keeling SD, LaBanc JP, Van Sickels JE, Bays RA, Cavalieros C, Rugh JD. Skeletal change at surgery as a predictor of long-term soft tissue profile change after mandibular advancement. J Oral Maxillofac Surg 1996;54:134-44 13. Kiyak HA, Zeitler DL. Self-assessment of profile and body image among orthognathic surgery patients before and two years after surgery. J Oral Maxillofac Surg 1998 May;46(5): 36 5-71 14. Lines PA, Steinhauser EX. Soft tissue changes in relationship to movement of hard structures in orthognathic surgery: A preliminary report. J Oral Surg 1974;32:891-6 2001 Apr;119(4):353-67 vancement 1983; 84:29-36 thop 2000 Jun;117(6):630-7 20. Van Sickels JE, Smith CV, Tiner BD, Jones DL. Hard and soft tissue predictability ar; 15. Mobarak KA, Espeland L, Krogstad O, Lyberg T. Soft tissue profile changes following mandibular advancement surgery: Predictability and long-term outcomeAm J Orthod Dentofacial Orthop 16. Phillips C, Trentini CJ, Douvartzidis N. The effect of treatment on facial attractiveness. J Oral Maxillofac Surg 1992; 50:590-594 17. Quast DC, Biggerstaff RH, Haley JV. The short-term and long-term soft-tissue profile changes which accompany the advancement of the mandibular adsurgery. Am J Orthod 18. Shelly AD, Southard TE, Southard KA, Casko JS, Jakobsen JR, Fridrich KL,Mergen JL. Evaluation of profile esthetic change with mandibular advancement surgery. Am J Orthod Dentofacial Or 19. Romani KL, Agahi F, Nanda R, Zernik JH. Evaluation of horizontal and verticaldifferences in facial profiles by orthodontists and lay people Angle Ortho 1993; 63(3):175-82 with advancement genioplasties. Oral Surg Oral Med Oral Pathol. 1994 M77(3):218-21 21. Woolass KF, Shaw WC. Validity and reproducility of rating dental attractiveness from study cases. Br J Orthod 1987 Jul;14: 187-190

PAGE 30

BIOGR APHICAL SKETCH attended Florida State University for his undergraduate study, with a B.S in biological scienceducation and graduated with honors from dental school in 2002, obtaining a Doctor of Dentaed his dental education at ortho Reid Wallace Montini was born and raised in West Palm Beach, Florida. He e. He was then admitted to Harvard School of Dental Medicine for his dental l Medicine degree. After graduation, Dr. Montini continu the University of Florida earning a Master of Science degree with a certificate in dontics in May 2005. 22


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PERCEPTIONS OF ORTHOGNATHIC SURGERY PATIENTS' CHANGE IN
PROFILE: A FIVE YEAR FOLLOW-UP















By

REID W. MONTINI


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2005















ACKNOWLEDGMENTS

I thank my wife Karin for all of her love, support, understanding and sacrifice. I

cannot wait to see what the future holds for us.

I thank my son Austin who has inspired to me to do my best, and when I fail,

always, "Try again."

I thank my parents and family for the solid foundation they created for me and their

emotional and financial support."

I thank the Southern Association of Orthodontists for their financial support of this

study.

I thank my committee members--Dr. Wheeler, Dr. Dolce, and Dr. McGorray. I

thank all of the patients and evaluators for their contributions to this study. I also thank

Marie Taylor for all of her time and effort.
















TABLE OF CONTENTS


page

A C K N O W L E D G M E N T S .................................................................................................. ii

LIST OF TABLES .................................................. .................. ..... ....

LIST O F FIG U RE S .... .............................. ....................... ........ .. ............... vi

ABSTRACT ........ .............. ............. .. ...... .......... .......... vii

CHAPTER

1 IN TRODU CTION ................................................. ...... .................

2 M ATERIALS AND M ETHOD S ........................................... ........... ............... 3

Su rgical Subjects ....................................................... 3
Evaluator Subjects .............. ................. ............ ................ ..... .... 4
E valuator D em graphics .............................................................. ....................... 5
Experim mental D design .......................... .............. .............................
Statistical M ethod ................................................................. ......... ............ 5

3 R E SU L T S ................................................................ .7

D em graphics .................................................................................................................7
Overall Perceptions of Profile Change ......................................................................7
Orthodontists' Perceptions of Profile Change .......................................................7
Oral Surgeons' Perceptions of Profile Change ........................................................8
Lay Persons' Perceptions of Profile Change .............................................................8
Evaluator D differences .................................................................. .. ...............

4 D ISC U SSIO N ..................................................... 14

Differences between Hard and Soft Tissue Arrangement of VAS ............................. 14
Perceptions of Change in Soft Tissue Profile .....................................................15
Evaluator Differences ...................... ........ .... ........ ................................16
Guidelines for Decision Making Regarding Surgical Advancement .........................17

5 CON CLU SION S ....................... ......... .. .......... .. .............19









L IST O F R E F E R E N C E S ...................................... .................................... ....................20

B IO G R A PH IC A L SK E TCH ...................................................................... ..................22
















LIST OF TABLES

Table p

2-1. Amount of mandibular advancement, page number, facial convexity, and time
point orientation of surgical patients ........................................ ....... ............... 6

3-1.Evaluator dem graphic inform action ................................................. ....... ........ 10

3-2. Perceived differences in profile (% of Orthodontists/ % of Oral Surgeons/ % of
L ay P person s). ....................................................... ................. 10

3-3. Perceived differences and the significance of evaluator group differences in
individual features (% of Orthodontists/ % of Oral Surgeons/ % of Lay
P erso n s).. ............................................................................... 1 1
















LIST OF FIGURES

Figure page

2-1. Exam ple of a survey page ....... ......... ......... .............................. ...............6.

3-1. Mean changes in VAS arranged by advancement of hard tissue pogonion. ..............12

3-2. Mean changes in VAS arranged by change in soft tissue Gb-Sn-Pg........................12

3-3. Significant differences in VAS between evaluator groups ........................................13















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

PERCEPTIONS OF ORTHOGNATHIC SURGERY PATIENTS' CHANGE IN
PROFILE: A FIVE YEAR FOLLOW-UP

By

Reid W. Montini

May 2005

Chair: Timothy Wheeler
Major Department: Orthodontics

The purpose of this study was to compare pairs of silhouettes generated from

pre-surgical and 5-year post-surgical cephalometric radiographs to evaluate whether

orthodontists, oral surgeons, and lay persons can perceive changes in profile after

orthodontic and mandibular advancement surgical treatment. A survey-based method of

data collection was used. A mailing was conducted to recruit orthodontist and oral

surgeon evaluators. Lay persons were recruited from the atrium of Shands hospital, the

lobby of the University of Florida College of Dentistry student clinic, neighbors of the

researcher in Jacksonville, Florida, and parents of elementary school children in Palm

Beach Gardens, Florida. Orthodontists and oral surgeons were randomly chosen from

professional directories, while lay persons were chosen via a convenience sample.

The survey was conducted during the summer and fall of 2004. Fifteen pairs of

silhouettes were evaluated. These included 1 control pair and 14 surgical pairs ranging

from 0.11 mm of mandibular advancement to 10.13 mm of mandibular advancement.









Collected data were analyzed to detect whether changes can be perceived and if these

changes were aesthetically pleasing.

The vast majority of evaluators (n=127, 53 orthodontists, 32 oral surgeons, 42 lay

persons) were able to identify changes in profile and individual features. At least one

group of evaluators was able to perceive significant (p<0.05) improvements in visual

analogue scale (VAS) for all silhouette pairs, except the pair with 10.13 mm of

mandibular advancement. The silhouette pair that represented the patient with 10.13 mm

of mandibular advancement was perceived to have a significant (p<0.05) worsening in

VAS by the lay person group. The control pair of silhouettes was identified by 104 of

127 evaluators. There were significant differences between groups of evaluators. The

pairwise Wilcoxon rank sum test showed significant VAS differences between evaluator

groups for silhouette pairs with 3.27 mm, 3.20 mm, 4.74 mm, and 10.13 mm of

mandibular advancement.

Esthetic improvement in profile was perceived in 13 of 14 surgically treated

silhouette pairs. The control was identified by 104 of 127 evaluators. In some cases,

orthodontists, oral surgeons, and lay persons perceived changes in profile differently.














CHAPTER 1
INTRODUCTION

Combined orthodontic and orthognathic surgical treatment has become a common

and stable treatment modality for the correction of facial deformities and occlusal

disharmonies. In a review of the literature concerning psychological aspects of

orthognathic surgery, Cunningham et al. 4 sites multiple studies stating that esthetic

improvement was the major motivating factor for patients undergoing surgery. Research

has been conducted to assess perceptions of surgical outcomes. 2,3'13,16,18,19 In general,

studies have looked at pre-treatment and post-treatment photographs, digitally altered

photographs simulating surgical outcomes, and silhouettes. Studies have found that

surgical patients perceive their own profile changes differently than lay persons and

dental professionals. Kiyak et al. 13 showed that patients may not always be able to

appreciate changes in profile even after successful surgical correction. Phillips et al. 16

used patient records and showed a 7.8mm visual analogue scale (VAS) improvement in

surgically treated Class II skeletal cases while camouflaged patients showed no

significant improvement in VAS. However, the results and retrospective nature of this

study suggest that more attractive patients were camouflaged while less attractive patients

were treated surgically. Shelly et al. 18 evaluated the silhouettes of 34 surgically treated

Class II patients and found a significant negative correlation between initial esthetic score

and esthetic change for lay evaluators and orthodontist evaluators. Burcal et al. 3 used

digitally altered photographs to show that lay persons and patients recognized a 2 mm

change at pogonion in 22% of retrognathic subjects. A 4 mm change was recognized in









44% of retrognathic subjects. A 6 mm change was recognized in 67% of retrognathic

subjects. Dental professionals were 5%, 6%, and 15% more accurate at the three levels

of advancement. Romani et al.19 also used digitally altered photographs and showed that

Orthodontists detected 1mm of horizontal change in mandibles in 65.9% of cases. The

detection rate improved significantly to 93. 9% at 3 mm of change and further improved

to 97% for a 5 mm change.

Controlled research is needed to assess whether dental professionals can

recommend orthognathic surgery as an option for observable esthetic improvement.

Several factors will play a part in such a recommendation. Dental professionals must

understand a patient's goals and perceptions of normal and how these differ from his or

her own goals and perceptions. A positive and perceivable result depends upon the soft

tissue effect and stability of the surgical correction as well as achieving a large enough

surgical movement for patients, dental professionals, and lay persons to recognize.

This study compared pairs of silhouettes generated from pre-surgical and 5-year

post-surgical cephalometric radiographs and utilized a control pair of silhouettes, a

feature which was absent in many other studies. The purpose of this study of

orthodontically and surgically treated patients was to evaluate whether profile changes

that occur following treatment are detectable 5 years after surgery, compare differences

in perception of profile change between orthodontists, oral surgeons, and lay persons,

evaluate how much hard tissue pogonion advancement and soft tissue profile change is

needed to cause perceivable profile changes, and establish a guideline for when esthetics

can be recommended as a reason for surgery.














CHAPTER 2
MATERIALS AND METHODS

Surgical Subjects

Records obtained from a group of 127 surgical subjects were used in this study.

These records included pre-operative (T2) and 5 year post-operative (T8) cephalometric

radiographs. These radiographs were also used in a prospective randomized clinical trial5

looking at hard and soft tissue stability following surgery using rigid or wire fixation. All

patients underwent bilateral sagittal split osteotomy (BSSO). Seventy-eight subjects

underwent rigid fixation and 49 subjects underwent wire fixation. Thirty-five of the

BSSO subjects underwent genioplasty with rigid fixation while 24 subjects underwent

genioplasty with wire fixation. Surgeries were performed at three different surgical

centers. Inclusion criteria for this study were the presence of pre-surgical and 5 year

post-surgical lateral cephalometric radiographs. Exclusion criteria included incomplete

or poor quality records. Patients that underwent genioplasty were not included.

Fourteen surgical subjects were used in this study. Their mandibular advancements

ranged from 0.11 mm to 10.13 mm. Measurements were made using an x-y coordinate

system and templates as described by Dolce et al.. 5,6 Surgical subjects were selected

based on the quality of the records and an effort was made to assure that the majority of

surgical subjects had advancements between 1 mm and 6 mm. Previous studies have

shown that this range of advancement is critical in the recognition of esthetic change in

profile following surgical advancement of the mandible. 3,18 Surgical subjects had their

profiles traced from cephalometric radiographs. The tracings were then scanned, set to a









standard size, converted into a silhouettes, and oriented using Frankfort horizontal.

These silhouettes were then used to create a survey. Pre-surgical and post-surgical

silhouettes were placed beside each other. Seven pages of the survey had silhouettes

from T2 on the left side of the page and silhouettes from T8 on the right side of the page.

Seven other pages of the survey had silhouettes from T8 on the left side of the page and

silhouettes from T2 on the right side of the page. The control pair of silhouettes had T8

silhouettes from the patient with a 4.74 mm advancement on the right and left side of the

page. The questions," Is there a difference between the two silhouettes?" and," What is

different?" were printed above the pairs of silhouettes. A 100 mm VAS was used to

assess the level of esthetic improvement, if any. VAS has been found to be valid,

reproducible, and reliable way of evaluating esthetics. 10,21 An example of a survey page

is presented in Figure 2-1. The amount of mandibular advancement, page number, soft

tissue Gb-Sn-Pg angle, and time point orientation of surgical subjects is shown on Table

2-1. Linear measurements (amount of hard tissue pogonion advancement) were obtained

from data used in a previously published study.5 Angular measurements (soft tissue Gb-

Sn-Pg) were made by one researcher for this study.

Evaluator Subjects

Pre-surgical and post-surgical profile silhouettes were assessed by 53 orthodontists,

32 oral surgeons, and 42 lay persons. The orthodontists and oral surgeons were randomly

chosen from professional directories. Randomization was achieved by generating a list

of random numbers and using these numbers to pick professionals from their directories.

Surveys were mailed to 421 orthodontists and 460 oral surgeons. Survey packets

included an informed consent letter, a self addressed and stamped envelope, and a copy

of the survey. Orthodontists and oral surgeons received no compensation.









A convenience sample of lay persons was obtained in the Shands Hospital lobby,

The University of Florida College of Dentistry student clinic lobby, a neighborhood in

Jacksonville, Florida, and an elementary school in North Palm Beach, Florida. Lay

person evaluators received a coupon for a free movie rental from Blockbuster Video as

compensation for their participation. The inclusion criterion was the acceptance of the

informed consent. Exclusion criteria included rejection of informed consent, inability to

follow survey instructions, and failure to return the survey.

Evaluator Demographics

Demographic information was collected from all evaluators. This information

included age, education, gender, and race.

Experimental Design

This study was a controlled survey based study. Surgical subjects were stratified

by the amount of hard tissue pogonion surgical advancement.

Statistical Method

The number of evaluators that saw differences between silhouette pairs and features

of silhouette pairs were calculated. These totals were then separated into their respective

evaluator groups. To assess group differences, the Chi-square and Fisher exact tests were

used. The level of significance used was p<0.05 (*).

The arithmetic means and standard deviations for the VAS were calculated for each

silhouette. The arithmetic means and standard deviations for the VAS differences (post-

surgical minus pre-surgical) were also calculated. These means and standard deviations

were then separated by evaluator groupings to evaluate group differences.

To assess differences in post-surgical minus pre-surgical VAS, paired t tests were

used. Evaluator group differences in post-surgical minus pre-surgical VAS were assessed











by Kruskal Wallis and pairwise Wilcoxon rank sum tests. Age differences between

evaluator groups were assessed using Kruskal Wallis tests. The level of significance used

was p<0.05 (*).


Is there a difference between the two silhouettes? YES NO
What is different? (Mark all that apply) Forehead Nose Upper Lip Lower Lip Chin Nothing


On the following scale, please mark with an "X" the level of attractiveness you attribute to each silhouette.


Less
Attractive


More
Attractive


Less
Attractive


More
Attractive


Figure 2-1. Example of a survey page.


Table 2-1. Amount of mandibular advancement, page number, facial convexity, and time
point orientation of surgical patients.
Surgical Page Soft Tissue Gb-Sn-Pg (degrees) Time Point
Advancement Number T2/T8/Difference Orientation
Control (4.74 mm patient) 8 164/164/0 T8/T8
0.11 mm 12 164/164/0 T2/T8
1.09 mm 2 159. 5/160. 5/1 T8/T2
2.27 mm 10 174. 5/175/0. 5 T2/T8
2.43 mm 4 162. 5/171/8. 5 T8/T2
3.20 mm 7 158/166. 5/8. 5 T2/T8
3.80 mm 6 162/170/8 T8/T2
4.74 mm 14 160/164/4 T2/T8
5.24 mm 15 169/174/5 T8/T2
5.90 mm 5 161/164/3 T2/T8
6.81 mm 9 162/169/7 T8/T2
7.38 mm 13 167. 5/173. 5/6 T8/T2
8.69 mm 11 172/176. 5/4. 5 T8/T2
9.56 mm 3 164/172/8 T2/T8
10.13 mm 1 166/177b/11 T2/T8














CHAPTER 3
RESULTS

Demographics

The demographic information obtained from the evaluators is presented in Table 3-

1. Differences in the mean ages of the evaluator groups were not significant (p>0. 05).

Statistical analysis of education, gender, and race were not considered due to expected

differences between the groups.

Overall Perceptions of Profile Change

The vast majority of evaluators were able to perceive changes in all surgical

silhouette pairs (Table 3-2). The control pair of silhouettes was correctly identified as

unchanged by 104 out of 127 evaluators. Many evaluators were able to perceive changes

to individual features. The majority of these changes took place at the chin, the lower lip,

and the upper lip. However, many evaluators perceived changes to the nose and the

forehead. (Table 3-3).

Overall VAS means arranged by the amount of hard tissue pogonion advancement

are presented in Figure 3-1, while overall means arranged by change in soft tissue Gb-Sn-

Pg are presented in Figure 3-2. However, the largest improvements in VAS occurred in

the patients with 3.20mm, 7.38 and 8.69mm of advancement. The patient with 10.13mm

of advancement experienced a worsening in VAS.

Orthodontists' Perceptions of Profile Change

The majority of orthodontists detected changes in profile and individual features

(Table 3-2, Table 3-3). The control pair of silhouettes was correctly identified as









unchanged by 47 out of 53 orthodontist evaluators. Orthodontist evaluators perceived

significant improvements in all surgical silhouette pairs except for the pairs with 9.56mm

and 10.13mm of advancement. The worsening of VAS in the 10.13 mm silhouette pair

and the improvement in the 9.56 mm silhouette pair did not reach statistical significance.

Orthodontist evaluators perceived no significant change in VAS for the control pair of

silhouettes.

Oral Surgeons' Perceptions of Profile Change

The majority of oral surgeons detected changes in profile and individual features

(Table 3-2, Table 3-3). The control pair of silhouettes was correctly identified as

unchanged by 25 out of 32 oral surgeon evaluators. Oral surgeon evaluators perceived

significant improvements in all surgical silhouette pairs except for the pairs with 2.43mm,

5.24, and 10.13mm of advancement. The pairs with 2.43mm and 5.24mm of

advancement were perceived to have non-significant improvement in VAS. The pair

with 10.13mm of advancement was perceived to have a non-significant worsening in

VAS. Oral surgeon evaluators perceived no significant change in VAS for the control

pair of silhouettes

Lay Persons' Perceptions of Profile Change

The majority of lay persons also detected changes in profile and individual features

(Table 3-2, Table 3-3). The control pair of silhouettes was correctly identified as

unchanged by 32 out of 42 lay person evaluators. Lay person evaluators perceived

significant improvements in all surgical silhouette pairs except for the pairs with 2.27mm,

2.43mm, 4.74mm, 5.24mm, and 10.13mm of advancement. The pairs with 2.43mm,

4.74mm, and 5.24mm of advancement were perceived to have non-significant

improvement in VAS. The pair with 2.27mm of advancement was perceived to have a









non-significant worsening in VAS. The pair with 10.13mm of advancement was

perceived to have a significant worsening in VAS. Lay person evaluators perceived no

significant change in VAS for the control pair of silhouettes.

Evaluator Differences

No evaluator group differences were seen when evaluating the detection of changes

to the silhouettes as a whole. However, there were multiple evaluator group differences

when individual facial feature evaluations were considered. All silhouette pairs had at

least one significant group difference for one feature except the control and the surgical

pairs with 0.11 mm, 3.80 mm, 6.81 mm, and 6.81 mm of advancement. The silhouette

pairs with 4.74mm, 5.25mm, 7.38mm, and 8.69mm all had three features reach

significance with regard to evaluator groups differences. These results and significant

group differences are presented on Table 3-3.

Evaluator groups were significantly different in their perception of profile change

for silhouette pairs representing 2.27 mm, 3.20 mm, 4.74 mm, and 10.13 mm of

mandibular advancement when evaluating silhouette pairs using the VAS. Figure 3-3

depicts the significant evaluator differences in VAS for these silhouette pairs. Lay

persons perceived significantly less improvement in VAS for pairs with 2.27 mm and

4.74 mm of advancement than did their orthodontist and oral surgeon counterparts. For

the silhouette pair with 3.20 mm of advancement, lay person perceived significantly less

improvement than oral surgeons but were similar to orthodontists. Lay persons also

perceived a significantly greater amount of worsening in VAS for the silhouette pair with

10.13mm of advancement than the orthodontist evaluator group.










Table 3-1.Evaluator demographic information.
Group Age (years) Education Level Gender Race
Orthodontists 53 +/- 13.23 8 female 2 Asian
45 male 1 Black
1 Hispanic
0 Other
49 White
Oral Surgeons 49 +/- 12.60 2 female 2 Asian
30 male 0 Black
0 Hispanic
0 Other
30 White
Lay Persons 46+/- 14.82 11 Highschool 27 female 0 Asian
8 Some college 15 male 5 Black
16 College graduate 2 Hispanic
7 Beyond college 1 Other
34 White


Table 3-2. Perceived differences in profile (% of Orthodontists/ % of Oral Surgeons/ %
of Lay Persons. An (*) indicates evaluator group differences. (N.S.) indicates
no evaluator group differences.
SurgicalAdvancement/ Detected Profile Significant Evaluator
Soft Tissue Gb-Sn-Pg Differences Group Differences
change
Control 23.8/21.9/11.3 N.S.
0.11 mm/0 degrees 100/100/94.3 N.S.
1.09 mm/1 degree 97.6/93.8/92.5 N.S.
2.27mm/0.5 degrees 100/100/94.3 N.S.
2.43mm/8.5 degrees 97.6/96.9/100 N.S.
3.20mm/8.5 degrees 100/100/100 N.S.
3.80 mm/8 degrees 95.2/96.9/94.3 N.S.
4.74 mm/4 degrees 88.1/96.9/98.1 N.S.
5.24 mm/5 degrees 95.24/96.9/88.7 N.S.
5.90 mm/3 degrees 95.2/100/94.3 N.S.
6.81 mm/7 degrees 97.6/100/96.2 N.S.
7.38 mm/6 degrees 100/96.9/98.1 N.S.
8.69mm/4.5 degrees 100/96.9/98.1 N.S.
9.56 mm/8 degrees 100/96.9/100 N.S.
10.13 mm/11 degrees 100/100/100 N.S.











Table 3-3. Perceived differences and the significance of evaluator group differences in
individual features (% of Orthodontists/ % of Oral Surgeons/ % of Lay
Persons). An (*) indicates evaluator group differences. (N.S.) indicates no
evaluator group differences.
Surgical
Advancement/ Detected Detected Detected Detected Detected
Soft Tissue Forehead Nose Upper Lip Lower Lip Chin
Gb-Sn-Pg Difference Difference Difference Difference Difference
change
9.5/3.1/ 9.5/12.5/ 2.4/6.3/ 2.4/6.3/ 7/1/18.8/
Control
3.8(N.S.) 9.4 (N.S.) 1.9 (N.S.) 3.8 (N.S.) 3.8 (N.S.)
0.11 mm/ 52.4/34.4/ 35.7/40.6/ 81.0/81.3/ 88.1/84.4/ 45.2/62.5/
0 degrees 41.5(N.S). 37.7(N.S.) 67.9 (N.S.) 90.6 (N.S.) 39.6 (N.S.)
1.09 mm/ 23.8/6.2/ 59.5/34.4/ 28.6/43.8/ 64.3/75.0/ 81.0/90.6/
1 degree 3.8 (*) 26.4 (*) 35.9 (N.S.) 75.5 (N.S.) 83.0 (N.S.)
2.27mm/ 61.9/16.1/ 45.2/25.8/ 64.3/45.2/ 81.0/81.0/ 83.3/93.6/
0.5 degrees 30.2(*) 20.8 (*) 41.5 (N.S.) 81.1 (N.S.) 86.8 (N.S.)
2.43mm/ 14.3/6.2/ 31.0/40.6/ 90.5/93.8/ 52.4/62.5/ 35.7/53.1/
8.5 degrees 5.6 (N.S.) 11.3 (*) 92.5 (N.S.) 52.8 (N.S.) 56.6 (N.S.)
3.20mm/ 78.6/40.6/ 66.7/68.8/ 64.3/53.1/ 76.2/84.4/ 85.7/96.9/
8.5 degrees 45.3 (*) 60.4(N.S.) 54.7 (N.S.) 88.7 (N.S.) 94.3 (N.S.)
3.80 mm/ 66.7/40.6/ 59.5/65.6/ 42.9/46.9/ 69.1/65.6/ 52.4/75.0/
8 degrees 50.9(N.S.) 52.8(N.S.) 26.4 (N.S.) 66.0 (N.S.) 60.4 (N.S.)
4.74 mm/ 21.4/3.1/ 30.1/12.5/ 54.8/40.6/ 59.5/65.3/ 57.1/100/
4 degrees 5.7 (*) 9.4 (*) 35.9 (N.S.) 71.7 (N.S.) 88.7 (*)
5.24 mm/ 24.4/6.3/ 51.2/25.0/ 78.1/65.6/ 70.7/78.1/ 39.0/56.3/
5 degrees 1.9 (*) 13.2 (*) 52.8 (*) 66.0 (N.S.) 39.6 (N.S.)
5.90 mm/ 28.8/9.4/ 45.2/46.9/ 69.1/90.6/ 64.3/84.4/ 54.8/75.0/
3 degrees 5.7 (*) 37.7(N.S.) 73.6 (N.S.) 73.6 (N.S.) 71.7 (N.S.)
6.81 mm/ 35.7/28.1/ 21.4/25.0/ 90.5/78.1/ 73.8/75.0/ 50.0/59.4/
7 degrees 26.4(N.S.) 11.3(N.S.) 83.0 (N.S.) 77.4 (N.S.) 41.5 (N.S.)
7.38 mm/ 66.7/25.0/ 64.3/56.3/ 52.4/53.1/ 83.3/87.5/ 57.1/84.4/
6 degrees 43.4 (*) 56.6(N.S.) 30.2 (*) 92.5 (N.S.) 77.4 (*)
8.69mm/ 47.6/18.8/ 64.3/34.4/ 73.8/50.0/ 85.7/87.5/ 38.1/59.4/
4.5 degrees 24.5 (*) 26.4 (*) 47.2 (*) 92.5 (N.S.) 47.2 (N.S.)
9.56 mm/ 21.4/21.9/ 38.1/31.2/ 78.6/50.0/ 71.4/84.4/ 50.0/81.2/
8 degrees 9.4 (N.S.) 20.8(N.S.) 54.7(*) 86.8 (N.S.) 67.9 (*)
10.13 mm/ 31.0/15.6/ 42.9/37.5/ 76.2/84.4/ 85.7/90.6/ 78.6/96.9/
11 degrees 13.2(N.S.) 17.0 (*) 66.0 (N.S.) 90.6 (N.S.) 98.1 (*)







'1 K


21'1
1i.
Post-Surgical VAS minus
Pre- Surgical VAS


Amount of Surgical Advancement at Hard Tissue Pogonion


Figure 3-1. Mean changes in VAS arranged by advancement of hard tissue pogonion. An
(*) indicates evaluator group differences.


us Pre.
S


Figure 3-2. Mean changes in VAS arranged by change in soft tissue Gb-Sn-Pg. An (*)
indicates evaluator group differences.


slidI~iiII


.Illl I Ili II





















Post-Surgical VAS
minus Pre-Surgical
VAS


2.27 rn 3.20 rn


I Orthodontists
o Oral Surgeons
* Lay Persons


10.13mm


Amount of Advancement of Hard Tissue Pogonion





Figure 3-3. Significant differences in VAS between evaluator groups. An (*) indicates
evaluator group differences.














CHAPTER 4
DISCUSSION

This study shows changes in soft tissue profile can be perceived five years after

surgery by groups of evaluators including orthodontists, oral surgeons and lay persons in

a patient population with a wide array of mandibular advancements. The results show

that the three groups had differing preferences and sensitivities to horizontal change of

mandibular position and the majority of evaluators were able to identify a lack of

significant change in the control silhouette pair.

Differences between Hard and Soft Tissue Arrangement of VAS

Multiple studies have evaluated various aspects of the hard and soft tissue change

brought about by orthognathic surgery. 5,6,8,9,12,14,17 Several Studies have found a 1:1

relationship between hard tissue surgical advancement and soft tissue change7'11'15'20

However, results from this study indicate that a predictable 1:1 ratio of hard tissue to soft

tissue movement may not be occurring five years after surgery. This is demonstrated by

differences in the distribution of VAS changes when comparing data arranged by hard

tissue and soft tissue change values. Previously published data supports the ideas that the

amount of advancement and time can play a role in the ratio of hard tissue to soft tissue

change. A study by Van Sickels et al. suggested that a 1:1 ratio of movement may not be

occurring when the hard tissue advancement exceeds 8mm. 20 Mobarak et al. showed

that significant relapse occurred three years after surgery and felt that a 1:1 ratio may be

too optimistic a prediction for treatment planning purposes. Other factors that may be at









work include the impact of individual features, small changes due to head position or lip

posture, and significant differences between evaluator groups.



Perceptions of Change in Soft Tissue Profile

This study agrees with previously published reports3'16'18'19 in that evaluators were

able to detect even the smallest changes in profile when evaluating silhouettes generated

from cephalometric radiographs. However, this study shows that all evaluators were

potentially more sensitive to overall changes in profile than previously reported as the

vast majority of evaluators recognized as least some amount of change in all surgical

silhouette pairs. When considering individual features, there appears to be a trend toward

recognizing changes in features such as upper lip, lower lip and chin as the majority of

changes detected lie in these three areas. These results appear to be logical as the

chances of affecting forehead or nasal contour by mandibular advancement would seem

to be rather small at best. It is likely that changes in forehead contour were the result of

changes in head positioning, while changes in nasal contour could have resulted from a

change in lip support brought about by a new relationship between the nose, lips, teeth,

and jaws. It should also be noted that the majority of evaluators successfully identified

the control pair of silhouettes. Previous studies have not examined changes less than

1mm and no comparison of control data can be done because previous studies have not

used controls.

Multiple significant improvements in VAS were also found. Significant

improvements in VAS were found for every surgical silhouette pair by at least one group

of evaluators. However, VAS did not change significantly for the control. This would

suggest that the significant change in VAS for the patient with 0.11 mm in hard tissue









pogonion advancement is truly being detected. This study also shows that there may be a

limit as to how far the mandible can be advanced before a particular patient experiences a

worsening in profile as perceived by various groups of evaluators. The other studies did

not show any worsening in profile following surgical correction

Evaluator Differences

Significant differences between evaluator groups were found in this study.

Previous studies have not found such differences. 16,18,19 Another study by Burcal et al.3

showed a trend toward dental professionals being more accurate and sensitive in their

identification of changes in profile, however, no statistical analysis was done to support

these observations. Arpino et al.1 showed that orthodontists were significantly more

accepting of deviations than oral surgeons, surgical patients, and acquaintances of

surgical patients. This study found that there were multiple evaluator group differences

when detecting changes in individual features but no group differences when detecting

overall changes in profile. The forehead (8 significant differences) and nose (7

significant differences) were the most common places to see differences in the detection

of change. This could be a result of different esthetic priorities in the various evaluator

groups, or one or more groups may not have focused as heavily on areas that were not

directly involved in jaw surgery. It is also interesting to note that no significant

differences between evaluator groups were found for the lower lip and significant

differences were only found for the upper lip and chin when the advancement was 4.74

mm or greater. There appears to be a trend toward lay persons being more sensitive to

changes in the upper lip while orthodontists were more sensitive to changes in chin

contour or position.









This study also showed that orthodontists perceived a greater number of significant

improvements in VAS than oral surgeons and oral surgeons perceived a greater number

of significant improvements in VAS than lay persons. This would seem to agree with

Burcal et al.3 as the professional groups were able to perceive improvements in patients

with small surgical advancements and small soft tissue changes. However, it could also

be suggested that orthodontists were merely more willing to accept small improvements

and their evaluations were inflated due to their acceptance of greater deviations from

normal. This idea would tend to agree with the results presented by Arpino et al.1

In general, when significant differences were present, lay persons saw significantly

less improvement in VAS than their professional counterparts. This could mean that lay

persons could not perceive the changes that were occurring or they did not view an

improvement in facial convexity as being important. It is possible that lay persons may

have focused on individual features such as nose, forehead, or chin when evaluating

improvements in esthetics or that these features had an overriding effect on their

evaluation.

Guidelines for Decision Making Regarding Surgical Advancement

One of the objectives of this study was to establish a guideline for when esthetics

can be recommended as a reason for surgery. However, it may not be possible to

establish a guideline for decision making regarding surgical advancement using the

results of this study. While this study showed that nearly everyone recognized that some

change had taken place, improvements in esthetics and VAS may have been dependent

on factors other than the amount of change in mandibular position. The unpredictable

amount of esthetic improvement when compared to soft and hard tissue change and the

large standard deviations would leave such a guideline weakly supported at best. The









only guidelines that can be given are that there may be a limit as to how far the mandible

can be advanced before a particular patient experiences a worsening in profile and

changes in profile can be detected five years after surgery.

The use of living patients with varying amounts of surgical advancements was a

strength of this study from the standpoint of soft tissue response to surgical change,

however, the variation in attractiveness of other facial features may have turned out to be

the weakness that prevented us from achieving our final objective. We attempted to

control for as many features as possible and differences based on sex of the patient by

using silhouettes. However, it would seem that digitally altered photographs offer the

best way to create such a guideline but the lack of a true soft tissue response may undo

this methodology as well. The results of such a study would only be as reliable as the

artist's ability to mimic true soft tissue responses at varying amounts of hard tissue

advancement. In the end, surgical decisions should be based on thorough study and

accurate diagnosis of individual cases.














CHAPTER 5
CONCLUSIONS

* Surgical changes were perceivable five years after surgery.

* There were significant differences between groups of evaluators.

* The control pair of silhouettes was correctly identified as unchanged by 104 out of
127 evaluators. However, the patient with the smallest mandibular advancement
(0.11 mm) showed significant improvements in VAS when evaluated by
orthodontists, oral surgeons, and lay person.

* Guidelines on surgical decision making should be determined based on thorough
study and accurate diagnosis of the patient. However, this study suggests that
excessively large changes in hard tissue pogonion and soft tissue Gb-Sn-Pg may
lead to less esthetic improvement or a worsening in profile esthetics.















LIST OF REFERENCES


1. Arpino VJ, Giddon, DB, BeGole EA, Evans CA. Presurgical profile preferences of
patients and clinicians. Am J Orthod Dentofacial Orthop 1998 Dec; 114 (6):631-7

2. Bell R, Kiyak A, Joondeph DR, McNeill RW, Wallen TR. Perceptions of facial
profile and their influence on the decision to undergo orthognathic surgery. Am J
Orthod 1985 Oct; 88(4):323-32

3. Burcal RG, Laskin DM, Sperry TP. Recognition of profile change after simulated
orthognathis surgery. J Oral Maxillofac Surg 1987;45:666-670

4. Cunningham SJ, Hunt NP, Feinmann C. Psychological aspects of orthognathic
surgery: A review of the literature. Int J Adult Orthod Orthognath Surg.
1995;10(3):159-172

5. Dolce C, Hatch JP, Van Sickels JE, Rugh JD. Rigid versus wire fixation for
mandibular advancement: Skeletal and dental changes after 5 years. Am J Orthod
Dentofacial Orthop 2002; 121:610-9

6. Dolce C, Johnson PD, Van Sickels JE, Bays RA, Rugh JD. Maintenance of soft
tissue changes after rigid versus wire fixation for mandibular advancement, with
and without genioplasty. Oral Surg Oral Med Oral Pathol Oral Radio Endod
2001;92:142-9

7. Ewing M, Ross RB. Soft tissue response to mandibular advancement and
genioplasty. Am J Orthod Dentofacial Orthop 1992;101:550-5

8. Hoffman GR, Staples G, Moloney FB. Cephalometric alterations following facial
advancement surgery: 1. Statistical evaluation. A review of aesthetic evaluation of
the face and an attempt to assess treatment validity. J Craniomaxillofac Surg 1994
Aug;22(4):214-9

9. Hoffman GR, Staples G, Moloney FB. Cephalometric alterations following facial
advancement surgery. W. Clinical and computerized evaluation. J Craniomaxillofac
Surg 1994 Dec;22(6):371-5

10. Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial
attractiveness for epidemiologic use. Am J Orthod 1995 Nov; 88: 402-408

11. Jensen AC, Sinclair PM, Wolford LM. Soft tissues associated with double jaw
surgery. Am J Orthod Dentofacial Orthop 1992: 101(3): 266-275









12. Keeling SD, LaBanc JP, Van Sickels JE, Bays RA, Cavalieros C, Rugh JD.
Skeletal change at surgery as a predictor of long-term soft tissue profile change
after mandibular advancement. J Oral Maxillofac Surg 1996;54:134-44

13. Kiyak HA, Zeitler DL. Self-assessment of profile and body image among
orthognathic surgery patients before and two years after surgery. J Oral Maxillofac
Surg 1998 May;46(5): 365-71

14. Lines PA, Steinhauser EX. Soft tissue changes in relationship to movement of hard
structures in orthognathic surgery: A preliminary report. J Oral Surg 1974;32:891-6

15. Mobarak KA, Espeland L, Krogstad O, Lyberg T. Soft tissue profile changes
following mandibular advancement surgery: Predictability and long-term outcome.
Am J Orthod Dentofacial Orthop 2001 Apr; 119(4):353-67

16. Phillips C, Trentini CJ, Douvartzidis N. The effect of treatment on facial
attractiveness. J Oral Maxillofac Surg 1992; 50:590-594

17. Quast DC, Biggerstaff RH, Haley JV. The short-term and long-term soft-tissue
profile changes which accompany the advancement of the mandibular advancement
surgery. Am J Orthod 1983; 84:29-36

18. Shelly AD, Southard TE, Southard KA, Casko JS, Jakobsen JR, Fridrich KL,
Mergen JL. Evaluation of profile esthetic change with mandibular advancement
surgery. Am J Orthod Dentofacial Orthop 2000 Jun; 117(6):630-7

19. Romani KL, Agahi F, Nanda R, Zernik JH. Evaluation of horizontal and vertical
differences in facial profiles by orthodontists and lay people Angle Ortho 1993;
63(3):175-82

20. Van Sickels JE, Smith CV, Tiner BD, Jones DL. Hard and soft tissue predictability
with advancement genioplasties. Oral Surg Oral Med Oral Pathol. 1994 Mar;
77(3):218-21

21. Woolass KF, Shaw WC. Validity and reproducility of rating dental attractiveness
from study cases. Br J Orthod 1987 Jul;14: 187-190















BIOGRAPHICAL SKETCH

Reid Wallace Montini was born and raised in West Palm Beach, Florida. He

attended Florida State University for his undergraduate study, with a B.S in biological

science. He was then admitted to Harvard School of Dental Medicine for his dental

education and graduated with honors from dental school in 2002, obtaining a Doctor of

Dental Medicine degree. After graduation, Dr. Montini continued his dental education at

the University of Florida earning a Master of Science degree with a certificate in

orthodontics in May 2005.