Soft tissue response after Class III bimaxillary surgery Impact of surgical change in face height and long-term skeletal relapse

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1 Originl Article Soft tissue response fter Clss III bimxillry surgery Impct of surgicl chnge in fce height nd long-term skeletl relpse Gundeg Jkobsone ; Arild Stenvik b ; Lisen Espelnd b ABSTRACT Objective: To nlyze the impct of surgicl chnge in nterior fce height nd skeletl relpse on the long-term soft tissue profile. Mterils nd Methods: Cephlometric rdiogrphs of 81 ptients tken before surgery nd t five time points during 3-yer follow-up period were nlyzed. All ptients hd Le Fort I nd bilterl sgittl split osteotomies. The ptients were divided into three subgroups ccording to the chnge in nterior fce height during surgery. Clcultions of soft to hrd tissue rtios were bsed on the long-term soft tissue response reltive to the surgicl repositioning. Results: The horizontl surgicl repositioning vried considerbly, depending on whether nterior fce height ws incresed or decresed. For upper lip prominence, the pttern of long-term chnge ws the sme irrespective of chnge in fce height. In ll groups, upper lip thickness decresed in both the short term nd the long term, prticulrly in ptients with surgicl increse in fce height. Lower lip thickness incresed in the short term but decresed during the follow-up period. There were significnt ssocitions between horizontl soft tissue nd corresponding hrd tissue chnges, except for soft tissue A-point nd upper lip, when fce height ws incresed. The rtios were higher for mndibulr vribles thn for mxillry vribles, prticulrly for B-point nd pogonion when nterior fce height hd decresed. Conclusion: A chnge in fcil height influences the soft tissue response. The mndibulr soft tissues closely follow skeletl relpse beyond 2 months postsurgery. The findings hve clinicl implictions for the reltive mxillry nd mndibulr repositioning when plnning surgery. (Angle Orthod. 2013;83: ) KEY WORDS: Orthognthic surgery; Soft tissue response; Clss III mlocclusion INTRODUCTION An importnt gol of orthognthic surgery is to improve fcil hrmony, nd clinicins require tools to predict postsurgicl soft tissue chnges tht lso fcilitte communiction with the ptient. Softwre tht predicts soft tissue responses is usully bsed on studies reporting rtios of soft to hrd tissue chnges. However, these rtios often do not tke into ccount potentil long-term skeletl relpse. Some uthors Associte Professor, Deprtment of Orthodontics, Rig Strdins University, Rig, Ltvi. b Professor, Deprtment of Orthodontics, University of Oslo, Norwy. Corresponding uthor: Dr Lisen Espelnd, Deprtment of Orthodontics, Institute of Clinicl Dentistry, University of Oslo, PO Box 1109, Blindern, N-0317 Oslo, Norwy (e-mil: lisene@odont.uio.no). Accepted: September Submitted: April Published Online: October 30, 2012 G 2013 by The EH Angle Eduction nd Reserch Foundtion, Inc. hve therefore suggested tht rtios should be estblished tht incorporte both soft nd hrd tissue relpse, nd such rtios hve been presented for mndibulr setbck surgery. 1,2 Other fctors tht hve been suggested to influence postopertive stbility of the soft tissues include the preopertive soft tissue thickness, 1,3,4 gender, 1,5 nd the mount of surgicl movement. 1,6 It hs been proposed tht most of the postsurgicl chnge in the soft tissue profile tkes plce during the first yer. 1,7 9 Some reports on shortterm soft tissue chnges fter bimxillry correction of Clss III mlocclusion re vilble, 6,10 16 but few hve ddressed the long-term chnges in the soft tissues. 8,17 Bimxillry surgery hs greter potentil to decrese or increse nterior fce height compred to one-jw osteotomies, nd the soft tissues my be ffected by relxtion or stretching. The reltive mount of mxillry dvncement nd mndibulr setbck should lso be plnned ccording to the desired profile chnges nd should tke into ccount the extent to which the soft tissues follow the hrd DOI: /

2 534 JAKOBSONE, STENVIK, ESPELAND tissue relpse in the long term. The purpose of the present study, therefore, ws to nlyze long-term chnges in the soft tissue fcil profile following Clss III bimxillry surgery with the objective to determine whether decrese or increse in fce height during surgery ffects the profile chnges, with emphsis on the nteroposterior (AP) direction. An dditionl objective ws to nlyze to wht extent the soft tissues follow the skeletl long-term relpse. MATERIAL AND METHODS The smple comprised 84 consecutively operted ptients who ll underwent combintion of stndrd one-piece Le Fort I osteotomy nd bilterl sgittl split osteotomy with rigid fixtion tht involved two minipltes on ech side in the mxill nd three 2.0-mm bicorticl screws with wshers on ech side in the mndible. Detils of the surgicl procedure hve been described previously. 18 A tem of five senior surgeons ws involved in the surgery. None of the ptients hd undergone dditionl surgery such s genioplsty. Ptients with syndromes, cleft of the lip nd/or plte, or dentofcil trum were excluded from the study. Ptient dt were retrieved from the files t the Deprtment of Orthodontics, University of Oslo. Surgery hd been performed t the Oslo University Hospitl, Ullevl, between 1990 nd The ptients were monitored over 3-yer period. In the present study, the records obtined within 1 week prior to surgery (T1); within 1 week fter surgery (T2); 2, 6, nd 12 months fter surgery (T3, T4, nd T5); nd 3 yers fter surgery (T6) were used. Cephlogrms of 81 ptients (55 mle nd 26 femle ptients) were vilble. When exmining the effect of skeletl relpse on postsurgicl soft tissue morphology, we focused on chnges occurring between T3 nd T6 becuse of postsurgicl swelling t T2. The shortterm soft tissue response ws thus clculted s chnges from T1 to T3. Soft tissue to hrd tissue rtios were clculted from the long-term soft tissue response (T1 to T6) reltive to surgicl repositioning (T1 to T2). The ge of the ptients t the time of surgery vried from 15.7 to 49.2 yers, with men of 24.4 yers (stndrd devition [SD] 7.3 yers). To nlyze the effect of chnges in nterior fce height (AFH) recorded between T1 nd T2, the ptients were llocted to one of three subgroups: the No Chnge group, ie, chnge in AFH of less thn 2 mm (n 5 30); the Decrese group, ie, ptients showing decrese in AFH of 2 mm or more (n 5 40); or the Increse group, ie, subjects with n increse in AFH of 2 mm or more (n 5 11). Six ptients in the increse group received bone grfts when the mxill ws repositioned downwrd. Chnges in the positions Figure 1. Skeletl, dentl, nd soft tissue lndmrks pplied in the cephlometric nlysis. A indictes A-point; A9, soft tissue A-point; ANS, nterior nsl spine; B, B-point; B9, soft tissue B-point; Cm, midpoint of columell of the nose; L1, superiormost point of the lower incisors; Li, lbrle inferior; Ls, lbrle superior; Me, menton; Me9, soft tissue menton; Pg, pogonion; Pg9, soft tissue pogonion; Pn, pronsle; S, sell; Sn, subnsle; Stm s nd Stm i, stomion superius nd inferius, respectively; nd U1, inferiormost point of the upper incisors. of ntomicl lndmrks were recorded using coordinte system (Figure 1). In ddition, two ngulr mesurements (nsolbil ngle nd mentolbil ngle) nd two liner mesurements (upper nd lower lip thickness) were mde. All cephlogrms were hnd-trced, nd the trcings were scnned nd digitized with Dentofcil Plnner Plus softwre (Dentofcil Softwre, Toronto, Ontrio, Cnd). The cephlometric nlysis nd nlysis of method error hve been described previously. 16 Sttisticl nlyses were performed with SPSS for Windows (SPSS, Chicgo, Ill). Pired t-tests were used to nlyze chnges between time points within subgroups, nd nlysis of vrince (ANOVA) ws pplied to exmine differences between subgroups. Associtions between soft nd hrd tissue chnges were nlyzed with Person s correltion coefficients. The study ws pproved by the Norwegin Socil Science Dt Services (Project no ). RESULTS The hrd nd soft tissues followed the sme ptterns of chnge in femle nd mle ptients, except for soft tissue B-point; the dt were therefore pooled.

3 SOFT TISSUE RESPONSE AFTER CLASS III SURGERY 535 Figure 2. Men nteroposterior chnges t hrd tissue (HT) nd soft tissue (ST) lndmrks s function of time in ech subgroup (No Chnge, Decrese, nd Increse in AFH during bimxillry surgery). The zero point on the y-xis represents the presurgicl position. The vlue on the y- xis t the zero point on the x-xis represents the surgicl chnge (T1 to T2). () Chnges in A-point. (b) Chnges in upper incisors nd upper lip. (c) Chnges in lower incisors nd lower lip. (d) Chnges in Pg. The men longitudinl hrd tissue nd corresponding soft tissue chnges in the AP direction for A-point, upper nd lower incisors, nd Pg pper in Figure 2. Surgicl Repositioning nd Skeletl Relpse On verge, AFH ws reduced by 5.5 mm in the Decrese group nd incresed by 7.3 mm in the Increse group (Tble 1). Reduction in fce height ws minly result of mndibulr repositioning, wheres n increse in AFH ws result of both mxillry nd mndibulr chnges. The men mxillry nd mndibulr surgicl AP chnge differed mong the groups: mxillry dvncement t A ws gretest in the No Chnge nd Decrese groups (3.6 nd 4.3 mm, respectively, versus 2.3 mm in the Increse group). In contrst, mndibulr setbck ws gretest in the Increse group (15.4 mm t Pg) nd lest in the Decrese group (2.6 mm). Mxillry dvncement ws stble over the long term, wheres mndibulr relpse t Pg vried from 1.7 mm in the Decrese group to 4.6 mm in the Increse group. The mounts of verticl relpse t ANS nd Me were only minor in the No Chnge nd Decrese groups but were notble in the Increse group (47% nd 58% of the surgicl chnge, respectively). The differences between the three groups were sttisticlly significnt for ll vribles, except for short-term chnge t A nd long-term chnge of U1. Soft Tissue Chnges The men nsiolbil ngle incresed significntly, prticulrly in the Increse group, nd the chnges were stble in ll groups (Tble 2). A reduction in the mentolbil ngle ws observed in ll groups; less relpse ws seen in the Increse group thn in the two other groups. Upper lip thickness (Ls-U1) decresed fter surgery nd continued to decrese in ll groups similrly. Upper lip (Ls) prominence hd relpsed to the presurgery level in the Increse group, wheres it ws bout 2 mm more nterior in the Decrese group (Figure 2b). Lower lip thickness (Li-L1) incresed in ll groups fter surgery, nd the net long-term increse ws gretest in the Decrese group (Tble 2). At the 3-yer follow-up, the lower lip ws bout 3.5 mm

4 536 JAKOBSONE, STENVIK, ESPELAND Tble 1. Men (SD) Skeletl Chnges (mm) in the Groups During Surgery (T1 to T2) nd Postsurgery (T2 to T6) No Chnge Group (n 5 30) Decrese Group (n 5 40) Increse Group (n 5 11) P Vlues T1 to T2 T2 to T6 T1 to T2 T2 to T6 T1 to T2 T2 to T6 T1 to T2 T2 to T6 Horizontl chnges A-point 3.6*** (2.3) 0.2 (1.0) 4.3*** (2.6) 20.4** (1.0) 2.3** (1.6) 0.2 (1.0) U1 3.0*** (3.1) 0.9* (1.8) 3.6*** (3.9) 0.0 (1.6) 0.2 (2.1) 2.6** (1.9) L1 27.8*** (3.7) 1.3** (2.3) 25.5*** (3.8) 1.4*** (1.4) 211.1*** (3.0) 2.3*** (1.5) B-point 28.2*** (4.6) 1.6** (2.5) 24.1*** (4.5) 1.2*** (1.7) 213.7*** (3.4) 3.8*** (1.6) Pg 28.5*** (5.6) 2.2*** (2.6) 22.6** (5.6) 1.7*** (2.2) 215.4*** (3.9) 4.6*** (2.1) Verticl chnges ANS 1.6* (3.2) 20.7* (1.6) 21.0 * (3.0) 20.3 (1.2) 4.9*** (2.9) 22.3* (2.5) U1 2.5*** (3.1) 21.0* (2.1) 20.9 (3.0) 20.4 (1.3) 5.5*** (2.7) 23.6*** (2.3) L1 0.4 (1.8) 21.4** (2.4) 26.0*** (2.6) 0.0 (1.6) 7.5*** (3.4) 24.1** (3.4) Me 0.1 (1.2) 21.0** (1.9) 25.5*** (2.2) 0.5 (1.8) 7.3*** (4.1) 24.2** (3.3) Positive vlues indicte forwrd nd downwrd movement; negtive vlues indicte bckwrd nd upwrd movement. Sttisticl significnce of chnges between time points within the groups (pired t-test): * P #.05; ** P #.01; *** P #.001. Sttisticl significnce of differences between the three groups ws tested by ANOVA. posterior compred to the presurgicl position in the Decrese group, versus more thn 8 mm in the Increse group (Figure 2c). The men chnges in the nsiolbil nd mentolbil ngles did not differ significntly between the groups in the long term. The soft tissue chin relpsed slightly more thn the underlying hrd tissue in the groups (rnge, mm; Figure 2d). Assocition Between Skeletl Relpse nd Soft Tissue Chnge from 2 Months to 3 Yers After Surgery A9 nd Ls tended to relpse in ll groups, wheres the corresponding hrd tissues remined stble in the long term (T3 to T6) (Figure 2,b). Li nd Pg9 closely followed the hrd tissue relpse (Figure 2c,d). The rtios for soft to hrd tissue chnge nd corresponding correltion coefficients pper in Tble 3. There were significnt ssocitions between AP soft nd hrd tissue chnges, except for A9 nd Ls, when fce height ws incresed. Rtios for soft to hrd tissue vribles nd correltion coefficients were generlly higher for mndibulr thn for mxillry vribles. The highest rtios nd correltion coefficients, bout 90% nd 0.9, respectively, were observed for B nd Pg in the Decrese group. For verticl vribles, ll correltions were significnt when fce height ws decresed. No significnt ssocitions were found for the other groups, except tht Li chnge correlted negtively with L1 repositioning when fce height ws incresed (Tble 3). DISCUSSION In previous long-term studies of isolted mndibulr setbck 1,2 tht presented rtios for soft to hrd tissue chnges, soft tissue response ws relted to the hrd tissue chnges (1) during surgery nd (2) t the end of the observtion period. Becuse significnt relpse occurred in severl of the vribles, it ws considered most relevnt to clculte rtios bsed on the net (T1 to T6) soft tissue chnge reltive to the immedite (T1 to T2) surgicl skeletl chnge. Rtios clculted from chnges in soft to hrd tissues over the sme time intervl re generlly higher becuse they do not incorporte the effect of skeletl relpse. 1,2 A number of corresponding soft nd hrd tissue chnges were closely relted, prticulrly AP chnges in the mndible, wheres other lndmrks chnged quite independently. This my be result of different chrcteristics such s the extent nd volume of soft tissues, but it could lso be ttributed to functionl spects such s musculr tonicity in the midfce region. 8 Proffit nd Phillips 19 investigted chnges in lip pressure fter orthognthic surgery nd found decrese in resting pressure of the upper lip when the mxill ws dvnced. Previous studies 20,21 hve shown extension of the hed fter mndibulr setbck to compenste for decrese in upper irwy spce. An experimentl study by Hellsing nd L Estrnge 22 observed n increse in upper lip pressure in conjunction with extension of the hed. A slightly greter nterior movement of soft tissue vs hrd tissue chin my be ttributed to thickening of the soft tissue in the re. A long-term thickening of the soft tissue chin fter Clss III surgery ws observed previously. 8 Although some chnges often ttributed to ging, such s lengthening of the upper lip, thickening of the chin, nd thinning of the lips, were observed in the present study, more extensive follow-up period is required before conclusion cn be reched bout the effect of ging. Comprison Between Groups Net AP chnges in A9 nd Ls positions were limited in ll groups nd re most likely relted to the long-

5 SOFT TISSUE RESPONSE AFTER CLASS III SURGERY 537 Tble 2. Men (SD) Soft Tissue Angulr (u) nd Liner (mm) Chnges in the Groups Short- (T1 to T3) nd Long-Term (T3 to T6) No Chnge Group (n 5 30) Decrese Group (n 5 40) Increse Group (n 5 11) P Vlues T1 to T3 T3 to T6 T1 to T3 T3 to T6 T1 to T3 T3 to T6 T1 to T3 T3 to T6 Nsolbil ngle 3.5* (8.1) 0.2 (3.3) 21.4 (10.0) 20.2 (6.7) 12.2* (17.7) 21.0 (7.5).001 NS Mentolbil ngle 211.9*** (11.8) 2.9 (8.0) 217.9*** (12.9) 5.9*** (7.8) 28.3* (11.4) 0.9 (10.0).036 NS Upper lip thickness 21.7** (3.1) 21.2*** (1.1) 21.3** (2.5) 21.0*** (1.5) 22.4* (2.8) 21.4* (1.6) NS NS Lower lip thickness 2.5*** (2.2) 21.0* (2.0) 3.3*** (2.5) 21.3*** (1.3) 1.6* (2.1) 20.5 (2.1) NS NS Upper lip length 20.3 (3.1) 0.4 (1.2) 20.3 (2.3) 0.8** (1.4) 21.5 (3.1) 0.5 (1.6) NS NS Nsolbil ngle: the ngle defined by the intersection of the line connecting Cm nd Sn nd the line connecting Sn nd Ls; mentolbil ngle: the ngle defined by the intersection of the line connecting Li nd B9 nd the line connecting B9 nd Pg9. Sttisticl significnce of chnges between time points within the groups (pired t-test): * P #.05, ** P #.01, *** P #.001. Sttisticl significnce of differences between the three groups ws tested by ANOVA. term reduction in lip thickness (Ls-U1), which is in ccordnce with previous long-term study of Clss III bimxillry surgery. 8 One study observed tht the chnges in the nsiolbil nd mentolbil ngles were not predictble fter bimxillry Clss III surgery. 11 In the present study, the gretest net increse in the nsolbil ngle (11.2u) ws observed in the Increse group. A previous study reported tht n increse in the nsiolbil ngle ws correlted with decrese of lower fce height 17 ; however, the men increse in tht smple ws only 1.9u. Decrese in lower fce height. In most ptients in the Decrese group, bimxillry surgery ws performed becuse of n excessive verticl dimension of the lower fce, nd surgery often involved mxillry posterior impction nd utorottion of the mndible. These surgicl movements hve been shown to be stble. 26,27 The surgicl repositioning in this group ws similr to tht observed by Mrşn et l, 17 nd some of our findings correspond to their results: decrese of the mentolbil ngle, decrese of upper lip thickness, nd increse in lower lip thickness. In the present study, the decrese in the mentolbil ngle ws gretest in this group (18u), but the reltive relpse ws lso greter (33%) compred to the other two groups. The significnt ssocitions between the verticl soft nd hrd tissue chnges were similr to the findings of Mrşn et l. 17 Two other bimxillry studies without mxillry impction reported significnt ssocitions nd high rtios for the verticl chnges. 10,12 In these studies, however, the mndibulr setbck ws smller thn in our group, with no chnge in the fce height, nd the observtion period ws only 6 months. Increse in lower fce height. In the Increse group, both jws rotted in clockwise direction during surgery to correct severe skeletl discrepncies in conjunction with pronounced projection of the chin. To our knowledge there is no other study investigting soft tissue chnges fter this type of repositioning becuse of restricted smple sizes (s in the present mteril). A risk of compromised stbility ws previously reported by Proffit et l, 26 which my explin why lrge smples re difficult to collect. Compred to the No Chnge group, the mgnitude of mndibulr relpse reltive to the surgicl repositioning ws only slightly higher in this group (30% vs 26% t Pg). Anterior relpse of the mndible ws lso relted to counterclockwise rottion of both jws. The wek ssocition between AP soft nd hrd tissue chnges for the upper lip in this group my be relted to the presurgicl presence of lip block in mny of the ptients. 16 The observtion tht the Tble 3. Person Correltion Coefficients nd Rtios for Soft to Hrd Tissue Chnges Soft Tissue Lndmrk Horizontl Hrd Tissue Lndmrk No Chnge Group (n 5 30) Decrese Group (n 5 40) Increse Group (n 5 11) Correltion Rtio (%) Correltion Rtio (%) Correltion Rtio (%) A9 A 0.57** ** Ls U1 0.49** ** Li L1 0.74** ** ** 74 B9 B 0.82** ** ** 70 Pg9 Pg 0.84* ** ** 64 Verticl Ls U ** Stm s U ** Li L ** * 73 Me9 Me ** Rtios re clculted from net soft tissue chnge (T1 to T6) reltive to hrd tissue surgicl chnge (T1 to T2) (5% trimmed men). * P,.05; ** P,.01.

6 538 JAKOBSONE, STENVIK, ESPELAND nsiolbil ngle incresed significntly nd upper lip prominence ws t the presurgicl level in the long term hs implictions for plnning of surgery. Thus, for ptients with retrusive upper lip, the long-term profile my benefit from reltively greter mxillry dvncement thn mndibulr setbck, prticulrly in ptients in whom the AFH is incresed. CONCLUSIONS N Ptients undergoing Clss III bimxillry surgery re morphologiclly heterogeneous nd hence require different directions nd mounts of surgicl repositioning. N The nsiolbil ngle incresed, prticulrly when fce height ws incresed, nd the mentolbil ngle decresed, especilly when fce height ws decresed. N The upper lip thickness decresed nd the lower lip thickness incresed, irrespective of chnge in fce height. N When fce height ws incresed, AP chnge of mxillry soft tissues ws only minor nd upper lip prominence returned to the presurgery level fter 3 yers. The mndibulr soft tissues followed the skeletl relpse closely. N Correltion coefficients for soft to hrd tissue AP chnges were sttisticlly significnt, except for mxillry vribles when the fce height ws incresed. N Different ptterns of soft tissue chnge depending on verticl surgicl chnge nd relpse tendencies should be tken into considertion when plnning the reltive mounts of mxillry dvncement nd mndibulr setbck. REFERENCES 1. Mobrk KA, Krogstd O, Espelnd L, Lyberg T. Fctors influencing the predictbility of soft tissue profile chnges following mndibulr setbck surgery. Angle Orthod. 2001; 71: Iizuk T, Eggensperger N, Wilke S, Seto I, Thüer U. An lterntive soft tissue nlysis following mndibulr setbck by sgittl split rmus osteotomy. Orl Surg Orl Med Orl Pthol Orl Rdiol Endod. 2005;100: Stell JP, Streter MR, Epker BN, Sinn DP. Predictbility of upper lip soft tissue chnges with mxillry dvncement. J Orl Mxillofc Surg. 1989;47: Jensen AC, Sinclir PM, Wolford LM. Soft tissue chnges ssocited with double jw surgery. Am J Orthod Dentofcil Orthop. 1992;101: Hu J, Wng D, Luo S, Chen Y. Differences in soft tissue profile chnges following mndibulr setbck in Chinese men nd women. J Orl Mxillofc Surg. 1999;57: Soncul M, Bmber MA. Evlution of soft tissue chnges with opticl surfce scn fter surgicl correction of Clss III deformities. J Orl Mxillofc Surg. 2004;62: Hck GA, de Mol vn Otterloo JJ, Nnd R. Long-term stbility nd prediction of soft tissue chnges fter LeFort I surgery. Am J Orthod Dentofcil Orthop. 1993;104: Biley LJ, Dover AJ, Proffit WR. Long-term soft tissue chnges fter orthodontic nd surgicl corrections of skeletl Clss III mlocclusions. Angle Orthod. 2007;77: Biley LJ, Duong HL, Proffit WR. Surgicl Clss III tretment: long-term stbility nd ptient perceptions of tretment outcome. Int J Adult Orthod Orthognth Surg. 1998;13: Lin SS, Kerr WJS. Soft nd hrd tissue chnges in Clss III ptients treted by bimxillry surgery. Eur J Orthod. 1998; 20: Encr A, Tner T, Toroglu S. Anlysis of soft tissue profile chnges ssocited with mndibulr setbck nd doublejw surgeries. Int J Adult Orthod Orthognth Surg. 1999;14: Chew MT. Soft nd hrd tissue chnges fter bimxillry surgery in Chinese Clss III ptients. Angle Orthod. 2005; 75: Altug-Atc AT, Boltoglu H, Memikoglu UT. Fcil soft tissue profile following bimxillry orthognthic surgery. Angle Orthod. 2008;78: Chew MT, Sndhm A, Wong HB. Evlution of the linerity of soft- to hrd-tissue movement fter orthognthic surgery. Am J Orthod Dentofcil Orthop. 2008;134: McCollum AGH, Dncster JT, Evns WG, Becker PJ. Sgittl soft-tissue chnges relted to the surgicl corrections of mxillry-deficient Clss III mlocclusions. Semin Orthod. 2009;15: Jkobsone G, Stenvik A, Espelnd L. Importnce of the verticl incisor reltionship in the prediction of the soft tissue profile fter Clss III bimxillry surgery. Angle Orthod. 2012;82: Mrşn G, Cur N, Emekli U. Soft nd hrd tissue chnges fter bimxillry surgery in Turkish femle Clss III ptients. J Crniomxillofc Surg. 2009;37: Jkobsone G, Stenvik A, Sndvik L, Espelnd L. Three-yer follow-up of bimxillry surgery to correct skeletl Clss III mlocclusion: stbility nd risk fctors for relpse. Am J Orthod Dentofcil Orthop. 2011;139: Proffit WR, Phillips C. Adpttions in lip posture nd pressure following orthognthic surgery. Am J Orthod Dentofcil Orthop. 1988;93: Achilleos S, Krogstd O, Lyberg T. Surgicl mndibulr setbck nd chnges in uvuloglossophryngel morphology nd hed posture: short- nd long-term cephlometric study in mles. Eur J Orthod. 2000;22: Muto T, Ymzki A, Tked S, Sto Y. Effect of bilterl sgittl split rmus osteotomy setbck on the soft plte nd phryngel irwy spce. Int J Orl Mxillofc Surg. 2008; 37: Hellsing E, L Estrnge P. Chnges in lip pressure following extension nd flexion of the hed nd t chnged mode of brething. Am J Orthod Dentofcil Orthop. 1987;91: Akgül AA, Toygr TU. Nturl crniofcil chnges in the third decde of life: longitudinl study. 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7 SOFT TISSUE RESPONSE AFTER CLASS III SURGERY Proffit WR, Phillips C, Turvey TA. Stbility fter surgiclorthodontic corrective of skeletl Clss III mlocclusion. III. Combined mxillry nd mndibulr procedures. Int J Adult Orthod Orthognth Surg. 1991;6: Cost F, Robiony M, Sembronio S, Polini F, Politi M. Stbility of skeletl Clss III mlocclusion fter combined mxillry nd mndibulr procedures. Int J Adult Orthod Orthognth Surg. 2001;16:

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