University of Duhok

College of dentistry

Soft tissue changes in orthodontic

surgery

Prepared by: Tara Maher Abdüllatif

Supervised by: dr. Sargon Eshon Daweed
2023-2024
contents

1. Introduction

2. Orthodontic considerations

o Movements of dentition

o Maxillary Movements

3. Mandibular Movements

4. Surgical Techniques
1.Introduction

Necessary to include a component of soft tissue changes in the surgical treatment plan while working to
achieve a stable, functional dentoskeletal unit.the surgical procedures -- to control the soft tissue changes
will be presented and evaluated.help the surgeon understand, control, and maximize the beneficial
aspects of the facial soft tissue response to surgery(J Jung, CH Lee et al,2018).

Historically
o Orthognatic surgery -- used to correct skeletofacial deformities and the resultant functional problems,
often at the expense of the facial soft tissue esthetics
o Early studies produced average ratios - which related hard / soft tissue landmarks
o Individual variability noted to be significant
o Facial soft tissue response to orthodontics and Sx was
MultiFactorial
o Prediction equations developed to help preop evaluation for surgical planning and post-op
assessment

Recent development of surgical procedures to control soft tissue response to Sx: alar cinch suture and
VY closure(J Jung, CH Lee et al,2018).
 2.Orthodontic Considerations

Tooth position and alveolar morphology result from the sum of applied forces during their
development,Skeletal imbalances are accompanied by soft tissue mblanaces - result = dental-
compensation for skeletalmalocclusions. Corrections initially result in worsening of the malocclusion
preoperatively + jaw-jaw discrepency to appear more severe,Pre-op records to be taken as close to Sx to
determine soft-tissue outcome(K Wermker et al,2014).

Cephalometric Considerations

o Must allow for visualization of the complete soft tissue profile

o
o Instruct pt to keep lips in repose for cephs
o
o Superimpose landmarks that remain unchanged
o
Presence of ortho hardware changes the lip profile(K Wermker et al,2014)

Figure(1) cephalometric land makes

Soft Tissue Considerations

To predict soft/hard tissue changes is critical to Tx planning for orthognathic Sx.Changes depending on:

o surgical procedure
o method of wound closure
o the new spatial arrangement of the skeletal/ dental elements
o adaptive qualities of soft tissues
o Growth
o orthodontic vectors o tooth movement
o lip thickness. tonus, area, contact (competence), strength
o interlabial gap
o amount of overjet
o amount offatty tissue
o Musculature
o postoperative edema.

Stabilize in approx 6 months - some studies suggest 12 months

Surgical Approach include Incision type may play a role - horizontal incision for the Le Fort I osteotomy
may cause shortening of the lip With loss of vermillion and Decrease in lip thickness
Vertical approach with tunneling and palatal flap shows minimal post-op lip changes ,Betts et. Al.
investigated soft tissue response to Max Sx - found soft tissue changes may be more related to type/position
of incision and method of closure than surgically induced hard tissue change,
Will mirror changes in the bony foundation should relapse occur.Thin lips move more predictably than thick
lips,"dead space" under the lip may absorb the first portion of a bony advancement before soft tissue
affected.Horizontal Changes - in soft tissue more predictable than vertical changes
Related to the stability of the hard tissue movements (less stable in vertical dimension( K Wermker et
al,2014).
Figure(2) soft tissue association with orthodontic tooth movement

2. Movement of dentition

1.maxillary movements

Maxillary surgical procedures

Most are soft tissue changes manifested in:

o Nasal
o Labial
Maxillary surgical procedures - Nasal
Affects lower aspect of the nasal dorsum , Widening of the alar base regardless of vector of movement,
shortening of the columellar / alar height, shortening of the nasal tip projection.Nasolabial angle
decreases or remains constant(K Wermker et al,2014).

1.Superior movement
o Elevation of the nasal tip
o Widening of the alar base
o Decreased nasolabial angle
o

2.Inferior repositioning
o Loss of nasal tip support
o Downward movement of columella and alar bases
o Thinning of the lip
o Increase in NL angle

2. Anterior
o Advancement in :
o upper lip
o Subnasale
o Pronasale
Thinning of the lip,Widening of the Alar base,Increase in Supratip break if ANS in tact
Nasal tip advances approx ½ the distance of the subnasale ,Counter clockwise rotation - raises the nasal
tip,and Clockwise rotation - decreases superior movement of the nasal(K Wermker et al,2014).
Figure (3) nasal effect on maxillary sinus

Maxillary procidure -labial

Upper lip is attached to the nose - prevents 1:1 soft tissue change, Widens and lengthens at the philtral
columns after Max Sx.
w/o VY closure - can cause shortening of the upper lip with loss of exposed vermillion. The general trends
of postsurgical changes in the nasal and labial soft tissues expressed in a nonvector format (the arrows are
not specific for length, but are specific for directions. ,generally The alar base of the nose widened and the
nasal tip decreased in height in relation to the adjacent soft tissues. The philtral columns of the lip widened
and became longer,and the nasolabial angle decreased,Adapted from Betts NJ. Changes in the nasal and
labial soft tissues after surgical repositioning of the maxilla(OE Kolokitha Et al,2012).
Maxillary Advancement
Greatest effect on the nose/ upper lip ,Ppts adv of upperlip, subnasale and nose,Shortening of upper lip
Thinning of upper lip (approx. 2 mm),Widening of Alar base,Deepening of supratip depression if ANS left
intact,Progressive increase in horizontal soft tissue displacement seen from tip of nose to free end of upper
and Decrease in NL angle.
the ratio of horizontal change of upper incision to vermillion border of the upper lip with use of the alar
cinch suture and the VY closure.The ratio reduces with larger advancements due to soft tissue stretching:
0.6:1 vs. 0.9:1 (OE Kolokitha Et al,2012).

Maxillary Impaction - superior

Elevation of nasal tip,Widening of alar base (2-4 mm),Decrease in NL angle,Nasal changes occur w/ o
changes in angulation of upper lip,Lip follows superiorly approx 40% of the vertical maxillary plane
Lip shortening accentuated with combined anterior/ superior max movements,It no VY - amnt of vertical
soft tissue change increases progressively from nasal lip to stomion with loss of vermillion(OE Kolokitha Et
al,2012).

Maxillary inferior repositioning

o Loss of nasal tip support
o Downward repositioning of the columella and alar bases
o Thinning of the lip
Increase NL angle(OE Kolokitha Et al,2012).

Maxillary posterior repositioning

 Loss of nasal tip support due to movement of ANS
 movement of bony area around piriform aperture
 Lip rotation
 Posterior and superiorly about SubNasale
Increased L angle(OE Kolokitha Et al,2012).

2Mandibular movment

Mandible surgical procedure

Generally soft tissues follow hard tissues closely،Exception is lower lip

Types of movements
o Anterior
o Posterior
o Anterior segmental
o Autorotation
o Genial Segmental procedures(OE Kolokitha Et al,2012).

Mandibular surgical procedures -anterior

Mandibular Advancement

Limited to the structures below the superior labial sulcus,Little change in the upper lip and none above
the ANS,Lower lip advancement is variable and lip often lengthens,Lower labial sulcus and chin adhere
to the bony structure and follow underlying osseous structures,Leads to opening of labio-mental fold.
Facial Height:In high angle II cases - results in large increase in FH,Lower lip positio:,Affected by
upper, lower incision and its contact with the upper lip,In class II - lower lip may touch the upper lip/
incisor and fold forward - correction of this is necessary to approximate true post-op position(
OE Kolokitha Et al,2012).
Figure(4) : mandible advancement

Mandibular surgical procedures -Posterior

•Mandibular Setback
-No net eftects on subnasale or tissues superior to it
-Soft tissues follow mandible posteiorly(Chin most closely) (DS Gill Et al,2017).

•Lower lip
-Shortens
-More protrusive and curls out
-labiodental fold deepens + becomes more acute(DS Gill Et al,2017).

Mandibular Surgical Procedures - autorotation

Soft tissues follow the osseous landmarks approx 1:1,Except lower lip - falls slightly lingual to the arc of
rotation(DS Gill Et al,2017).

Mandible surgical procedure -genioplasty

Anterior
 Osseous resorption at pogonion and deposition at menton. Adapted from Polido WD, Bell WH. Long-
term osseous and soft tissue changes after large chin advancements(DS Gill Et al,2017).

Figure (5) genioplasty change of mandible

Mandibular Surgical procedures -Vertical Augmentation/reduction Genio

Soft tissues follow hard tissues very closely in augmentation
genio compared to reduction(DS Gill Et al,2017).

3. Surgical techniques
Controling soft tissue

o Poor Surgical Results

o Surgical Techniques
o VY closure
o Cinch Suturing(Dual alar cinch suture)
o Contouring ANS
o Double VY closure
o Bilateral alar base wedge resection
o Septoplasty
o Advancement genioplasty / liposuction - excess submental adipose tissue and/ or short cervicomental
distance(S Rupperti et al,2019).
o

VY closure
Figure (6) VY closure
o A, The V-Y closure is accomplished during closure of the maxillary vestibular incision. The
midportion of the incision is identified and retracted anteriorly with a single skin hook. One cen-
timeter of the incision is closed in an anteroposterior direction. B, Using a separate suture mucosa,
periosteum and interposed muscular tissue are engaged by the needle on either side of the incision
and sutured in a continuous fashion. The superior aspect of the incision is gradually advanced toward
the midline by taking smaller bites of tissue in the upper margin of the incision and larger bites in the
lower margin. Both sides of the incision are closed in similar fashion to the midline suture(S
Rupperti et al,2019).

Cinch sutures
Figure (7) cinch suture

A, Alar base cinch suture. The upper lip is grasped between the forefinger and thumb, with the forefinger
placed directly on the junction ofthe ala with the face. B, The lip is inverted and the rissue lying over the
forefinger is grasped with a forceps. The lip is released and the tissue grasped in the forceps is manipulated
to ensure that the alar base moves properly. If appropriate movement is not observed, the process must be
repented until correct needle placement is ensured. C-E, A nouresorbable suture (ie, 2-0 Prolerse) is passed
from the fibroadipose tissue (or transverse nasalis musde) on one side of the alar base to the other and is ried
to a predetermined width. F-H, The figure-eight alar cinch suture technique. Following the initial steps
described above, the suture is passed in a lateral to medial direction through the fibroadipose tis-
sue on one side, and in the identical fashion (lateral to medial direction) on the other side of the nose.
It is then tied in the midline to a predetermined width) (S Rupperti et al,2019).
Dual alar cinch suture

Figure (8) dual alar cinch suture

1-K, The dual-suture alar cinch technique. Before identifying the appropriate tissues described above, a hole
is drilled in the S. Individual sutures are placed through the fibroadipose rissues, then through the hole
below ANS and tied to a predetermined width for each nostril.
todification of this technique. Instead of the sutures being placed through the ANS, the individual sutures
are passed through the anterior candal sep(S Rupperti et al,2019).
CONTOURING ANS

Figure (9)contouring ANS

Reduction of the anterior nasal spine during a maxillary osteotomy. This procedure is
indicated in patients undergoing large advancements or impactions of the maxilla who
already have good nasal tip projection. This procedure is contraindicated in patients who
have poor preoperative nasal tip projection or are having a maxillary setback procedure
(LJLO et al,2018).
Double VY

Figure (10) double VY

A, Double V-Y advancement closure showing initial retraction and closure of anterior components of
vestibular incision. B, Clo- sure completed(LJLO et al,2018).

Bilateral Alar Base wedge resection

Figure (11)bilatteral alar base wedge resection

Bilateral alar base wedge resec- tions. A, Resected area of the alar base. B, The nostril area following
suturing demonstrating narrowing of the width of the nostrils and nasal base(LJLO et al,2018).

Septoplasty
o Cartilagenous septum - should be reduced during maxillary impactions of > 3 mm to prevent post-op
deviation
Avoid over reduction - as it can cause saddle nose deformity or poly-beak deformity(LJLO et al,2018).

Figure(12) septoplasty

A, Septal reduction during maxillary impaction osteotomy. The cartilaginous nasal septum should be
reduced during maxillary impactions of greater than 3 mm to prevent postoperative deviation or buckling of
the septum. This is done by incising the nasal mucosa and reflecting the septal perichondrium and removing
the appropriate amount of cartilage with a scissor or scalpel blade. The same amount of septum should be
removed as the maxilla is impacted. This technique can be combined with reduction of the maxillary nasal
crest(LJLO et al,2018).
Reference

1. J Jung, CH Lee, JW Lee, BJ Choi - Head & face medicine, 2018 – Springer
2. K Wermker, J Kleinheinz, S Jung, D Dirksen - … Cranio-Maxillofacial Surgery, 2014 – Elsevier
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4. DS Gill, T Lloyd, C East, FB Naini - Facial Plastic Surgery, 2017 - thieme-connect.com
5. S Rupperti, P Winterhalder, I Rudzki, G Mast… - Clinical oral …, 2019 – Springer
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