J. Maxillofac. Oral Surg.
https://doi.org/10.1007/s12663-019-01298-7
ORIGINAL ARTICLE
Quantitative Prediction of Change in Chin Position in Le Fort I
Impaction
Jayalakshmi Jayakumar1 • N. Jayakumar1 • Bobby John1 • P. G. Antony1
Received: 27 July 2019 / Accepted: 10 October 2019
 The Association of Oral and Maxillofacial Surgeons of India 2019
Abstract
Background Vertical maxillary excess, a dentofacial defor-
mity present in a large proportion of population impute an
increased lower facial height due to increased maxillary height.
This results in a clockwise rotation in the mandible, and the chin
advances posteriorly and inferiorly. Le Fort I superior reposi-
tioning of the maxilla begets movement of pogonion point
anteriorly and cranially. Cephalometric analysis helps to access
change in position of chin following Le Fort I impaction. In our
study, from this analysis a formula was defined to perceive the
exact amount of this change in chin position along the vertical
and sagittal plane as a result of autorotation.
Materials and Methods This experimental study assessed 45
patients with vertical maxillary excess over a period of 2 years
and 6 months (January 2016–May 2018) in Government
Medical College Hospital, Kottayam, Kerala, India. The plan-
ned procedure was Le Fort I superior impaction for correction
of vertical maxillary excess. Pre-operative cephalograph was
taken initially. Post-operative cephalograph after 3 months was
then compared with initial pre-operative cephalograph to assess
the change in position of the pogonion and menton.
Results Forty-five participants were studied. The multiple
regression model was applied to predict the changes in the chin
& Jayalakshmi Jayakumar
jjsmilesalot@gmail.com
N. Jayakumar
drjkndct@gmail.com
Bobby John
johnbobbyj@gmail.com
P. G. Antony
drpgantony@yahoo.com
1
Department of Oral and Maxillofacial Surgery, Government
Dental College Kottayam, Kerala 686008, India
(dependent factor) according to the vertical change in the
maxilla (predictive factor). For every 1 mm change in the
maxilla vertically, the chin was estimated to move 0.59 verti-
cally. For a standard deviation increase of 1 in the position of
the maxilla, the chin moved superiorly by 0.744 of the standard
deviation. For every 1 mm of vertical change in the maxilla, the
chin could be expected to move 0.22 mm horizontally. For a
standard deviation increase of 1 in the maxillary position, the
chin advanced by 0.273 of the standard deviation.
Conclusion This study draws to a conclusive finding that
the movement of maxilla in the superior direction has an
effect on the repositioning of the chin in the anterior and
cranial directions. This has led to a formulation that 1 mm
of superior impaction of maxilla results in 0.6 mm of
vertical and 0.2 mm of sagittal movement of chin. This
might help to have a glance of future chin position and aid
in deciding the need for mandibular surgery.
Keywords Autorotation  Le Fort I impaction  Chin 
Maxillary osteotomy
Introduction
A smile is the prettiest thing you ever wear. But some
individuals hide it because they have a ‘‘gummy smile’’.
Vertical maxillary excess is prevalent in approximately
22.2% of population [1]. The correction of vertical max-
illary excess usually includes maxillary Le Fort I superior
impaction. After maxillary superior impaction, one of the
effects on mandible is the anterosuperior displacement of
bony chin position. The mandible rotates from the patient’s
original occlusion to a more superior position.
The chin is defined by a graceful transition of the mandibular
angles towards the midline [2]. Hence, it is of prime importance
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to predict the amount of autorotation in maxillary superior

impaction and pogonion displacement in vertical and sagittal
planes as it causes significant changes in the lower third of the
face. In the surgical orthodontic treatment of dentofacial
deformities, cephalometric prediction tracings are important to
assess the bony and soft tissue changes. Cephalometric analysis
enables one to make a quantitative assessment of the location
and magnitude of the dentofacial deformity (Fig. 1).
In our study, we evaluate the extent of change in chin
position in sagittal and vertical planes following Le Fort I
superior impaction using cephalometric analysis.

Materials and Methodology

This clinical study was conducted in the Department of
Oral and Maxillofacial Surgery, Government Medical
College, Kottayam. Forty-five patients with vertical max-
illary excess were selected. The planned procedure was Le
Fort I impaction for correction of vertical maxillary excess.
Out of 45 patients operated, 26 were females and rest were
males, and their age ranged from 19 to 28 years.
Pre-operative cephalograph was taken initially. Post-op-
erative cephalograph after 3 months was then taken to assess
the change in position of the pogonion and menton. All
patients underwent post-operative orthodontic treatment.
Duration of Study
The study was conducted over a period of 2 years and
6 months (January 2016–May 2018)
Fig. 1 In VME patients, the increased maxillary height causes a
clockwise rotation in the mandible and the chin moves posteriorly and
inferiorly. After the Le Fort I superior impaction surgery, the
pogonion will rotate anteriorly and superiorly [3]
repositioning. Hard tissue cephalometric analysis under-
taken was based on COGS analysis.
Tracing Technique
All the cephalograms were traced by a single operator.
Cephalometric landmarks were located, identified, and
marked. Pre-operative and post-operative cephalometric
analyses were used to determine the amount of the max-
illary superior repositioning.

Inclusion Criteria

All patients who attained completion of skeletal maturity

having vertical maxillary excess planned for superior
impaction by Le Fort I osteotomy.

Exclusion Criteria

• Patients with syndrome/cleft palate

• Patients who underwent mandibular advancement/set-
back procedures.
• Medically compromised patients.
• Patients with history of trauma.
• Use of distraction techniques in mandible

Cephalometric Analysis

Lateral cephalograms taken were used to assess the change

in chin position and the amount of maxillary superior

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J. Maxillofac. Oral Surg.
The distance from nasion to menton was taken to assess
the vertical change in chin position, and the distance from
true horizontal plane to pogonion was used to assess the
sagittal change in chin position.
• SN_7 plane A 7 degree line is drawn from line
connecting sella (S) to nasion (N) which is the true
horizontal plane (SN_7). All the vertical measurements
are taken perpendicular to this plane, and all the
horizontal measurements are measured parallel to this
plane.
• U6V and U1V plane The analysis measured the linear
distances (in millimetres) from the maxillary landmarks
at upper molar (U6) and upper central incisor (U1) to
vertical reference lines that dropped perpendicular to
the true horizontal plane passing through sella point.
The difference in the vertical distance provides the
amount of superior impaction of maxilla post-
operatively.
• N-Me line The distance from the nasion to menton
point was applied to assess the vertical changes of the
chin before and after the operation.
• N-Pog Line The most prominent point of the chin,
pogonion, was used to determine the sagittal changes of
the chin before and after surgery. The measurement was
made parallel to the true horizontal plane from a
perpendicular dropped through N of the true horizontal
plane.
• SNA Plane The changes in A point in the anterior–
posterior direction were measured parallel to the true
horizontal plane from a perpendicular that dropped
through N of the SN _7.
• PNSN line A perpendicular dropped from the true
horizontal plane to the posterior nasal spine (PNS)
provides the posterior maxillary height.
Assessment of the Patients
Assessment of the patients was done daily following sur-
gery for 5 days and after that every week till 1 month.
Then, a monthly review for 3 months followed by a half
yearly assessment of the patient was performed.
Post-operative Lateral Cephalogram
Lateral cephalogram was taken at three months following
surgery to assess the change in chin position vertically and
sagittally.
Vertical change in chin position was obtained from the
distance from the nasion to menton, and the horizontal
change in position of chin was assessed from the distance
from the perpendicular line that dropped from the true
horizontal plane (SN_7) to the most prominent point on
chin, pogonion.
Results
The assessment of the data using a multiple regression
model demonstrated that approximately 89.1% of the ver-
tical change in the chin could be predicted by knowing the
amount of the maxillary superior repositioning
(R2 = 0.891). For every 1-mm change in the maxilla ver-
tically, the chin was estimated to move 0.59 vertically. For
a standard deviation increase of 1 in the position of the
maxilla, the chin moved superiorly by 0.744 of the standard
deviation (b = 0.744).
The multiple regression model showed that approxi-
mately 59.8% of the horizontal change in the chin could be
accounted for by the amount of maxillary superior repo-
sitioning (R2 = 0. 598). For every 1 mm of vertical change
in the maxilla, the chin could be expected to move
0.22 mm horizontally. For a standard deviation increase of
1 in the maxillary position, the chin advanced by 0.273 of
the standard deviation (b = 0.273).
The equation thus obtained for prediction of the change
in chin position vertically following Le Fort I superior
impaction is
YMe ¼ 0:233 þ 0:594V1 þ 0:152V2
YMe is the difference of vertical change in chin N-Me
after 3 months (NMe pre–NMe 3 Mon), V1 is difference of
vertical distance at U6 from SN (i.e. amount of superior
impaction to be obtained), V2 is difference of vertical
distance at U1 from SN (i.e. amount of superior impaction
to be obtained).
The equation thus obtained for prediction of the change
in chin position horizontally following Le Fort I superior
impaction is
YPog ¼ 0:568 þ 0:218V1  0:525V2
YPog is the difference of horizontal distance in chin
N-MePog after 3 months (N-Pog pre–N-Pog3 Mon), V1 is
difference of vertical distance at U6 from SN (i.e. amount
of superior impaction to be obtained), V2 is difference of
vertical distance at U1 from SN (i.e. amount of superior
impaction to be obtained).
Discussion
This study pointed out the high predictability of the chin
position based on the amount of maxillary superior
repositioning.
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Sagittal Changes After Autorotation
Wang et al. [4] concluded in their study that the horizontal
movement of the Pog point demonstrated high correlation
with the vertical movement of the ANS point and the upper
first molar, but not affected by the vertical movement of the
PNS point. The horizontal movement of the Pog point was
almost in 1:1 ratio to the vertical movement of the ANS
point and the U6 point suggesting that the ratio could be
used to predict horizontal chin position.
In our study, we obtained a 5:1 ratio of the horizontal
movement of Pog point to the vertical movement of U6 point.
This difference in ratio may be due to the change in
centre of condylar rotation after surgery and prior to sur-
gery. Mandibular movement may be a simple rotation or
translation or a combination of these; this might be the
other reason for the difference observed. This could be also
due to difference in techniques used for mandibular splint
fabrication.
The above study also states that there is a large indi-
vidual variation in finding the centre of rotation. It could
overestimate the horizontal position of chin by 2 mm in
5 mm of surgical maxillary impaction [4]. A further study
to determine the condylar centre along with the dimen-
sional change of chin position would give more light to this
discrepancy.
Vertical Changes After Autorotation
The vertical dimensions of the lower-face change via max-
illary impaction followed by mandibular autorotation. There
are many reports in the literature on the extent of reduction in
lower facial height in relation to maxillary impaction.
Schendel et al. [5], Bell et al. and Fish et al. who dealt
with the question of impaction of the maxilla and autoro-
tation of the mandible at an early stage recommended a
simulation of the outcome using templates on the lateral
cephalogram.
Lee et al. [6] observed that the soft tissue structures
followed the skeletal structures to almost the same extent
after maxillary impaction [3, 7].
Bell et al., Fish et al. and Epker and Fish [5, 8, 9]
described a 1:1 ratio between lower-face shortening (cra-
nial movement of the chin prominence) after maxillary
impaction and mandibular autorotation.
In our study, the vertical distance was measured from
nasion to menton, and we got a ratio of 1:0.8 which is
approximately 1:1.
Pitfall in the Study
A study by Arabion [3] concluded when maxillary
impaction was more than 8 mm, the regression model did
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J. Maxillofac. Oral Surg.
not follow a linear correlation between the amount of
maxillary superior repositioning and horizontal change in
the pogonion. All the 45 cases of maxillary impaction
performed were less than 8 mm; hence, our study could not
confirm this finding.
The formula derived for prediction of vertical in chin is
for cases with superior impaction less than 8 mm.
Wang et al. [4] in their study concluded that when the
condyle acted a centre of rotation, the erroneous determi-
nation of the true rotatory axis of the mandible encom-
passed the overestimated horizontal position of the Pog
point by 1.7 mm and underestimated vertical position of
the Me point by 1.3 mm in the results. This might offer
surgeons or orthodontists the wrong information in decid-
ing the surgical plan and facial profile. In our study, centre
of rotation and its correlation with the mandibular shift was
not assessed.
Conclusion
From this study, we conclude that there is a change in chin
position following Le Fort I impaction that could be pre-
dicted using a formula. Applying thus obtained formula, we
found that with a 1-mm superior impaction of maxilla ver-
tically, the position of chin moves 0.6 mm vertically and
0.2 mm horizontally. This derived formula has to be applied
in a larger population to determine the accuracy of the model.
Funding None.
Compliance with Ethical Standards
Conflict of interest None.
Ethical approval The institutional ethical committee approved this
experimental study.
References
1. Ming TC (2006) Spectrum and management of dentofacial
deformities in a multiethnic Asian population. Angle Orthod
76(5):806–809
2. Naini FB, Gill DS (2008) Facial aesthetics: 1. Concepts and
canons. Dent Update 35(2):102–104
3. Arabion H, Tabrizi R, Fattahi H, Khaghaninezhad M, Bahramnia F
(2015) Spatial changes of the chin in the vertical and sagittal
planes after superior repositioning of the Maxilla. J Craniofac Surg
26(3):e249–e253
4. Wang Y, Ko EW, Huang C, Chen Y (2006) The inter-relationship
between mandibular autorotation and maxillary LeFort I impaction
osteotomies. J Craniofac Surg 17(5):898–904
5. Schendel SA, Eisenfeld JH, Bell WH, Epker BN (1976) Superior
repositioning of the maxilla: stability and soft tissue osseous
relations. Am J Orthod 70(6):663–674
J. Maxillofac. Oral Surg.

6. Lee D, Bailey L, Proffit WR (1996) Soft tissue changes after 9. Stoker NG, Epker BN, Peter J, Hospital S, Worth F et al (1974)
superior re- positioning of the maxilla with Le Fort I osteotomy: The posterior maxillary ostectomy: a retrospective study of
5-year follow up. Int J Adult Orthod Orthognath Surg 11:301–311 treatment results. Int J Oral Surg 3:153–157
7. Steinhäuser S, Richter U, Richter F, Bill J, Rudzki-janson I (2008)
Profile changes following maxillary impaction and autorotation of
Publisher’s Note Springer Nature remains neutral with regard to
the mandible. J Orofacial Orthoped 69(1):31–41
jurisdictional claims in published maps and institutional affiliations.
8. Fish LC, Epker BN (1980) Surgical-orthodontic cephalometric
prediction tracing. J Clin Orthod 8:119–125

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