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ORIGINAL ARTICLE

Predicting lower lip and chin response to mandibular advancement and genioplasty
Trevor Veltkamp, DDS, MS,a Peter H. Buschang, MA, PhD,b Jeryl D. English, DDS, MS,c James Bates, DDS, MD,d and Sterling R. Schow, DMDe Dallas, Tex The purposes of this retrospective study were to examine the multidimensional nature of soft tissue changes associated with mandibular advancement and genioplasty and to develop predictive models. Longitudinal lateral cephalograms of 62 nongrowing patients (27 men and 35 women) were taken in centric relation with the lips in repose within 4 weeks before surgery and at least 6 months postoperatively (median postsurgical duration was 11 months). The mandibular incisor and pogonion were advanced surgically approximately 6 mm and 11 mm, respectively. The lower lip lengthened slightly (2.5 3.8 mm), and its surface contour straightened because of thinning at labrale inferior ( 2.8 2.0 mm); there was a slight thickening at the labiomental fold (1.0 2.3 mm) and a slight thinning at soft tissue pogonion ( 0.8 2.2 mm). Multiple regression models (explaining from 80% to 94% and 66% to 82% of the variation for horizontal and vertical movements, respectively) showed that soft tissue response to advancement surgery depended on pretreatment tissue thickness, horizontal skeletal movement, vertical skeletal movement, and the position of the maxillary incisors. Similar amounts of variation were explained when the models were applied to an independent validation sample of 15 subjects. It was concluded that lower lip and chin response to mandibular advancement and genioplasty is multifactorial but can be accurately and reliably predicted. (Am J Orthod Dentofacial Orthop 2002;122:627-34)

rthognathic surgery as an adjunctive aid for orthodontic correction has become a common treatment procedure.1 Although the dental and skeletal relationships are the strongest indicators of a perceived need for surgery,2 the soft tissue prole has emerged as perhaps the most important consideration for planning surgery and assessing treatment outcomes.3 Facial appearance plays a signicant role in a persons psychological well-being and social acceptance, perhaps because the face is the most important part of the body in regulating social interaction.4-6 It has been shown that the public places more emphasis on the lips than on other facial structure when evaluating facial esthetics.2 This might explain why the patients overall satisfaction when undergoing maxillofacial surgery is primarily driven by the nal position of the soft tissues.7 On that basis, the effects of orthognathic surgery on the soft tissue prole, especially the lips, must be understood and predictable.
From the Department of Orthodontics, Baylor College of Dentistry, The Texas A & M University System, Dallas. Reprint requests to: Dr Peter H. Buschang, Department of Orthodontics, Baylor College of Dentistry, The Texas A & M University System, 3302 Gaston Ave, Dallas, TX 75246; e-mail, phbuschang@tambcd.edu. Submitted, January 2002; revised and accepted, April 2002. Copyright 2002 by the American Association of Orthodontists. 0889-5406/2002/$35.00 0 8/1/128864 doi:10.1067/mod.2002.128864

Presurgical predictions are important tools to demonstrate possible postsurgical results. They serve as an instrument for patient communication and provide a goal for operative treatment planning.8 Whatever the method for establishing these predictionsacetate layouts, landmark digitizations and line drawings, digital imaging, and soft tissue morphingthe accuracy of the prediction ultimately depends on the algorithms used to dene the response of the soft tissue to the bony change, not on the technology used to project the possible result. Although useful predictive algorithms exist for the upper lip, accurate predictions for the lower lip do not presently exist. Lines and Steinhauser,9 who were among the rst to attempt prediction in this area, concluded that the lower lip advanced at a 0.66:1 ratio to the mandibular incisor advancement, and soft tissue pogonion advanced at a simple 1:1 ratio to hard tissue pogonion advancement. Other studies have conrmed the 1:1 ratio for soft tissue pogonion,10-15 but predictive ratios for the lower lip have been highly variable, ranging from 0.26:1 to 0.85:1.1,8,9,16-22 The poor correlations associated with these ratios are striking, with most ranging from 0.38 to 0.72, indicating much unexplained variance. Few attempts have been made to incorporate these factors into the predictions, although various predictive
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elements have been suggested, including soft tissue thickness; patient age, gender, and weight; degree and direction of advancement; and the relationship of the maxillary incisor to the lower lip.19,22-25 The current literature makes clear that more than 2 factors must be considered simultaneously to make accurate soft tissue predictions.26-28 Engel et al,29 for example, argued that strong linear correlations of hard and soft tissue landmarks are highly unlikely because of the variability of soft tissue. Betts et al,27 Van Sickels et al,15 and Brooks28 compared multivariate analysis with bivariate analysis and demonstrated signicant improvements in predictability using the former. Because changes in the lower lip are of paramount importance to the patient undergoing surgery and current methods are limited in their ability to predict soft tissue changes,5,6 the specic goals of this study were to (1) examine the multidimensional nature of lower lip and chin soft tissue changes associated with mandibular advancement and genioplasty, (2) develop predictive mathematical models to improve the ability of orthodontists and oral surgeons to forecast soft tissue effects after treatment, and (3) verify the applicability of the mathematical models by cross-validating them against an independent sample.
MATERIAL AND METHODS

A total of 62 patients (27 men, 35 women; 95% white, 5% Hispanic) were selected from the ofces of 2 oral surgeons on the basis of the following criteria: 1. Mandibular advancement surgery with or without concomitant genioplasty. 2. Minimal growth potential (women over the age of 15 years, men over the age of 17 years). 3. Use of rigid internal xation. 4. No history of congenital defects or syndromes. 5. No prior surgery involving the maxilla or the mandible. 6. No use of alloplastic augmentation material for genioplasty. 7. Available lateral cephalogram radiographs taken at T1 (within 4 weeks before surgery) and T2 (a minimum 6 months after surgery) in a standardized fashion with the teeth in centric relation and the lips in repose (ie, no obvious strain). Radiographs were considered usable only after an assessment of image quality and clarity. All hard and soft tissue landmarks had to be readily identiable. The patients had to have been manipulated into centric relation with the lips demonstrating no obvious strain when the radiographs were produced. Two patients were rejected because of unclear landmarks, and 2 were

excluded because of obvious lip strain in preoperative radiographs. Preoperative radiographs were taken within 4 weeks of surgery to minimize any presurgical soft tissue changes that might have resulted from orthodontic treatment. Postsurgical records were taken at a median of 11 months (range, 6-32 months). The postsurgical delay of 6 months was necessary to minimize the effects of transient soft tissue edema.8,17,24,30,31 Postsurgical soft tissue changes related to orthodontic treatment could not be completely eliminated. All patients had presurgical orthodontic treatment and underwent a mandibular advancement via bilateral sagittal ramus osteotomy; 28 (45%) also had an advancement genioplasty. Twenty-nine (47%) patients also received an accompanying maxillary procedure. The double-jaw surgery group received a multi-segmented maxillary surgical procedure. Soft tissue manipulations involved application of an alar base cinch suture to ensure proper transverse alar base dimension. Each cephalogram was traced on 0.03-mm acetate. Fourteen landmarks were located on each tracing and digitized (Fig 1, Table I). In addition to 14 traditional measures, 8 measurements of tissue thickness and tissue length were constructed. Soft tissue changes that accompanied mandibular advancement and genioplasty procedures were evaluated in both the horizontal and vertical dimensions. As shown in Figure 1, the horizontal reference axis was dened by registering on sella (S) and orienting 7 inferior to the S-nasion (N) plane; the vertical axis was perpendicular to the horizontal axis, passing through S. All hard and soft tissue changes that occurred were evaluated relative to those 2 axes. Both intraoperator and interoperator technical reliabilities were established. Ten randomly selected radiographic tracings were duplicated by 2 operators who traced all cephalograms. No statistically signicant systematic errors were noted. The random method error, ( d2/2n), which ranged between 0.18 and 1.20 mm, was greatest for the horizontal aspect of menton (Me ) (Table I). SPSS 10.0 (Statistical Package for the Social Sciences, Chicago, Ill) was used for statistical evaluation of the data. The skewness and kurtosis statistics demonstrated normal distributions. A sample of 47 people was randomly selected from the larger group to develop regression models for the horizontal and vertical changes at stomion inferius (Stoi), labrale inferior (Li), supramentale (labiomental fold) (Bpt ), and pogonion (Pg ). Stepwise multiple regression analysis was used to identify the pretreatment lip dimensions and hard tissue treatment changes most closely associated with

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Fig 1. Cephalometric landmarks of hard and soft tissue points and associated reference planes as dened by Table I: 1, U1; 2, L1; 3, infra; 4, Bpt; 5, Pg; 6, Me; 7, Sto5; 8, Stoi; 9, LI; 10, Bpt ; 11, Pg ; 12, Me ; 13, S; 14, Na.

posttreatment soft tissue changes. Dummy variables were created to evaluate the effects of sex, genioplasties, and 1-jaw versus 2-jaw surgeries. The models were validated with the remaining 15 persons (24%). The correlation between the resulting predicted changes and the observed changes is the cross-validated multiple correlation.32
RESULTS

Paired t tests showed that advancement surgery resulted in the anterior repositioning of all hard tissue landmarks except the maxillary incisor (U1) (Table II). The amount of hard tissue advancement ranged from 0.6 to 13.7 mm and was statistically signicant for all landmarks except for the U1 in the single-jaw sample. Mean changes in the horizontal position at the mandibular incisor (L1) and pogonion (Pg) for the single-jaw sample were 5.1 and 9.1 mm, respectively. The doublejaw group demonstrated signicantly greater horizontal changes at all landmarks, with mean changes of 7.3 mm at L1 and 13.6 mm at Pg. Although the hard tissue vertical changes were more limited (0.2-2.7 mm), group differences existed because of the differing

directions of movement associated with the single-jaw and double-jaw procedures. In the single-jaw sample, hard tissue movement was directed inferiorly (1.1 mm at L1 and 1.2 mm at Pg). The double-jaw group demonstrated superior repositioning (L1 moved 2.1 mm and Pg moved 1.2 mm). The accompanying soft tissue followed the hard tissue advancement but to a lesser extent (Table II). The amount of soft tissue horizontal change ranged from 0.5 to 12.7 mm and was statistically signicant for all landmarks except Stos in the single-jaw group. The mean anterior changes at Li and Pg for the single-jaw group were 4.3 and 8.2 mm, respectively. Signicantly greater anterior changes of these landmarks were noted in the double-jaw group (Li at 6.5 mm and 12.7 mm at Pg ). Vertical movements for soft tissue landmarks also varied between groups. Li and Pg moved superiorly 7.2 and 1.6 mm, respectively, in the double-jaw group. In the single jaw group, Li moved superiorly 4.5 mm, but Pg moved inferiorly 1.1 mm. Table III shows that the superior aspect of the lower lip decreased in thickness ( 4.4 mm), the middle aspect increased slightly in thickness (1.0 mm), and the

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Table I. Denitions of hard and soft tissue landmarks with accompanying calculated method errors on 10 replicate tracings Method errors Landmark Sella Nasion Maxillary incisor Mandibular incisor Infradentale Supramentale Pogonion Menton Stomion superius Stomion inferius Labrale inferior Supramentale (labiomental fold) Pogonion Menton Abbreviation S N U1 L1 Infra Bpt Pg Me Stos Stoi Li Bpt Pg Me Denintion Center of bony contour of sella turcica Most anterior point of nasofrontal suture on midsagittal plane Most inferior point on most anterior maxillary incisor Most superior point on most anterior mandibular incisor Most anterior and superior point of alveolar process of mandible at its labial contact with mandibular central incisors Most posterior point in midline of symphyseal outline of mandible in concavity between infradentale and pogonion Most prominent or anterior point on symphysis of mandible in median plane Most inferior midline point on symphyseal outline of mandible Lowermost point on vermilion border of upper lip Uppermost point on vermilion border of lower lip Most anterior point on vermilion border of lower lip Most posterior point in midline of outline of soft tissue of mandible in concavity between lower lip and chin Most anterior point on contour of chin Most inferior midline point on soft tissue outline of mandible H NR NR .45 .49 .60 .60 .59 .59 .45 .40 .34 .45 .42 1.2 V NR NR .18 .33 .22 .28 .23 .21 .33 .33 .28 .37 .33 .40

NR, Not recorded; H, horizontal; V, vertical. Table II.

Horizontal and vertical movements (mm) of hard and soft tissue landmarks (T1-T2)
Horizontal Single jaw Double jaw Mean SD Difference (P) Single jaw Mean SD Vertical Double jaw Mean SD Difference (P)

Landmark Hard tissue U1 L1 Infra Bpt Pg Me Soft tissue Stos Stoi Li Bpt Pg Me

Mean

SD

0.6 5.1* 5.4* 6.1* 9.1* 8.6* 0.5 2.8* 4.3* 7.1* 8.2* 7.5*

1.7 2.5 2.6 2.9 4.1 4.3 3.0 2.2 2.7 2.9 3.5 5.7

3.4* 7.3* 8.3* 9.5* 13.6* 13.7* 2.5* 6.0* 6.5* 10.2* 12.7* 12.6* .05.

3.1 3.3 3.9 4.1 6.0 6.2 3.3 3.3 4.0 4.3 5.6 5.9

.001 .004 .001 .001 .001 .001 .018 .001 .013 .001 .001 .001

0.2 1.1* 1.2* 1.7* 1.2* 2.7* 0.1 2.1* 4.5* 0.7 1.1 2.3*

1.3 1.7 1.8 2.9 2.5 2.6 1.8 2.4 3.0 2.7 3.9 3.0

1.5* 2.1* 2.1* 1.4 1.2 0.75 0.1 5.2* 7.2* 4.4* 1.6 0.3

3.2 4.3 4.0 5.7 4.4 4.8 2.8 5.0 5.7 4.8 5.0 3.7

.007 .001 .001 .006 .009 .001 .801 .003 .021 .001 .023 .020

*Change (T1-T2) signicant at P

inferior aspect decreased slightly in thickness ( 0.8 mm). Lip length increased approximately 2.5 mm. T tests showed that treatment changes in lip dimensions were not signicantly different between the single-jaw and the double-jaw groups except for U1 to Li and Stoi, which had a signicantly greater decreases and less increase, respectively, in the double-jaw group. The multiple correlations for the horizontal soft

tissue change were highly signicant, ranging between 0.89 and 0.97, and explained 80% to 94% of the variation (Table IV). The standard errors of the estimates ranged from 1.0 to 1.6 mm. Three to 5 variables were included in the horizontal predictive models. The effects of sex, age, genioplasty, and maxillary procedures did not account for signicant amounts of variation in the prediction equation. Correlations between

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Table III.

Mean treatment changes (T1-T2) in lip dimensions


Single jaw Mean SD Mean Double jaw SD Group difference P

Lip thickness U1-Li L1-Li Bpt-Bpt Pg-Pg Infra-Bpt L1-Stoi U1-Stoi Lip length Me -Stoi *Change (T1-T2) signicant at P Table IV.

1.1* 4.4* 1.2* 0.7 0.1 2.9* 2.0* 2.5* .05.

2.0 2.1 2.1 2.6 1.5 2.2 1.9 3.8

2.9* 4.3* 0.9 0.8* 0.4 2.0* 0.9* 2.4*

2.9 2.0 2.5 1.9 1.5 1.8 2.1 3.7

.01 .88 .66 .85 .24 .09 .05 .92

Stepwise multivariate regression models for changes (T1-T2) of lower lip and chin and correlations between predicted and observed values for cross-validation sample
Prediction equation Dependent variables Horizontal Stoi Li Bpt Pg Vertical Stoi Li Bpt Pg R SEE Constant First Second Third Fourth Fifth Cross-validation correlations

0.89* 0.89* 0.97* 0.96* 0.87* 0.91* 0.87* 0.81*

1.5 1.6 0.1 1.4 1.9 2.0 1.9 2.7

3.69 2.49 4.19 5.27 9.26 0.13 5.9 10.0

0.21 (Bpt-H) 0.49 (Bpt-Bpt ) 0.23 (Infra-H) 0.62 (PgH) 0.88 (Infra-V) 0.51 (L1-Li) 0.96 (L1-V) 0.87 (L1-V)

0.46 (L1-Stoi) 0.78 (Bpt-H) 0.316 (Pg-H) 0.41 (Infra-H) 0.60 (L1-Li) 0.35 (Pg-H) 0.14 (Stos-H) 0.17 (Me -Stoi)

0.63 (L1-H) 0.2 (U1-Li) 0.12 (Bpt-V) 0.37 (Bpt-Bpt ) 0.31 (Bpt-H) 0.37 (Bpt-Bpt ) 0.44 (Bpt-Bpt ) 0.16 (Stoi-H) 0.58 (Bpt-Bpt ) 0.89 (L1-V) 0.32 (L1-Li) 0.56 (Pg-V) 0.27 (Bpt-V)

0.15 (L1-Stoi) 0.31 (L1-H) 0.19 (Pg-H)

.93* .88* .92* .96* .88* .95* .91* .84*

*P .01. SEE, Standard error of estimate. Equations are derived as follows: Y Constant (First) (Second) For example, equation for predicting horizontal movement of Pg is: Y

(Third) (Fourth) (Fifth). 5.27 (0.62*Pg-H) (0.41*Infra-H)

( 0.37*Bpt-Bpt ).

actual and predicted horizontal movements in the validation sample explained 80% to 93% of the total variation. The multiple correlations for the vertical soft tissue changes ranged between 0.81 and 0.91 and explained 66% to 82% of the variation. The standard errors of the estimates ranged between 1.9 and 2.7 mm. Once again, 3 to 5 variables were included in the predictive models. The validation sample demonstrated high correlations between the actual and the predicted vertical movements of the soft tissue variables, ranging from 0.84 to 0.95 and explaining 67% to 93% of the total variation.
DISCUSSION

The hard and soft tissue changes that we saw fell within the ranges previously observed for surgical advancement. Table V shows that published ratios of hard to soft tissue advancement at the level of Pg range

from 0.75:1 to 1.04:1.1,8-22 Our 0.92:1 ratio for Pg falls within those currently established parameters, albeit on the low end. Ratios for Li range from 0.26:1 to 0.85:1.1,8,9,16-22 Our 0.79:1 ratio also fall within that range, but on the high end. A possible explanation for the differences between our estimates and those of previous studies was that our study included both mandibular advancements and genioplasties in the same group, effectively increasing the average total advancement at Pg. This increased movement would have a tendency to decrease the ratio of hard to soft tissue.14 Another possibility for the discrepancy was our use of internal rigid xation. This surgical technique decreases the tendency for relapse33-36 and might help to explain why our observed ratio of soft to hard tissue response at Li was greater than the published values. The focus of this study was to develop algorithms

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Table V. Summary of existing literature providing ratios of soft tissue movement in response to mandibular advancement surgery and/or genioplasty Study Mandibular advancement and:or genioplasty Lines and Steinhauser9 Talbot16 Quast et al17 Mommaerts and Marxer18 Dermaut and De Smit19 Ewing and Ross1 Hernandez-Orsini et al20 Thuer et al21 Keeling et al22 Mobarak et al8 Genioplasty only McDonnell et al10 Busquets and Sassouni11 Wittbjer and Rune12 Kremanov and Kahnberg13 Polido and Bell14 Van Sickels et al15 Present study NR, Not recorded. Year Sample size Pg /Pg Li:L1

1974 1975 1983 1987 1989 1992 1993 1994 1996 2001 1977 1981 1989 1992 1993 1994 2001

9 12 11 35 31 14 31 30 20 61 15 14 17 17 10 18 62

1.00:1 1.04:1 0.97:1 0.97:1 1.10:1 1.00:1 0.93:1 1.00:1 0.96:1 1.02:1 0.75:1 0.80:1 0.94:1 0.94:1 0.83:1 0.92:1 0.92:1

0.66:1 0.85:1 0.38:1 0.55:1 0.26:1 0.80:1 0.43:1 0.67:1 0.45:1 0.60:1 0.40:1 NR NR NR NR NR 0.79:1

that more accurately predict soft tissue changes associated with mandibular advancement. Currently, predictive algorithms are highly variable and not particularly efcient. The best predictive equations explain only approximately 50% of the variation in soft tissue response to mandibular advancement. Few attempts have been made to predict vertical changes. By using multivariate regression analysis, we could relate many factors that, in combination, explained relatively large amounts of variation in the soft tissue response to mandibular advancement and genioplasty in both the horizontal and the vertical planes. Our model increased the predictive accuracy by up to 40%. The general differential movements of lip prole were noted clinically as a slight straightening in lower lip contour, projection of the chin, and a slight loss of lip pout, with different independent variables contributing at each level. At the level of Pg , the effects of hard tissue movement were the most important, perhaps because the tissues in this region are directly associated with the underlying bone. Although horizontal changes at Bpt were also affected by the horizontal movement of the underlying skeleton, soft tissue thickness also played a role. The thicker the pretreatment tissue was at Bpt , the less soft tissue advancement was observed, indicating that labile tissue expressed some compression and adaptation to the alveolus. This effect has been previously noted in studies evaluating the soft tissue response of the upper lip.23,24,28,29 The regression model indicated that horizontal skel-

etal movement, tissue thickness, the separation of the maxillary incisor from the lower lip, and the vertical movement of the hard tissues were all important determinants of movement at Li. As supramentale (Bpt) was moved forward, the lower lip followed. However, the thicker the pretreatment tissue was at Bpt , the less Li translated forward, again indicating a compressibility component of tissues. Also, the greater the presurgical distance between Li and the maxillary incisor, the more Li moved forward. This relationship probably has a 2-fold explanation. First, the distance of the upper incisal edge to the lower lip could indicate a skeletal discrepancy and reect a need for more extensive mandibular advancement. Second, a larger overjet allows the lower lip to rest behind the maxillary incisor, creating a larger discrepancy in the relationship of Li to U1, and requires more advancement at Li to establish lip competence. The regression models explaining vertical movements were more complicated and, with the exception of Li, explained less of the variation than did their horizontal counterparts. The vertical movements of Pg were explained by vertical movements of Pg, Bpt, and L1, as well as the length of the lower lip (Me -Stoi) and the horizontal movement of Pg. The longer the pretreatment lip and the less Pg was moved anteriorly, the less Pg moved inferiorly. This relationship may be explained by the tendency of lower lip contour to straighten after mandibular advancement and genioplasty.9,17 If the pretreatment contour of the lower lip

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Fig 2. Deviations (predicted-observed) for horizontal movement of Li, comparing regression model predictions with commonly used ratio.

was relatively straight, then less tissue redundancy would have been possible for the descent of Pg . Bpt changes were related to the same vertical hard tissue movements as Pg , as well as thickness of the lip tissue at Li. The thicker the lower lip, the less tendency Bpt had to descend; this might again be explained by tissue compressibility and adaptabilitythe more tissue available at pretreatment relative to the amount of surgical bony movement, the less net vertical change observed. Labrale inferior responded similar to Bpt . There was a direct relationship between the amount of vertical descent observed at Li and the total movement at L1. Also, the thicker the lower lip, the less tendency Li had to descend. In contrast, there was the tendency for Li to descend postsurgically if presurgical lip thickness was large. This apparent inconsistency might be explained by relative tissue thickness; if the tissue at Bpt was thicker at pretreatment relative to the thickness at Li and Pg , then lip prole would be expected to be straighter initially. In other words, less tissue was available to adapt to the effects of the underlying skeletal advancement, thereby increasing the susceptible tissue response at Li to vertical movement. By using multivariate regression models, we could explain more variation in soft tissue response than has previously been possible with simple ratios. The regression model enabled us to accurately predict the soft tissue response at Li to within 2 mm of the observed change 80% of the time, but a simple ratio was this effective only 50% of the time (Fig 2). More importantly, by applying our predictions to an independent group, we could validate the models, thereby increasing the likelihood that they can be similarly applied to other independent samples.32 Currently, most computer-imaging software relies on ratios or simple regression

models for predicting soft tissue change.37,38 However, the use of simple ratios permits highly inaccurate predictions, especially in instances of unusually thick or thin tissue, or of substantial surgical repositioning in both the horizontal and the vertical dimensions. For example, in a hypothetical treatment situation where the pretreatment lip thickness was 10.0 mm at Bpt-Bpt and 11.0 mm at U1-Li, and the mandible was advanced 7.0 mm and opened vertically 3.0 mm, our algorithm would predict the new position of Li to be 5.5 mm forward from its original position (2.49 [0.49*10.0] [0.78*7.0] [0.2*11.0] [0.12*3.0] 5.5 [Table IV.]). A standard ratio of 0.55:1 as the algorithm predicts 3.6 mm for horizontal movement at Li; this severely underestimates the actual change because of the thin pretreatment tissue and does not account for changes in the vertical dimension. Although this study represents a clear improvement in predictability over existing studies, it is limited in that considerable variation remains to be explained. One confounder might have been the resolution of edema and the point at which soft tissue remodeling was complete.8,17,20 We used a minimum of 6 months as the standard of postsurgical follow-up for the crosscomparison,16-18,20-22 which is relatively short. However, the longer the postsurgical duration, the greater the variability in relapse and remodeling, possibly changing the predictive outcome.1,17 Another variable that might have adversely affected the predictive accuracy was the inability to better control for variation in lip posture and the centric relation manipulation when the radiographs were taken. We also could not control for individual differences in physical properties of the lower lip, which might inuence how it responds. Because our results pertain to white adults, the regression models might not apply to other populations. Finally, our study did not have the statistical power to delineate the effects of the different surgical procedures on the soft tissue; this might account for some of the variation. Perhaps future studies can increase the reliability of the predictions by developing regression models on more homogeneous samples.
CONCLUSIONS

1. Direction of surgical movement and preoperative soft tissue thickness have a denitive effect on postoperative lower lip position. 2. As the mandible is displaced anteriorly, the lower lip contour straightens, and its vermilion thins. 3. When pretreatment tissue thickness and hard tissue movement are controlled for, the effects of maxillary surgery in conjunction with anterior mandibular

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repositioning on the soft tissue contour of the lower lip are similar to an isolated single-jaw procedure. 4. When using a multivariate regression model, the nal horizontal and vertical lip position can be more accurately (smaller errors) and reliably (stronger correlations) predicted.
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