Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e87ee92

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Journal of Cranio-Maxillo-Facial Surgery

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The evaluation of the nasal morphologic changes after bimaxillary surgery in

skeletal class III maloccusion by using the superimposition of cone-beam
computed tomography (CBCT) volumes
Soo-Byung Park a, Jong-Kyoon Yoon a, Yong-Il Kim a, *, Dae-Seok Hwang b, Bong-Hae Cho c,
Woo-Sung Son a
a
Department of Orthodontics (Head: Prof. W.S. Son), Pusan National University Hospital, Yangsan, South Korea
b
Department of Oral & Maxillofacial Surgery (Head: Prof. I.K. Chung), Pusan National University Hospital, Yangsan, South Korea
c
Department of Oral & Maxillofacial Radiology (Head: Prof. K.S. Nah), Pusan National University Hospital, Yangsan, South Korea

a r t i c l e i n f o a b s t r a c t

Article history: Background: The purpose of this study was to evaluate nasal morphologic and maxillary skeletal changes
Paper received 27 December 2010 occurring after bimaxillary surgery in skeletal class III patients, using a new method entailing super-
Accepted 25 May 2011 imposition of cone-beam computed tomography (CBCT) volumes.
Materials & methods: The subjects consisted of 30 adults (15 males and 15 females) who had presented
Keywords: with skeletal class III deformities. The subjects underwent Le Fort I advancement and impaction
Nasal change
osteotomy and mandibular setback surgery. For closure of the maxillary vestibular incision, alar cinch
Bimaxillary surgery
suture and V-Y closure were performed. The pre- and post-operative CBCT data were superimposed and
CBCT superimposition
evaluated by voxel-by-voxel registration.
Results: After surgery, the nasolabial angle, nasal tip angle, nasal tip inclination and columellar angle
showed significant increases (P < 0.01). The nasal tip protrusion and nasal height, meanwhile, had
significantly decreased (P < 0.01), and the alar base width had increased (P < 0.01). The columellar
length and nostril axis angle also had decreased, but the nostril area did not show any significant change.
Conclusions: After surgery, as the maxilla had been moved upward and forward, the nasal tip was shifted
antero-superiorly and the alar base width and nostrils were widened. CBCT superimposition, enabling 3D
assessment of nasal morphologic changes, can be an effective tool for simultaneous measurement of
skeletal and soft-tissue changes.
Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction forward movement of the maxilla into their bimaxillary-surgical

In treating skeletal class III malocclusion with transverse,
vertical and severe antero-posterior skeletal discrepancies, it is
often difficult to achieve aesthetically satisfactory results with
mandibular surgery alone. In these cases, bimaxillary surgery nor-
mally is performed, after due and careful consideration of func-
tional requirements, aesthetic preferences and post-operative
stability. Despite all care and precaution, however, relocation of the
maxilla can result in disfiguring changes to the nose. Therefore, in
the treatment of class III malocclusion, especially where accom-
panied by midfacial deficiency, surgeons should incorporate
* Corresponding author. Department of Orthodontics, School of Dentistry,
Medical Research Institute, Pusan National University Hospital, 3-3, Beomeo,
Mulgeum, Yangsan, Gyeongnam 626-770, South Korea. Tel.: þ82 55 360 5154;
fax: þ82 55 360 5153.
E-mail address: kimyongil@pusan.ac.kr (Y.-I. Kim).
procedure (Park and Lee, 2008).
There has been much research on facial soft-tissue changes after
orthognathic surgery. Reports show that forward and upward
movement in the maxilla effected by Le Fort I osteotomy generally
increases alar base width (Sarver and Weissman, 1991; Guymon et al.,
1988; Rosen,1988). This kind of disfiguring post-surgery change to the
nose possibly is a more sensitive problem for Asians, who typically
have a wider alar base and a lower columellar height than Caucasians
(Farkas et al., 2005; Choe et al., 2006). Some surgeons have reported
that alar cinch suture prevented this expansion and, thereby, helped
to control the eventual alar base width (Guymon et al., 1988).
Morphologic changes in the nose after bimaxillary surgery have
been assessed in studies employing lateral cephalometric radio-
graphs and clinical photographs. Three-dimensional changes have
been investigated using 3-dimensional laser scanning as well as
3-dimensional Computed Tomography (3D-CT) (Rosen, 1988;
McCance et al., 1992; Chung et al., 2008). However, there is

1010-5182/$ e see front matter Ó 2011 European Association for Cranio-Maxillo-Facial Surgery.
doi:10.1016/j.jcms.2011.05.008
e88 S.-B. Park et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e87ee92
Fig. 1. Superimposed CBCT image (Ondemand3DTM). The pre- and post-surgery CBCT scan data were superimposed automatically using stable skeletal structures unaffected by the
surgeries. Midsagittal reference (MSR) plane, perpendicular to FH plane and passing through Nasion (Na) and Basion (Ba); FH plane, drawn by connecting both sides of Po and right
Or; Coronal plane, perpendicular to FH and MSR planes and bisecting right Po.
a limitation to bilateral structure measurement, given that in lateral
cephalometric radiographs, many structures are superimposed. And
since skeletal positional relationships cannot be reconstructed in
clinical photos, there can be distortions of length, angle and shape
through superimposition. Three-dimensional laser scanning also has
shortcomings: errors can occur in image superimposition owing to
the lack of stable references. Also, patients are at risk of undue
exposure to the radiation emitted by 3D-CT (McCance et al., 1992).
Alternatively, cone-beam computed tomography (CBCT), which has
seen wide application in dentistry recently, has several advantages:
patients are at lower risk of exposure to radiation, it is possible to
obtain actual measurements with lower distortion and enlargement
of images, images can be rotated for observation from any direction,
and hard and soft tissues can be evaluated at the same time (Park
et al., 2006).
Cevidanes et al. (2010) introduced a new method by which the
skull base can be used as a stable reference structure for image
superimposition. Rychman et al. (2010) reported soft-tissue
changes from movement of hard tissue after advancement
surgery on the maxilla and mandible, as evaluated using over-
lapped pre- and post-orthognathic-surgery CBCT images.
In recent years, it has been reported that a faster and simpler
way is to superimpose CBCT volumes is to apply the mutual
information principle designed by 3D-CT or magnetic resonance
imaging (MRI) area (Maes et al., 1997; Choi and Mah, 2010). The
important advantage of this strategy is that skeletal and soft-tissue
changes pre- and post-treatment can be evaluated on the same
reference planes, even without stable reference structures in 3D
laser-scanned or clinical photographs. The purpose of the present
study was to evaluate, by the CBCT superimposition method, pre-
and post-bimaxillary-surgery nasal morphologic changes in the
frontal and lateral views in cases of skeletal class III deformities.
2. Materials and methods
2.1. Subjects
The subjects comprised 30 adults (15 men and 15 women; mean
age, 22.4  2.9 year; age range, 19e30 year) presenting with
prediagnosed skeletal class III jaw deformities. All of them had
received pre- and post-operative orthodontic treatment at Pusan
National University Hospital. None manifested any craniofacial
syndromes, cleft lip and palate or any severe facial asymmetry. This
study was reviewed and approved by the ethics committee at Pusan
National University Hospital (No. E-2010-062).
Orthognathic surgery was performed in the same way by the
same surgeon: the maxilla by Le Fort I osteotomy was moved
forward and upward, while the mandible by bilateral sagittal split
ramus osteotomy (BSSRO) was relocated. The isolated maxilla was
set by rigid internal fixation, and alar cinch suture and V-Y
soft-tissue closure were performed. Additional surgery, which can
cause changes in the shape of the nose either during surgery or
after, was not undertaken.
2.2. Methods
2.2.1. CBCT and image processing
CBCT scans (Pax-Zenith3D; Vatech, Seoul, Korea) were
performed prior to surgery (T1) and after a period of at least
6 months post-surgery (T2). The FH plane of the sitting subjects
was parallel to the floor. The maxillofacial regions were scanned by
CBCT (90 kVp, 4.0 mA, 24 s scan time, 24  19 cm field of view
(FOV), effective dose: 138.57 mSv (ICRP 2007) under FOV
24  19 cm, 120 kVp, 6.9 mA, 24 s, pulsed condition). The obtained
Digital Imaging and Communication in Medicine (DICOM) data
were reconstructed into 3D images using a 3D imaging program
(OnDemand3DÔ; Cybermed Co., Seoul, Korea).
2.2.2. Superimposition of images
The pre- and post-operative CBCT data were superimposed by
automatic voxel-by-voxel registration at the cranial bases, using the
OnDemand3DÔ fusion module. The superimposed images were
suitable for measurements on the same reference plane (Fig. 1).
2.2.3. Measurement points and reference planes
On the superimposed 3D CBCT images, the FH plane was set
with the right and left Porion and the right Orbitale as the hori-
zontal reference plane, and the midsagittal reference (MSR) plane,
 S.-B. Park et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e87ee92 e89

Fig. 2. (A) Lateral reference points and reference lines: 1, nasion (N); 2, orbitale (Or); 3, subspinale (A); 4, porion (Po); 5, subnasale (Sn); 6, pronasale (Prn); 7, projected Prn (Prn0 ); 8,
projected N (N0 ); 9, projected Sn (Sn0 ); 10, labrale superius (Ls); 11, posterior nasal spine (PNS); 12, columella tangent (CT) line: line drawn from NV to tangent of inferior border of
soft-tissue columella; 13, nasion vertical (NV) line: vertical reference line drawn 90 to FH plane; (B) Frontal reference points: 1, right medial canthus (Enr); 2, left medial canthus
(Enl); 3, right ala (Alr); 4, left ala (All); 5, columella (C0 ); 6, subnasale (Sn); 7, highest point of right nostril (Nhr); 8, lowest point of right nostril (Nlr); 9, highest point of left nostril
(Nhl); 10, lowest point of left nostril (Nll).

as the vertical reference plane, was set according to the plane
perpendicular to the FH plane and passing through the Nasion and
Basion (Kim et al., 2000). The coronal vertical reference plane,
utilized to measure the forward movement of the maxilla, was
perpendicular to the horizontal and vertical planes and passed
through the right Porion (Fig. 1). Measurement points on the
reconstructed 3D images were defined and measured preparatory
to assessment of the lateral and frontal views of the nose pre- and
post-operatively (Figs. 2e4).
2.2.4. Statistical analysis
All of the measurements were statistically analyzed using
a statistical program (SPSS 14.0; Chicago, Il, USA). The differences in
the morphologic nose changes and skeletal movement relative to
maxillary movement after orthognathic surgery were analyzed by
means of a paired t-test (P < 0.05). In order to evaluate the reliability
of the measurements, an intraclass correlation was performed for
each of the reference points with 10 randomly selected subjects.
3. Results
The average distance from the coronal vertical reference plane to A
point, in the assessment of the amount of forward maxilla movement
before and after surgery, was 2.73  1.23 mm. The average of the
upward maxillary movement at A point was 3.41  1.77 mm. The
average upward maxillary movement of the posterior nasal spine
(PNS) was 3.27  1.26 mm. The average backward mandibular
movement was 5.79  3.84 mm (P < 0.05) (Table 1).
According to the post-surgery lateral measurements, the naso-
labial angle had increased an average of 10.34  7.36 . The nasal tip
angle, the nasal tip inclination and the angle of the columellar
inclination had all been increased (P < 0.05). In the evaluation of the
antero-posterior position of the nasal tip, the average change of the
tip protrusion was 1.08  0.83 mm, a decrease (P < 0.05). With the
diminished nasal tip protrusion, the columella length was reduced
an average of 0.96  0.53 mm. The post-surgery frontal
measurement of the nose change indicated that the alar base width
had increased an average of 2.45  1.52 mm (P < 0.05). Nostril axis
angle showed reductions, 2.31  4.92 on the left side
and 2.51  5.34 on the right, but the nostril area showed no
statistically significant difference pre-to post-surgery (Tables 2
and 3). The intraclass correlation analysis showed a reliable repro-
ducibility for all of the reference points (r ¼ 0.93  0.96, P < 0.01).
4. Discussion
Most of the studies on the nasal soft-tissue response to skeletal
changes in the nose after orthognathic surgery have utilized lateral
e90 S.-B. Park et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e87ee92
cephalometric radiographs, with the FH, PM vertical and SN planes
as the horizontal and vertical references (Burstone et al., 1990;
McFarlane et al., 1995; Kang et al., 2000). However, this approach
has a drawback, in that with lateral cephalometric radiographs,
there is no midsagittal reference plane, and so measurement errors
can occur due to overlapping of bilateral structures (Rychman et al.,
2010). With CBCT, contrastingly, images can be reconstructed
according to the reference planes, and measurement points such as
Orbitale and Gonion, which are considered to be difficult to
measure in lateral cephalometric radiographs, can be accurately
defined (Ludlow et al., 2009). In the present study, the FH plane,
widely used and reproducible in CBCT, was set as the horizontal
reference plane, and the line perpendicular to the FH plane and
passing through the right Porion was set as the coronal reference
line.
Facial photographic analysis, which frontally assesses changes to
the nose, can incur errors according to the head postures of pho-
tographed patients, and is further limited in that it cannot recon-
struct images from captured photos. McCance et al. (1992) assessed
post-surgery changes of facial soft tissue through superimposition
of 3D laser-scanned images; however, because in 3D facial imaging
Fig. 3. Lateral measurements: 1, nasolabial angle (C0 -Sn-Ls); 2, nasal tip angle
(N0 Prn-CT); 3, nasal tip inclination (NV-N0 Prn); 4, columellar inclination (NV-CT); 5,
nasal tip protrusion (Sn-Prn); 6, nasal height (N-Prn); 7, nasal depth (Prn-Prn0 ); 8, Sn
depth (Sn-Sn0 ); 9, vertical nasal tip position (Sn-Prn/Sn-N).
Fig. 4. Frontal measurements: 1, alar base width (Alr-All); 2, intercanthal width (Enr-Enl); 3, columellar length (Sn-C0 ); 4, right nostril axis angle (Nhr-Nlr-Sn); 5, left nostril axis
angle (Nhl-Nll-Sn); 6, right nostril area; 7, left nostril area.
there is no setting for the MSR, reference points further from the
midline had larger measurement errors. Additionally, this method
also incurred many errors originating from patients’ head orien-
tations (Park et al., 2006). On the other hand, CBCT has advantages
in that it can measure changes with high reproducibility on the
same reference planes, through superimposition based on stable
structures such as the skull base; also, both soft and hard tissues
can be evaluated with high resolution (Rychman et al., 2010).
Superimposition of CBCT data can be accomplished in one of the
two ways: rigid registration or non-rigid registration. Cevidanes
et al. (2010) reported that rigid registration is suitable for the
study of pre-to-post-surgery longitudinal changes. In the present
study, CBCT was measured and analyzed by the voxel-by-voxel
superimposition method, referencing the anterior cranial base as
the stable structure. This method faster and more convenient than
the alternative means of surface superimposition, and is very useful
for comparison of soft-tissue changes after orthognathic surgery,
since it cannot only display overlapped images according to the
reference plane, but also measure and confirm each pre- and post-
image in relation to the multiplanar reformation (MPR) image.
Soft-tissue swelling immediately after surgery makes evaluation
of post-operative changes more difficult. In response to this
problem, Suckiel and Kohn (1978) and Kang et al. (2000) used
lateral cephalometric radiographs 2w3 months after surgery. For
enhanced accuracy of analysis, some studies have recommended
waiting as long as 6 months or 1 year after surgery (Rosen, 1988;
Betts et al., 1993; Chung et al., 2008). However, Moss et al. (1994)
reported almost no change in soft tissue from 3 months to 1 year
after surgery. Day and Lee (2006), though, reported changes in
facial soft tissue after early post-orthognathic-surgery swelling
involved soft-tissue remodelling, tissue relocation, relapse of hard
tissue and change in weight complexly. Thus, in the present study,
the CBCT data used in the analysis were obtained a minimum of
6 months after surgery.
The maxilla of all of the patients, in the present study, was
moved forward and upward; also, the nasolabial angles showed
increases on assessment of the morphological changes of the nasal
tip. This result differs from that of Betts et al.’s (1993) study, in
which the nasolabial angle was either the same or decreased after
maxillary forward movement. However, it was considered that the
upper labial vertical dimension was increased by bimaxillary
surgery and that the upper lip position affected by the lower lip and
lower incisors was improved, in the skeletal class III patients.
Moreover, the nasal tip angle increased as the maxilla moved
forward and the nasal tip protrusion decreased. This seemed to
have been caused by the forward movement of the subnasale and
the increase of columella angles. It is also considered that columella
length has been shortened for the same reason. Suckiel and Kohn
(1978) reported that forward maxilla movement rotated the nasal
 S.-B. Park et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) e87ee92 e91

Table 1 of reducing enlargement of the nasal base. However, the effects of

Horizontal and vertical skeletal changes after bimaxillary surgery in mm. alar cinch suture remain controversial. Howley et al. (2011)
Measurements Amount of skeletal movement reported that alar cinch suture has no efficacy in controlling the
Mean SD
alar base width. Muradin et al. (2011) also suggested that alar cinch
and V-Y closure have no beneficial effect on vertical changes of the
Vertical changes (T2eT1)
Point A 3.41 1.77 nasal tip, but are efficacious for the labial form and helpful in
PNS 3.27 1.26 preventing excessive nasal tip rotation. Also, the type of Le Fort I
Horizontal changes (T2eT1)
osteotomy might be other factor contributing to change of the alar
Point A 2.73 1.23 base width and nasal profile. However, Mommaerts et al. (1997)
Point B 5.79 3.84 compared the effect of subspinal Le Fort I osteotomy on the
All variables were measured in millimetres; T1: pre-operative, T2: post-operative. interalar rim width (without alar cinch or V-Y closure) with that of
(þ): Superior movement (impaction) and anterior movement. conventional Le Fort I osteotomy (with alar cinch and V-Y closure),
(): Inferior movement and posterior movement (setback). and reported that the difference decreases with time. Moreover,
subspinal osteotomy was not superior to conventional Le Fort
I-type osteotomy in regard to minimizing nasal tip changes and
Table 2
Descriptive statistics for nasal morphologic change after surgery, from lateral
obtaining control over the columello-labial angle (Mommaerts
measurements. et al., 2000).
In the present study, the effectiveness of alar cinch suture could
Measurements T1 T2 T1eT2 Significance
not be definitively assessed post-surgery, because all of the patients
Mean SD Mean SD Mean SD underwent both alar cinch suture and V-Y closure. However, in
Nasolabial angle (degree) 89.94 9.44 100.28 9.93 10.34 7.36 ** cases where both procedures are performed, nasal morphologic
Nasal tip angle (degree) 87.70 6.90 92.65 6.83 4.94 2.99 **
change in the form of extension of the nasal base can still be
Nasal tip inclination 23.10 2.85 26.15 2.57 3.05 1.49 **
(degree) incurred. This must be borne in mind by physicians undertaking
Columellar inclination 113.59 6.19 120.59 6.27 7.00 4.01 ** surgery for maxilla forward movement is planned.
(degree) For the patients with maxillomandibular defomities, CBCT
Nasal tip protrusion (mm) 16.03 1.69 14.95 1.51 1.08 0.83 ** imaging could definitely be used for a more comprehensive diag-
Nasal height (mm) 48.27 4.37 45.89 3.88 2.38 1.48 **
nosis, treatment plan and assessment of the treatment outcome
Nasal depth (mm) 27.14 2.76 28.93 2.82 1.79 0.92 **
Subnasale depth (mm) 14.42 2.87 17.44 2.98 3.02 1.60 ** (Schendel and Lane, 2009). Even though the levels of radiation
Vertical nasal tip position 0.19 0.03 0.20 0.02 0.01 0.02 ** exposure incurred in CBCT imaging usually remain far below those
(ratio) in conventional CT imaging, full-FOV CBCT scanning delivers
**P < 0.01, paired t-test was performed, T1: pre-operative, T2: post-operative. a significantly greater radiation dose to the patient than traditional
dental imaging techniques. Therefore, it is important that the
clinicians need the evidence-based selection criteria for CBCT
Table 3 scanning.
Descriptive statistics for nasal morphologic change after surgery, from frontal
measurements.
5. Conclusions
Measurements T1 T2 T2eT1 Significance

Mean SD Mean SD Mean SD Nasal morphologic change according to maxillary forward and
Alar base width (mm) 36.64 2.43 39.09 2.79 2.45 1.52 ** upward movement was evaluated by the new CBCT superimposi-
Alar base ratio (ratio) 1.02 0.08 1.08 0.08 0.06 0.04 **
tion method. The results were as follows. The nasal tip in the lateral
Colummellar length (mm) 6.68 0.98 5.72 0.90 0.96 0.53 **
Right nostril axis angle 57.61 2.96 55.73 3.10 2.51 5.34 ** view was rotated antero-superiorly, the nasal supratip depression
(degree) became prominent, the nose protrusion was diminished, and the
Left nostril axis angle 55.31 3.24 53.51 3.21 2.31 4.92 ** nasal base and nostril area were extended. To minimize nasal
(degree) morphologic changes after orthognathic surgery, it is imperative to
Right nostril area (mm2) 60.01 4.51 60.59 5.53 0.05 1.54 NS
review the patient’s nasal anatomy and skeletal characteristics
Left nostril area (mm2) 58.51 5.54 59.51 4.64 0.13 2.31 NS
thoroughly. CBCT superimposition, enabling 3D assessment of nasal
NS: Not significant, **P < 0.01, paired t-test, T1: pre-operative, T2: post-operative.
morphologic changes, can be an effective tool for simultaneous
measurement of skeletal and soft-tissue changes.

tip forward and upward, emphasizing the nasal supratip depres-

sion. Their results also showed that the nasal height, which is
related to changes in the vertical position, decreased, and that the
nasal depth, a function of horizontal positional changes in the nasal
tip, increased.
In the present study, there was an increase to the alar base
width (average: 2.45  1.52 mm), which result is consistent with
previous studies’ reports of nasal base increases with forward
maxilla movement (Rosen, 1988; Kang et al., 2000; Rychman et al.,
2010). Rosen (1988) suggested the following reasons for enlarge-
ment of the nasal base: superior and anterior changes in skeletal
bone, which incur swelling and nasal cavity floor; the relaxation of
the muscle around the nose and of the periosteum attachment; the
contraction of the muscle when separated from the origin or the
insertion areas; shortened muscle length after reattachment. Betts
et al. (2000) suggested alar cinch suture and V-Y closure as means
Source of the support
This study was supported by a grant from Pusan National
University Hospital.
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