J Oral Maxillofac Surg

65:2301-2310, 2007

Soft Tissue Profile Changes Following

Mandibular Advancement and Setback
Surgery an Average of 12 Years
Postoperatively
Nicole M. Eggensperger, MD, DMD,* Olivier Lieger, MD, DMD,†
Urs Thüer, DMD,‡ and Tateyuki Iizuka, MD, DDS, PhD§
Purpose: The aim of this study was to assess long-term changes in position of soft tissue landmarks
following mandibular advancement and setback surgery.
Materials and Methods: Twenty-seven patients (14 women, 13 men; mean age, 36 years) who had
undergone either mandibular advancement (15 patients) or setback surgery (12 patients), were available
for a long-term follow-up an average of 12 years postoperatively. In all of these cases, lateral cephalo-
metric radiographs taken immediately before operation, at 1 week, 14 months, and 12 years postoper-
atively, were studied.
Results: During the 14 months postoperatively, soft tissue chin and mentolabial fold followed its
underlying hard tissue in all patients. A continuous skeletal relapse was observable 12 years after
mandibular advancement, but soft tissue chin moved more in an anterior direction. After mandibular
setback, soft and hard tissue landmarks remained almost unchanged. Over the entire observation period,
a thickening of soft tissue at pogonion was generally seen, and particularly a thickening of the whole chin
in the setback group. All patients showed a significant lengthening and thinning of the upper lip. In all
except 2 males, the patient’s body weight increased markedly.
Conclusion: In contrast to the immediate postoperative stage, soft tissue changes observed an
average of 12 years after the primary operation do not directly follow the movements of the
underlying skeletal structure. The soft tissue profile changes observed over such a long term seem
to be influenced not only by the underlying skeletal structure but also by other factors such as weight
gain and aging process.
© 2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:2301-2310, 2007

It is a well-known fact that surgical procedures to
correct skeletal deformities result in changes in shape
and position of the overlying soft tissue. However, it
*Resident, Department of Cranio- and Maxillofacial Surgery, Uni-
versity of Bern, Inselspital, Bern, Switzerland.
†Resident, Department of Cranio- and Maxillofacial Surgery, Uni-
versity of Bern, Inselspital, Bern, Switzerland.
‡Associate Professor, Department of Orthodontics, University of
Bern, School of Dental Medicine, Bern, Switzerland.
§Professor and Senior Maxillofacial Surgeon, Department of
Cranio- and Maxillofacial Surgery, University of Bern, Inselspital,
Bern, Switzerland.
Address correspondence and reprint requests to Dr Eg-
gensperger: Department of Cranio-Maxillofacial Surgery, University
of Bern, Inselspital, CH-3010 Bern, Switzerland; e-mail: nicole.
eggensperger@insel.ch
© 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6511-0026$32.00/0
doi:10.1016/j.joms.2007.06.644
is not so well known to what extent and in what
direction these soft tissue changes, compared with
the hard tissue movements, occur in the long-term
follow-up of more than 10 years.
These changes in the relationship of hard tissue to
soft tissue were first reported by McNeill et al1 in 1972.
Since then, several investigators have addressed their
attention on soft tissue responses following mandibular
advancement2-13 and setback.14-25 In previous stud-
ies,13,25 we reported the soft and hard tissue changes of
60 patients 1 year after mandibular advancement (n ⫽
30) and setback (n ⫽ 30) surgery. In these studies we
found a 1 to 1 ratio of mandibular soft and hard tissue
changes in both patient groups, which is in accordance
with most former publications.2-5,14,15,18,19,21,22 In con-
trast, horizontal changes of the upper and lower lip
following maxillar and mandibular incisal edge move-
ments seemed to be more variable and therefore less
predictable.2,9,10,13,23,25,26
Most former studies describe soft tissue changes

2301
2302 SOFT TISSUE PROFILE CHANGES

Table 1. SOFT TISSUE CHANGES AFTER MANDIBULAR ADVANCEMENT AS REPORTED IN THE LITERATURE

No. of Patients PG=:Pg SLI:B Li to Ii Follow-up Period

Study Type of Surgery (n) (%) (%) (%) (mo)

Lines & Steinhauser, 19742 BSSO 9 100 — 75 ⬎6

Quast & Biggerstraff, 19833 BSSO 11 97 97 38 ⬎12
Mommaerts & Marxer, 19874 BSSO 35 103 106 55 12
Hernández-Orsini et al, 19895 BSSO 31 94 93 43 14
Dermaut & DeSmit, 19896 BSSO 31 110 119 26 12
Ewing & Ross, 19927 BSSO 14 100 100 80 12
Jensen et al, 19928 Bimaxillary 17 100 98 72 18
osteotomy
Keeling et al, 19969 Bimaxillary 20 100 — — 24
osteotomy
Mobarak et al, 200110 BSSO 61 106 91 60 36
Veltkamp et al, 200211 BSSO 62 92 116 79 6
Dolce et al, 200312 BSSO 78 127 111 46 60
Iizuka et al, 200413 BSSO 30 97 86 54 14
Present study, 2006 BSSO 15 133 76 48 12 yrs
Abbreviation: BSSO, bilateral sagittal split osteotomy.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.

after a mean observation period of 1 to 3 years (Tables 1
and 2). To our knowledge, the longest follow-up in the
literature was 5 years.12 Therefore, the question of
whether the process of soft tissue change continues
over a long-term period has not been definitively an-
swered. On the other hand, we know that skeletal
changes continue in the long-term,27 especially after
mandibular advancement surgery. So, if soft tissue
changes are a long-term process, the question arises
whether they are only the result of altered underlying
skeletal structures or whether other factors, for example
in/-decreased weight or aging may be primarily respon-
sible for these changes.
The aim of this study was to determine long-term
soft tissue changes an average of 12 years after man-
dibular advancement or setback surgery, to investi-
gate whether or not soft tissue movements correlate
to that of underlying hard tissue after such a long
postoperative period and which factors may be re-
sponsible for the observed changes.

Table 2. SOFT TISSUE CHANGES AFTER MANDIBULAR SETBACK REPORTED IN THE LITERATURE

No. of Patients PG=:Pg SLI:B Li to Ii Follow-up Period

Study Types of Surgery (n) (%) (%) (%) (mo)

Lines & Steinhauser, 19742 BSSO 8 100 — 75 ⬎6

Hershey & Smith, 197414 BSSO 24 95 98 88 6
Suckiel & Kohn, 197815 BSSO 50 96 95 83 3-6
Willmot, 198116 BSSO 26 93 84 85 12
Gjorup & Athanasiou, 199117 BSSO 50 91 91 93 12
Schatz & Tsimas, 199518 BSSO 13 100 100 72 12
Lin & Kerr, 199819 Bimaxillary 17 98 102 90 3-6
osteotomy
Gaggl et al, 199920 BSSO 61 84 unspecified 84 8
Hu et al, 199921 BSSO 43 100 91 77 6-12
Enacar et al, 199922 BSSO 12 103 106 55 12
Bimaxillary 12 94 93 43 12
osteotomy
Mobarak et al, 200123 BSSO 80 104 108 102 36
Soncul & Bamber, 200424 Bimaxillary 46 98 91 65 6
osteotomy
Iizuka et al, 200525 BSSO 30 79 106 88 14
Present study, 2006 BSSO 12 60 40 77 12 yrs
Abbreviation: BSSO, bilateral sagittal split osteotomy.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.
EGGENSPERGER ET AL
Materials and Methods
The sample consisted of 60 patients who had com-
bined orthodontic and surgical treatment for mandib-
ular retrognathia (n ⫽ 30) and prognathia (n ⫽ 30) in
our department between 1986 and 1989. Fifteen
(47%) of the advancement patients and 12 (38%) of
the setback pateints were available for a long-term
cephalography in 2002. The mean time between the
primary orthognathic surgery and the final cephalo-
metric examination was 12 years (range, 11 to 14
years). The mean age at long-term follow-up was 36
years (range, 29 to 68 years). There were 11 women
and 4 men in the advancement group and 3 women
and 9 men in the setback group. Hospital charts were
reviewed for preoperative weight. Patients were ques-
tioned for their actual weight in 2002. Preoperatively,
patients presented with a mandibular retrognathia/
prognathia with a Sella-Nasion-B-point angle of 75.8°
and 83.6°, respectively. Patients were surgically
treated by sagittal split ramus osteotomy and mandib-
ular advancement or setback without genioplasty ac-
cording to the Obwegeser/Dal-Pont method. Bone
fragments were fixed using 3 positioning screws (2
mm diameter) at each osteotomy site. No splints were
used for stabilization of the mandible during surgery.
Rigid maxillomandibular fixation was maintained for
4 to 6 days postoperatively, followed by functional
training with light guiding elastics. The mean duration
of postoperative orthodontic treatment was 14
months (range, 11 to 20 months).
In all cases, lateral cephalometric radiographs were
available for this study. They were taken 1 to 2 days
before operation (T0), 1 week afterward (T1), after
completion of the postoperative orthodontic treat-
ment lasting 14 months on average (T2), and after
long-term follow-up averaging 12 years (T2). To keep
variability of measurement error to a minimum, all
radiographs were taken in the same cephalostat using
a cephalometric head holder, and all patients were
asked to relax upper and lower lips.
All radiographs were traced and analyzed by the
same examiner. As a basis for measurement, an x-y
cranial base coordinate system was constructed on
the radiographs. An x-axis was drawn 7° to the Sella-
Nasion line (Se-N-line) as a horizontal reference line; a
constructed vertical reference line was drawn per-
pendicular to this line at sella (y-axis). The cephalo-
metric landmarks identified and the reference lines
used are shown in Figure 1. Definitions of the land-
marks are listed in Table 3. Magnification for linear
measurements was 3.3%, and was identical in all pa-
tients. The magnification was not corrected. Standard
statistical parameters and tests were used to evaluate
the results. The systematic and accidental errors of
cephalometric analysis have been described else-
2303
FIGURE 1. Hard and soft tissue landmarks used in cephalometric
analysis.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac
Surg 2007.
where.28 In our study, 7 cephalograms were selected
at random from a group of 21. These were retraced
and the determinations remeasured. These values
were then analyzed using a paired t test, which re-
vealed no systematic errors. Accidental errors (si)
were calculated using the formula,
si ⫽ 冑 ⌺d2
2n
,
where d is the difference between the repeated mea-
surements and n is the number of duplicate determi-
nations. For most of the angular variables and linear
coordinates of the reference points, the accidental
errors were less than 1.0° and 1.0 mm, respectively.
Initially, the horizontal and vertical movements
were registered in the region of hard tissue structures
such as the incisal point in the maxilla (incision su-
perior, Is) and the mandible (incision inferior, Ii),
B-point (B), pogonion (Pg), and menton (me). Simi-
larly, translations were recorded in relation to soft
tissue references such as labrale inferior (Li), inferior
labial sulcus (SLI), as well as soft tissue pogonion
(PG=) and menton (Me). Changes in upper lip profile
were also determined using the soft tissue reference
points subnasale (Sn), superior labial sulcus (SLS),
labrale superius (Ls), and stomion (Stoms), as well as
the nasolabial angle (Cm-Sn-Ls).
Changes between preoperative (T0) and postoper-
ative (T2, T3) positions of the soft tissue reference
points were compared with movements of 3 hard
tissue references: Li to Ii, SLI to B-point, and soft tissue
pogonion to skeletal pogonion (PG= to Pg). The per-
centage of relative positional change (ratio) between
the soft tissue points and the corresponding skeletal
points was calculated by dividing the amount of
change in soft tissue by that of hard tissue over the
2304 SOFT TISSUE PROFILE CHANGES

Table 3. CEPHALOMETRIC LANDMARKS

Landmark Definition

A Innermost point on contour of maxilla between anterior nasal spine and incisor tooth
B Innermost point on contour of mandibula between incisor tooth and bony chin
Ii Incision inferior: midpoint of incisal edge of most prominent mandibular central incisor
Is Incision superior: midpoint of incisal edge of most prominent maxillary central incisor
me Menton: most inferior midline point on mandibular symphesis
Pg Pogonion: most anterior point on osseous contour of chin
S Sella: center of sella turcica
N Nasion: most anterior point of frontonasal suture
Cm Columella point: midpoint of columella of nose
Sn Subnasale: point at which columella (nasal septum) merges with upper lip in midsagittal plane
SLS Superior labial sulcus: point of greatest concavity in middle of upper lip between subnasale and
labrale superius
Stoms Stomion superius: most inferior point of upper lip
Stomi Stomion inferius: most superior point of lower lip
Ls Labrale superius: most anterior point of upper lip
Li Labrale inferius: most anterior point of lower lip
SLI Inferior labial sulcus: point of greatest concavity in midline of lower lip between labrale inferius and
soft tissue pogonion
PG= Soft tissue pogonion: most prominent or anterior point on chin in midsagittal plane
Me Soft tissue menton: lowest point on contour of soft tissue chin
ML-NL Mandibulo-nasal plane angle: angle between mandibular plane and nasal plane
Cm-Sn-Ls Nasolabial angle: angle between columella and labrale superius
G-Sn-PG= Facial convexity: angle between soft tissue glabella, subnasale and soft tissue pogonion
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.

postoperative interval between T0 and T2/T3 (ratio of
soft-to-hard tissue).
Ratio (%)
Long-term soft tissue changes (T0-T2 ⁄ T0-T3)
⫽ determine the difference between measurements at
Long-term hard tissue movement (T0-T2 ⁄ T0-T3)
⫻ 100
Values measured were compared between the 4 dif-
ferent time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Changes in linear and angular parameters were also
compared with the magnitude of surgical advancement/
setback and the amount of skeletal relapse.
Statistical analysis was performed to compare and
correlate the linear and angular relationships. The
Wilcoxon matched pairs signed-ranks test was used to
each interval. Statistical significance was defined as P
less than .05. Spearman’s correlation analysis was
used to test the significant relationships between vari-
ables. The degree of correlation was classified as:
strong correlation (r ⬎ 0.8), moderate correlation (r
⫽ 0.5– 0.8), and weak correlation (r ⬍ 0.5).

Table 4. HORIZONTAL CHANGES IN THE SKELETAL AND SOFT TISSUE CEPHALOMETRIC VARIABLES OF THE
ADVANCEMENT PATIENTS (n ⴝ 15)

Landmark T0-T1 SD T1-T2 SD T2-T3 SD T0-T3 SD

Dental Is (mm) 0.0 0.0 ⫺0.3 2.3 1.1 3.6 0.7* 3.1
Ii (mm) 4.1* 2.5 ⫺0.4 2.4 0.5 2.2 4.0* 3.2
Hard tissue B (mm) 4.1* 2.7 ⫺1.2 2.7 ⫺0.8 4.1 2.1 3.8
Pg (mm) 4.9* 2.4 ⫺1.6 3.3 ⫺1.0 4.5 2.4 3.6
me (mm) 4.3* 4.0 ⫺1.3 3.6 ⫺0.5 4.6 2.5 4.8
Soft tissue Stomi (mm) 2.9* 3.0 ⫺2.2* 2.7 ⫺1.2* 1.7 ⫺0.5 2.2
Lower lip Li (mm) 3.7* 2.6 ⫺2.5* 2.7 0.7 2.0 1.9 3.2
SLI (mm) 3.1* 3.0 ⫺1.6 3.1 0.1 2.4 1.6 2.9
PG= (mm) 3.7* 3.1 ⫺1.4 3.4 0.9* 0.8 3.2 2.4
Me (mm) 1.7 3.5 0.1 4.1 ⫺0.5 2.6 1.3 3.8
Divergent ML/NL (°) ⫺1.2 3.2 1.8 2.1 2.4* 2.8 2.9* 3.9
Abbreviation: SD, standard deviation.
*P ⬍ .05, measured between time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.
EGGENSPERGER ET AL 2305

Table 5. HORIZONTAL CHANGES IN THE SKELETAL AND SOFT TISSUE CEPHALOMETRIC VARIABLES OF THE
SETBACK PATIENTS (n ⴝ 12)

Landmark T0-T1 SD T1-T2 SD T2-T3 SD T0-T3 SD

Dental Is (mm) 0.0 0.0 0.4 1.5 ⫺0.2 1.8 0.3 2.2
Ii (mm) ⫺6.7* 4.2 1.0 1.4 ⫺0.3 1.3 ⫺6.0 3.9
Hard tissue B (mm) ⫺6.4* 5.3 1.1 4.0 ⫺0.1 2.1 ⫺5.4* 4.7
Pg (mm) ⫺6.5* 6.6 1.0 3.2 ⫺0.1 2.2 ⫺5.5* 6.0
me (mm) ⫺6.1* 7.2 0.8 2.6 0.8 2.5 ⫺4.6 5.1
Soft tissue Stomi (mm) ⫺2.3 4.5 ⫺2.2* 1.6 ⫺0.1 1.4 ⫺4.6* 2.0
Lower lip Li (mm) ⫺0.8 2.8 ⫺2.8* 1.8 ⫺1.1 2.0 ⫺4.6* 3.4
SLI (mm) ⫺2.8 2.4 ⫺0.4 1.8 0.1 1.6 ⫺3.2 2.3
PG= (mm) ⫺1.4 2.8 ⫺0.6 3.6 ⫺0.2 2.1 ⫺2.2 5.1
Me (mm) ⫺1.0 2.7 0.3 3.1 0.9 2.5 ⫺2.2 2.5
Divergent ML/NL (°) ⫺0.9 3.1 0.4 2.7 1.2 3.4 0.7 4.4
Abbreviations: SD, standard deviation.
*P ⬍ .05, measured between time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.

Results followed its underlying skeletal structure immediately

Horizontal and vertical soft and hard tissue
changes after mandibular advancement and setback
surgery (T0-T1), at 1 year (T1-T2), and at 12 years
(T2-T3) are presented in Tables 4 through 9, where
the mean and standard deviation for each time
interval are reported.
CHANGES IN THE FIRST YEAR OF OBSERVATION
(T0-T1, T1-T2)
Mandibular advancement of 4.9 mm at pogonion
(Pg) was accompanied by a significant anterior move-
ment of soft tissue of 3.7 mm at soft tissue pogonion
(PG=) (P ⬍ .05, Wilcoxon matched pairs) immediately
after the surgery. In the first year of observation hard
tissue showed a skeletal relapse of approximately 1.6
mm (33%) at Pg, which was accompanied by a similar
posterior soft tissue movement of 1.4 mm at PG=.
After mandibular setback of 6.5 mm at Pg, soft tissue
only slightly after surgery. Although there was a de-
cent relapsing movement of hard tissue structures
(15% at Pg), soft tissue continued its posterior move-
ment in the first year of observation (Table 5). Corre-
lations between the amount of surgical (T0-T1) hard
tissues movement and 1 year (T1-T2) soft tissue
changes, as well as 1 year soft and hard tissue changes
after either mandibular advancement or setback sur-
gery were weak (r ⬍ 0.5, Spearman).
CHANGES AT LONG-TERM FOLLOW-UP (T2-T3)
In the advancement patients, although skeletal re-
lapse continued in the horizontal plane of an other
20% at pogonion (Pg), soft tissue chin showed a
significant anterior movement of 0.9 mm at soft tissue
pogonion (PG=) (P ⬍ .05, Wilcoxon matched pairs)
during the long-term follow-up period between T2
and T3 (Table 4). Although significant inferior rota-

Table 6. VERTICAL CHANGES IN THE SKELETAL AND SOFT TISSUE CEPHALOMETRIC VARIABLES OF THE
ADVANCEMENT PATIENTS (n ⴝ 15)

Landmark T0-T1 SD T1-T2 SD T2-T3 SD T0-T3 SD

Dental Is (mm) 0.0 0.0 0.5 1.1 0.9 2.3 1.5* 1.7
Ii (mm) 0.3 1.6 0.2 1.2 0.2 1.8 0.7 2.0
Hard tissue B (mm) 1.7* 2.3 ⫺0.4 1.5 2.3* 3.8 3.1 3.9
Pg (mm) 0.7 2.9 0.0 1.6 1.5 3.8 2.3 5.8
me (mm) 2.3 5.4 0.6 2.9 1.5* 2.8 4.5 4.7
Soft tissue Stomi (mm) ⫺0.5 2.1 0.3 2.5 1.5* 1.9 1.3 2.6
Lower lip Li (mm) 1.3 3.5 ⫺1.0 2.7 ⫺0.1 2.4 0.1 3.9
SLI (mm) 0.7 2.8 0.1 2.5 ⫺0.1 2.5 0.8 3.6
PG= (mm) ⫺0.4 2.6 1.1 3.2 0.0 4.2 0.7 4.6
Me (mm) 1.7 2.3 ⫺0.6 3.1 1.5 2.1 2.7 1.6
Abbreviation: SD, standard deviation.
*P ⬍ .05, measured between time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.
2306 SOFT TISSUE PROFILE CHANGES

Table 7. VERTICAL CHANGES IN THE SKELETAL AND SOFT TISSUE CEPHALOMETRIC VARIABLES OF THE SETBACK
PATIENTS (n ⴝ 12)

Landmark T0-T1 SD T1-T2 SD T2-T3 SD T0-T3 SD

Dental Is (mm) 0.0 0.0 ⫺0.1 1.3 0.8 1.7 0.7 1.6
Ii (mm) ⫺0.8 3.2 ⫺0.3 1.8 1.8* 2.2 0.6 0.3
Hard tissue B (mm) ⫺0.7 4.0 ⫺1.2 2.1 2.1* 2.4 0.1 4.0
Pg (mm) ⫺0.3 2.8 0.1 3.3 0.8 2.3 0.7 3.9
me (mm) ⫺0.6 2.7 ⫺0.3 1.5 1.3 1.8 0.4 2.7
Soft tissue Stomi (mm) 1.4 2.3 0.9 2.2 0.1 1.6 2.3* 2.7
Lower lip Li (mm) 3.1* 3.2 ⫺0.8 1.8 1.1 2.6 3.4* 3.2
SLI (mm) 0.2 2.9 ⫺0.8 2.4 1.8* 2.4 1.2 2.7
PG= (mm) ⫺0.3 4.3 0.8 3.7 1.8 2.9 2.3* 2.6
Me (mm) 0.7 2.3 ⫺1.4 2.8 2.1 3.0 1.3 2.3
Abbreviation: SD, standard deviation.
*P ⬍ .05, measured between time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.

tion of the mandible with an increase of the man-
dibulo-nasal plane angle (ML/NL) (P ⬍ .05, Wilcoxon
matched pairs), mandibular soft tissue remained sta-
ble in the vertical plane (Table 5). In the setback
patients, hard and soft tissue chin remained stable in
the horizontal plane where as labrale inferius (Li)
showed further posterior movement during the long-
term follow-up period between T2 and T3 (Table 5).
An inferior rotation of the mandible with a small
increase of the mandibulo-nasal plane angle (ML/NL)
was accompanied by an inferior movement of hard
and soft tissue mandibular landmarks (Table 7). Cor-
relations between long-term (T2-T3) soft and hard
tissue changes after either mandibular advancement
or setback surgery were weak (r ⬍ 0.5, Spearman).
RELATIONSHIP BETWEEN SOFT TISSUE AND HARD
TISSUE MOVEMENTS IN THE HORIZONTAL PLANE
In both groups ratios between soft and hard tissue
changes increased from 1 year postoperatively at T2
to the long-term follow-up at T3 (Table 10). In the
advancement patients, the ratio at soft tissue pogo-
nion (PG=:Pg) was even 133% at T3, demonstrating an
increase in soft tissue thickness compared with values
at T0. In the setback group, all ratios were lower than
100%, demonstrating a reduction in thickness of
lower lip (Li:Ii) and chin (SLI:B-point, PG=:Pg). There
were no significant changes of the ratios (P ⬎ .05,
Wilcoxon matched pairs).
CHANGES OF WEIGHT
The preoperative weight of the retrognathic pa-
tients was a mean of 63 kg (range, 49 to 72 kg). Over
the whole observation period (T0-T3) there was a
significant increase of all patient’s weight of an aver-
age of 7.1 kg (range, 1 to 24 kg) (Table 11). The
preoperative weight of the prognathic patients was a
mean of 68 kg (range, 50 to 96 kg). Long-term (T0-T3)
change of all 12 patients’ weight of 3.8 kg (range,
⫺11 to 11 kg) was not significant because of 2 male
patients, who showed a decrease of weight of 6 kg
and 11 kg over the whole observation period (T0-T3)
(Table 11). The other 10 patients had a significant
increase in weight of mean 6.2 kg (range, 1 to 11 kg).
Correlations between long-term changes at mandibu-
lar soft tissue landmarks (Li, SLI, PG=) (T0-T3/ T2-T3)

Table 8. CHANGES IN SOFT TISSUE PROFILE OF THE UPPER LIP OF THE ADVANCEMENT PATIENTS (n ⴝ 15)

Landmark T0-T1 SD T1-T2 SD T2-T3 SD T0-T3 SD

Horizontal (mm) SLS 0.6 1.9 ⫺1.1 2.0 0.6 2.1 0.1 2.3
Ls 0.5 1.3 ⫺1.5 2.5 0.4 1.6 ⫺0.6 2.2
Stoms 0.8 1.8 ⫺1.1 3.0 ⫺0.5 2.5 ⫺0.8 3.1
Vertical (mm) SLS 0.5 2.6 1.6 2.9 0.1 2.7 2.2* 3.7
Ls 0.9 2.3 1.8* 2.2 ⫺1.6* 2.6 1.1* 2.3
Stoms ⫺0.1 2.3 0.9 2.0 0.7 1.9 1.5* 2.3
Angular (°) Cm-Sn-Ls ⫺0.1 3.6 0.7 3.0 0.9 3.3 1.5 3.1
G-Sn-PG= 3.0* 2.6 ⫺0.9 2.8 ⫺0.5 3.5 1.5 3.0
Abbreviation: SD, standard deviation.
*P ⬍ .05; measured between time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.
EGGENSPERGER ET AL 2307

Table 9. CHANGES IN SOFT TISSUE PROFILE OF THE UPPER LIP OF THE SETBACK PATIENTS (n ⴝ 12)

Landmark T0-T1 SD T1-T2 SD T2-T3 SD T0-T3 SD

Horizontal (mm) SLS 1.0 2.3 ⫺1.0* 1.0 ⫺0.7 1.4 ⫺0.7 2.1
Ls 1.0 2.3 ⫺2.0 1.1 ⫺0.3 1.2 ⫺1.3 2.3
Stms ⫺0.3 3.0 ⫺2.3* 1.6 ⫺0.6 1.5 ⫺3.1* 2.7
Vertical (mm) SLS ⫺0.3 2.1 1.4* 1.9 0.0 2.3 1.2 3.0
Ls 0.8 1.7 1.5* 1.1 0.9* 0.9 3.2* 2.3
Stms 0.8 1.9 0.8 1.2 1.1 1.9 2.7* 2.7
Angular (°) Cm-Sn-Ls ⫺0.1 4.7 5.0* 5.3 1.7 2.8 6.6* 4.1
G-Sn-PG= ⫺2.8* 3.4 0.7 3.1 2.3* 3.6 0.3 2.7
Abbreviation: SD, standard deviation.
*P ⬍ .05, measured between time intervals T0-T1, T1-T2, T2-T3, and T0-T3.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.

and patients weight (T0-T3) were weak (r ⬍ 0.5, Discussion

Spearman) in both (advancement and setback)
groups. Also, there was only weak correlation be-
tween the age of the patients and the change in
weight. Female and male patients showed no signifi-
cant difference in weight gain in the long-term (P ⬎
.05, Wilcoxon matched pairs).
CHANGES IN THE UPPER LIP PROFILE
Horizontal and vertical changes in upper lip profile
are shown in Tables 8 and 9.
In the advancement group, a slight forward move-
ment of all upper lip landmarks was observable in the
horizontal plane at the immediate postoperative stage
(T1) (Table 8). In the first year of observation (T1-T2)
there was a remarkable thinning and lengthening of
the upper lip that did not fully return to preoperative
thickness and shortness during the long-term period
(T2-T3). The correlations between labrale superius
(Ls) and labrale inferius/incisor inferior (Li/Ii) were
moderate during the first year (T1-T2) (r ⫽ 0.7, Spear-
man). Correlations between long-term (T1-T3) move-
ment of Li and total (T0-T3) patients weight changes
were weak (r ⬍ 0.05, Spearman). In the setback
group, an initial (T0-T1) forward movement at supe-
rior labial sulcus (SLS) and labrale superius (Ls) was
observable. After the mean postoperative period of 14
months (T2), all landmarks showed a noticeable pos-
terior and inferior movement that continued in the
long-term follow-up (T2-T3). In total (T0-T3), the up-
per lip was thinner and remarkably longer than pre-
operatively. The correlations between the move-
ments of labrale superius (Ls) and labrale inferius (Li)
were weak during the first year (T1-T2) as well as in
the long-term (T1-T3) period (r ⬍ 0.05, Spearman).
The correlation of movements of Ls and patients
weight changes was also weak (T0-T3, r ⬍ 0.05,
Spearman).
The aim of this study was to determine long-term
soft tissue changes an average of 12 years after
mandibular advancement or setback surgery and
which factors may be responsible for the observed
changes.
In a former publication,29 we reported that there is
skeletal relapse after mandibular advancement sur-
gery in a posterior direction of about 30% after the
first year postoperatively. Our results of this study
show that soft tissue landmarks in the 15 advance-
ment patient followed their underlying skeletal land-
marks (Pg, B-point, Ii) to 70% at soft tissue pogonion
(PG=) to 52% at inferior labial sulcus (SLI) and only to
32% at lower lip (li). Most previous articles report a
higher ratio of 100% of soft tissue chin (PG=, SLI)
whereas predictive ratios of lower lip vary between
38% and 80% (Table 1). Jensen et al8 explained the 1:1
ratio by the tight attachment of soft tissue chin to the
underlying skeletal basis. Lines and Steinhauser2
stated that the lower lip advanced at a 75% ratio to the
mandibular incision advancement, and soft tissue
pogonion advanced at a simple 100% ratio to hard
tissue pogonion advancement. They explained this
Table 10. CONVENTIONAL AND ALTERNATIVE
RATIO OF SOFT TISSUE CHANGES TO HARD TISSUE
MOVEMENT (n ⴝ 15)
Advancement Setback
12 Years
T0-T3/T0-T3
SLI:B Point (%) 76 60
PG=:Pg (%) 133 40
Li:Ii (%) 48 77
NOTE. All changes are in the horizontal axis.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac
Surg 2007.
2308
Table 11. WEIGHT CHANGES IN THE ADVANCEMENT AND SETBACK PATIENTS
Advancement
n⫽15
Mean SD
Increase of Weight (kg) Female 6.6* 7.1
Male 8.6* 4.8
Male
Total 7.1* 6.4
*P ⬍ .05, Wilcoxon matched pairs.
a
All 12 patients: 10 with increase and 2 with decrease of weight.
b
Only the 10 patients with increase in weight.
Eggensperger et al. Soft Tissue Profile Changes. J Oral Maxillofac Surg 2007.
different ratio of soft tissue chin and lower lip in 2
ways. The first explanation was that many patients
have deep bites before surgery, their lower lip pro-
truding because of contact with the upper incision.
Their second explanation was that even in patients
without a deep bite there is a soft tissue compensa-
tion where the lower lip pushes forward and attempts
to make a lip seal. Stella et al30 provided another
explanation, reasoning that increased soft tissue
thickness may have a tendency to absorb a larger
amount of skeletal movement without a perceptible
change in soft tissue contour, and thus produce a
lower ratio of soft to hard tissue change.
In our setback group, skeletal relapse was only 15%
of the initial mandibular setback31 with the 1-year
(T2) soft tissue ratios of 60% at inferior labial sulcus
(SLI), 63% at lower lip (Li), and only 36% at soft tissue
pogonion (PG=). It seems that especially the latter
(PG=) is determined mostly by itself more than the
underlying skeletal structure. Contrary to our results,
most previous articles reported higher ratios of 90%
to 100% of soft tissue chin (PG=, SLI), whereas pre-
dictive ratios of lower lip varied between 43% and
99% (Table 3). Gjorup and Athanasiou17 observed an
individual variation in the ratios that they explained
by the different preoperative soft tissue thickness at
different landmarks. Soncul and Bamber24 explained
the 1:1 ratio at soft tissue chin after mandibular set-
back surgery by the close proximity of the soft tissue
pogonion to the underlying bone, the mentalis mus-
cle and mental slips of the orbicularis oris muscle.
They also refer to the increased relaxation of the
lower lip after the tension, caused by the lower teeth,
was eliminated with a mandibular setback and there-
fore responsible for a low ratio at lower lip. Discrep-
ancies between our findings and those from previous
investigations could be partially explained by differ-
ences in sample size, case selections, surgical fixation
techniques, and amount of skeletal relapse.2,5-9,14-25,32
SOFT TISSUE PROFILE CHANGES
Setback
n⫽12
T0-T3
Range Mean SD Range
1 to 24 6.7* 4.5 2 to 11
4 to 14 2.8a 7.3 ⫺ 11 to 11
6.0*b 3.9 1 to 11
1 to 24 3.8a 6.8 ⫺ 11 to 11
6.2*b 3.8 1 to 11
In the long-term follow-up (T2-T3), our results
showed that soft tissue did not follow its hard tissue
counterparts in direction of movement after mandib-
ular advancement. Skeletal relapse continued with
posterior movement of the mandible, whereas soft
tissue landmarks moved further anteriorly. Further-
more, ratios for soft tissue lower lip (Li), mentolabial
fold (SLI), and chin (PG=) were shown to have in-
creased differently in the long-term follow-up, to 48%
(Li), 76% (SLI), and 133% (PG=). It is well known that
changes in facial esthetics following orthognathic sur-
gery are highly dependent on skeletal stability of the
surgical procedure. Our observed high ratio at PG=
may partially mask the patient’s profile again becom-
ing convex due to skeletal relapse. In the literature,
the longest soft tissue follow-up time after mandibular
advancement surgery is 5 years.12 This study from
Florida12 found similar ratios at PG= and Li but a
higher ratio at SLI (111%). Contrary to the advance-
ment group, our long-term results of the setback
group revealed that most of the soft and hard tissues
remained stable in the horizontal axis except for the
lower lip, which showed further posterior move-
ment. Similarly, ratios for mento-labial fold (SLI:B-
Point) and soft tissue chin (PG=:Pg) remained stable
and the ratio at lower lip (LI:Ii) increased. In the
literature, the longest follow-up time of previous stud-
ies, reporting on long-term changes of soft tissue after
mandibular setback, is 3 years.23 In agreement with
our results, these authors also reported stable ratios
from 1 to 3 years of observation at inferior labial
sulcus and soft tissue chin, whereas the ratio of lower
lip increased slightly by approximately 6%.
Concerning our results, the question arises, which
factors are responsible for our observed long-term
soft tissue changes. Contrary to a study from Florida9
that stated there is no association between facial soft
tissue thickness and patients weight changes, we
think that the increased weight in all of our advance-
EGGENSPERGER ET AL
ment patients in the long-term period (T2-T3) may
contribute to the increase in soft tissue thickness.
Considering that lower lip (Li) and mentolabial sulcus
(SLI) in these patients reduced in thickness over the
whole observation period, there must be other factors
also responsible for the long-term soft tissue behavior
in these 2 groups. In the literature,6,9,33-39 the normal
aging process is described to affect long-term behav-
ior of facial soft tissue. Skin thickness reaches a max-
imum in women at approximately age 35 and in men
at 45, decreasing gradually afterward.33 Considering
that the mean age of our patients was approximately
36 years, the total (T0-T3) increased soft tissue thick-
ness at soft tissue pogonion (PG=) in the advancement
group and at all mandibular landmarks in our setback
patients could also be the result of the aging process.
But there is still no explanation for the reduced thick-
ness at SLI and Li in the advancement patients. Prob-
ably skeletal remodeling may be responsible for the
decreased thickness at SLI and Li. It seems that, as
long as there is continuous remodeling of the under-
lying bone, as was observed in our advancement
group, there is not a stabile situation of the overlying
soft tissue. So if skeletal remodeling would stop one
day, there will probably be a thickening of soft tissue
chin in our advancement patients, as is observed in
our setback patients.
In the advancement patients, there was a reduction
of thickness and a lengthening of upper lip visible at
the end of the observation period. This occurred
predominantly during the first year postoperatively,
and was most probably due to the early mandibular
and lower lip movements. Although there is a dense
fascial-fatty layer of the upper lip, containing only
minimal fat and bounded tightly to the skin superficial
and to the perioral muscles deep to it, we think that
the slight increase of upper lip thickness in the long-
term (T2-T3) could be due to the observed significant
increase in weight. On the other hand, it is known
that the aging maxilla is continuously retroposi-
tioned.40 Therefore, our slight increase in upper lip
thickness from 1 to 12 years postoperatively (T2-T3)
may also be due to soft tissue compensation of this
maxillary retroposition. In our setback patients, there
was also a significant lengthening and a slight thin-
ning of the upper lip during the first year of observa-
tion, which, in contrast to the advancement patients,
continued in the long-term follow-up. This change in
thickness and length could be explained by the dif-
ferent, more vertical direction of traction of orbicu-
laris oris muscle after the surgery, compared with the
rather oblique anterior orientation of the muscle be-
fore mandibular setback. Our changes of upper lip in
the setback group during the first year of observation
are in agreement with previously reported re-
sults.17,23,26,41 In 1975, Wisth41 observed a lengthen-
2309
ing and a thinning of the upper lip after mandibular
setback surgery. He stated that the upper lip is pre-
operatively too short in prognathic patients, and sur-
gery brings the upper lip to a more physiologic length
and position. The same was stated by Gjorup and
Athanasiou,17 who explained that the upper lip, be-
cause of the abnormal incisal relationship before sur-
gery, is kept in a “pseudoposition” as a form of adap-
tation and compensation. The achievement of a
normal incisal relationship lengthens and flattens the
upper lip, leading to better lip competence and pos-
ture. Kajikawa26 observed a postoperative lengthen-
ing of the upper lip, but in contrast to our results,
accompanied by a thickening at the vermilion border.
He explained this as being due to the reduction of the
origins of the depressor anguli oris muscle when
setting the mandible back. Similar to our long-term
results of the upper lip, Mobarak et al23 also observed
a lengthening and thinning in their 3-year study.
The question as to whether the normal aging pro-
cess contributes significantly to these observed
changes of the upper lip is rather difficult to answer.
Unfortunately, there is still no consensus on the aging
process of the upper lip in the literature: whereas
some authors36,37 report that normal aging does not
appreciably change the upper lip, others42 describe
broadening and reduction in height with aging. In
accordance with our results, a study from Pennsylva-
nia33 also observed a lengthening and reduction of the
upper lip’s thickness with aging, which is explained
by the loss of underlying tone and bulk of the orbic-
ularis muscle.36,37 Another study from France39 also
observed a lengthening of the upper lip up to the age
of 35 and afterwards a shortening again. The obser-
vation in the present study of an increase in upper lip
length with subsequent reduction in maxillary incisor
exposure in both advancement and setback patients
over the whole observation of 12 years, delineates the
need for careful treatment planning especially in pa-
tients who have a starting low lip line.
Taken together, all these modifications may lead to
troublesome esthetic consequences: a big variation in
weight is generally not only dispersed throughout the
body, but might be also be reflected undesirably in
the face. A reduced upper incisal tooth exposure due
to lengthening of the upper lip may modify the attrac-
tiveness of the smile. Furthermore, aging is an inevi-
table process and, as mentioned above, will also
contribute to changed facial appearance. When dis-
cussing the treatment plan, patients should be advised
that weight change and aging are, so far, not predict-
able factors. Therefore, long-term prediction by the
conventional cephalometric method of especially
mandibular soft tissue profile changes after orthog-
nathic mandibular surgery cannot be made.
2310
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