J Oral Maxillofac Surg

66:98-103, 2008

Evaluation of the Soft and Hard Tissue

Changes After Anterior Segmental
Osteotomy on the Maxilla and Mandible
Je Uk Park, DDS, PhD, MS,* and Young-Sook Hwang, DDS†

Purpose: The purpose of this study was to determine the relationship between the changes of soft and
hard tissues after modified anterior segmental osteotomy on the maxilla and mandible and to evaluate
unintended facial changes using cephalometric and photometric analyses.
Materials and Methods: The subjects included 29 women and 1 man (22 to 50 years of age) who were
diagnosed as bialveolar or bimaxillary protrusion and underwent modified anterior segmental osteotomy
on the maxilla and mandible. Lateral cephalograms and lateral and frontal photographs taken preoper-
atively and postoperatively were analyzed.
Results: There was a significant change in all soft and hard tissue parameters except the labiomen-
tal angle. The ratio of upper lip to maxillary incisor retraction was 0.67:1 and the ratio of lower lip
to mandibular incisor retraction was 0.89:1. Nasolabial angle and philtrum length were increased,
and vermilion length and lip width were decreased. Nasal change could be kept as small as possible,
although slight widening of the nasal width and anti-tip rotation of the nasal tip were observed.
Conclusion: Anterior segmental osteotomy might be recommended as the treatment modality of choice in
patients with bimaxillary and/or dentoalveolar protrusion. Because the technique is simple, postoperative
complications are minimal, relapse is limited, and soft tissue changes in response to surgery are more
predictable.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:98-103, 2008

It is well-documented that East Asians generally have a
greater tendency toward bimaxillary or bialveolar pro-
trusion than Caucasians.1,2 Four-premolar extraction to
retract the anterior teeth was one of the treatment
choices of typical orthodontics. However, it has become
more complicated in adult patients because of the diffi-
culty in achieving physiologic tooth movement, longer
treatment time, relatively worse periodontal status, and
increasingly strict social conditions. Considering these
inherent limitations, surgery with extraction of premo-
lars and surgical retraction of anterior segments using
the subapical osteotomy technique is gaining accep-
tance as a better treatment modality than orthodontics
alone. Anterior segmental osteotomy on the maxilla was
first described by Cohn-Stock5 in 1921. Since then, mod-
ifications in the design of the soft tissue incisions and
Received from Kangnam St Mary’s Hospital, Medical College, the
Catholic University of Korea, Seoul, Korea.
*Associate Professor, Department of Craniomaxillofacial Surgery.
†Resident, Department of Orthodontics.
Address correspondence and reprint requests to Dr Park: #505
Banpo-Dong, Seocho-Gu, Seoul, 137-701, Korea; e-mail: jupark@
catholic.ac.kr
© 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6601-0016$34.00/0
doi:10.1016/j.joms.2005.09.007
bony osteotomies have been made by many surgeons
such as Wassmund,7 Cupar,6 Wunderer,8 and Bell and
Condit.3 However, many problems remained such as
necrosis of the repositioned anterior segment, devital-
ization of teeth (especially canines), widening of the alar
base, and anti-tip rotation of the nasal tip. To avoid such
complications, modified anterior segmental osteotomy
on the maxilla was developed and reported by the au-
thor at the European craniomaxillofacial surgeon’s con-
gress in Zurich in 1996. This new technique requires a
vestibular incision alone from canine to canine. A verti-
cal bone cut is performed on the extraction space. The
bicortical horizontal osteotomy between the canine root
tip and the apertura piriformis is then carried out to
connect the vertical osteotomies on the right and left
sides (Fig 1). “Bicortical” means that a palatal bone cut is
performed in 1 operation with the facial horizontal os-
teotomy.
There have been many reports in the literature of
hard and soft tissue changes after orthognathic surgery,
but very few about the anterior segmental surgery of the
maxilla and mandible. In addition, studies of the frontal
view of the face, as compared with profile studies, were
scarce. However, changes in frontal view are clearly of
substantial clinical importance and are often one of the
key criteria by which patients judge the success of the
treatment. Therefore, we evaluated changes in both

98
PARK AND HWANG 99

FIGURE 1. Modified anterior segmental osteotomy on the maxilla. A, An illustration of modified anterior segmental osteotomy shown in the skull.
B, Subperiosteal preparation and horizontal osteotomy were performed from the inferior side of the anterior nasal spine and apertura piriformis and
a sufficient gap was left from the root apex. C, The anterior segment is secured in a new position.
Park and Hwang. Soft and Hard Tissue Changes After Segmental Osteotomy. J Oral Maxillofac Surg 2008.

frontal and lateral views of the face before and after 5. Labrale superius (Ls): The most prominent
surgery. The aim of this report was to determine the point on the vermilion border of the upper lip
relationship between the changes of soft and hard tis- in the mid-sagittal plane.
sues after modified anterior segmental osteotomy on the 6. Stomion (Sto): An imaginary point at the cross-
maxilla and mandible and to evaluate unintended facial ing of the vertical facial midline and the hori-
changes using cephalometric and photometric analyses. zontal labial fissure between gently closed lips,
with teeth shut in the natural position.
7. Labrale inferius (Li): The most prominent point
Materials and Methods
on the vermilion border of the lower lip in the
The subjects included 29 women and 1 man (22 to 50 mid-sagittal plane.
years of age). They were diagnosed with bialveolar or
bimaxillary protrusion and underwent modified anterior
segmental osteotomy on the maxilla and mandible.
The preoperative/postoperative records consisted of
lateral cephalograms and lateral and frontal photo-
graphs. Postoperative measurements were taken at least
6 months after surgery. Lateral cephalograms with a
shadow of the facial soft tissue profile with the lips in
repose were obtained with barium sulfate from the
hairline to the sternum. Size difference between cepha-
lograms and photographs was corrected by superimpo-
sition using a V-ceph 4.0 (Cybermed Inc, Seoul, Korea)
program (Fig 2).
The reference planes constructed for measurements
were the Frankfort horizontal plane (H line) and the
nasion vertical plane, which is perpendicular to the FH
plane (V line) (Fig 3). The following landmarks were
used:

1. Soft-tissue nasion (N’): The deepest point on

the concavity overlying the area of the fronto-
nasal suture.
2. Pronasale (Prn): The most prominent or ante-
rior point of the nose tip.
3. Columella point (Cm): The most anterior point
on the columella of the nose.
FIGURE 2. Superimposition of cephalometrics to facial photograph.
4. Subnasale (Sn): A point located at the junction The photographs were superimposed to observe detailed structural
between the lower border of the nose and the changes in the nose and lip.
beginning of the upper lip at the mid-sagittal Park and Hwang. Soft and Hard Tissue Changes After Segmental
plane. Osteotomy. J Oral Maxillofac Surg 2008.
100 SOFT AND HARD TISSUE CHANGES AFTER SEGMENTAL OSTEOTOMY

FIGURE 3. Cephalometric landmarks.

Park and Hwang. Soft and Hard Tissue Changes After Segmental
Osteotomy. J Oral Maxillofac Surg 2008.

8. Soft-tissue B point (B’): The point at the deep-

est concavity between the labrale inferius and
soft-tissue pogonion.
9. Soft-tissue pogonion (Pg’): The most promi-
nent or anterior point on the soft tissue chin in
the mid-sagittal plane.
10. Incision anterius (IA): The most prominent
point on the maxillary incisor as determined by
a tangent to the incisor passing through the
subspinale.

FIGURE 5. Frontal view of facial photograph. a, Nasal width. b, Lip

width. c, Philtrum length. d, Vermilion length. e, Inner intercanthal
width.
Park and Hwang. Soft and Hard Tissue Changes After Segmental
Osteotomy. J Oral Maxillofac Surg 2008.

11. Incision anterius (IB): The most prominent

point on the mandibular incisor as determined
by a tangent to the incisor passing through the
supramentale.

In the lateral aspect, 4 linear and 3 angular measure-

ments were evaluated: upper lip and incisor protrusions,
lower lip and incisor protrusions, nasolabial angle, and the
nasal tip inclination and labiomental angle (Fig 4).

1. Upper lip protrusion: Ls to V line

2. Upper incisor protrusion: IA to V line
3. Lower lip protrusion: Li to V line
4. Lower incisor protrusion: IB to V line
5. Nasolabial angle: Cm-Sn-Ls
6. Nasal tip inclination: N’-Prn to H line
FIGURE 4. Profile view of superimposition of cephalometrics to facial 7. Labiomental angle: Li-B’-Pg’
photograph. a, Upper lip protrusion. b, Upper incisor protrusion. c,
Lower incisor protrusion. d, Lower lip protrusion. e, Nasolabial angle.
f, Nasal tip inclination. g, Labiomental angle. In the frontal aspect, 4 linear measurements were
Park and Hwang. Soft and Hard Tissue Changes After Segmental evaluated: nasal width, lip width, philtrum length,
Osteotomy. J Oral Maxillofac Surg 2008. and vermilion length (Fig 5). The ratios between
PARK AND HWANG 101

Table 1. SUMMARY OF SOFT TISSUE CHANGE IN LATERAL ASPECT

Measurement Cephalometric Point Preoperative Postoperative Change P Value

Upper lip protrusion (mm) Ls to V line 21.14 ⫾ 3.16 17.28 ⫾ 3.31 3.86 ⫾ 0.92 ⬍.01
Upper incisor protrusion (mm) IA to V line 11.14 ⫾ 3.29 5.21 ⫾ 3.26 5.93 ⫾ 1.15 ⬍.01
Lower lip protrusion (mm) Li to V line 19.49 ⫾ 3.76 13.94 ⫾ 3.59 5.55 ⫾ 1.19 ⬍.01*
Lower incisor protrusion (mm) IB to V line 7.57 ⫾ 3.54 1.14 ⫾ 3.73 6.43 ⫾ 1.25 ⬍.01*
Nasolabial angle (°) Cm-Sn-Ls 94.96 ⫾ 9.67 109.03 ⫾ 9.08 ⫺14.07 ⫾ 5.22 ⬍.01*
Nasal tip inclination (°) N=-Prn to H line 59.90 ⫾ 3.45 59.18 ⫾ 3.34 0.72 ⫾ 0.70 ⬍.01*
Labiomental angle (°) Li-B=-Pg 139.67 ⫾ 18.61 130.86 ⫾ 13.68 8.81 ⫾ 16.60 .042
*Indicates overall significant change (P ⬍ .01).
Park and Hwang. Soft and Hard Tissue Changes After Segmental Osteotomy. J Oral Maxillofac Surg 2008.

these measurements and the inner intercanthal width
were also calculated.
1. Nasal width: alar to alar
2. Lip width: commissure to commissure
3. Philtrum length: subnasale to stomion
4. Vermilion length: top of the cuspid bow to
stomion
The preoperative and postoperative changes were
calculated by subtraction of the corresponding values
for each patient, and the mean and standard deviation
were calculated for each measure. Data were analyzed
with a commercial statistical package (SAS for Windows,
version 8.1; SAS Institute Inc, Cary, NC).
The Wilcoxon signed rank test was used to analyze
the differences between preoperative and postoperative
measurements. Spearman correlation analysis was used
to analyze the correlation between hard and soft tissue
changes.
Results
Analyses of treatment (Tables 1, 2) showed that there
was a significant change in all the soft and hard tissue
parameters measured, except the labiomental angle.
The mean of the skeletal changes was a maxillary
setback of 5.93 ⫾ 1.15 mm, and a mandibular setback of
6.42 ⫾ 1.25 mm. The ratio of upper lip retraction to
maxillary incisor retraction was 0.67:1, and the ratio of
lower lip retraction to mandibular incisor retraction was
0.89:1. Spearman correlation coefficients were, respec-
tively, 0.21 and 0.47 (Fig 6).
According to the Spearman correlation analysis, the
correlation coefficient (r) was 0.646 for upper lip move-
ment of the upper incisor movement, and 0.756 for
lower lip movement of the lower incisor movement.
Figure 6 shows the correlation between hard and soft
tissue changes.
The increase of the nasolabial angle from 94.96 ⫾
9.67° to 109.03 ⫾ 9.08° gave patients a less prominent
upper lip and a more prominent nasal tip projection.
Even though the nasal change could be kept as small as
possible, nasal width was increased by 2.92% (P ⬍ .01),
nasal tip inclination was decreased by 0.73% (P ⬍ .01),
and slight widening of the alar base and anti-tip rotation
of the nasal tip were observed. The lip width and lip
thickness were decreased by 5.54% (P ⬍ .01) and 2.96%
(P ⬍ .01), respectively, and the philtrum length was
increased by 2.50% (P ⬍ .01). This indicates that the lip
got smaller. No statistically significant change occurred
in the labiomental angle.
Discussion
Anterior segmental osteotomy is indicated in the case
where substantial movement of the anterior teeth is
required, but where tooth repositioning by orthodontic
treatment alone is impossible because of objective fac-
tors such as the amount of tooth movement and peri-
odontal circumstances, and subjective factors such as
patient age, treatment time, and economic status.

Table 2. SUMMARY OF SOFT TISSUE CHANGE IN FRONTAL ASPECT

Measurement Preoperative Postoperative Change P Value

Nasal width (%) 103.23 ⫾ 7.54 106.14 ⫾ 7.17 ⫺2.91 ⫾ 3.57 ⬍.01*
Lip width (%) 135.28 ⫾ 12.04 129.74 ⫾ 10.78 5.54 ⫾ 5.46 ⬍.01*
Philtrum length (%) 67.42 ⫾ 7.37 69.93 ⫾ 6.79 ⫺2.51 ⫾ 1.67 ⬍.01*
Lip thickness (%) 24.32 ⫾ 4.20 21.36 ⫾ 3.60 2.96 ⫾ 2.44 ⬍.01*
*Indicates overall significant change (P ⬍ .01).
Park and Hwang. Soft and Hard Tissue Changes After Segmental Osteotomy. J Oral Maxillofac Surg 2008.
102 SOFT AND HARD TISSUE CHANGES AFTER SEGMENTAL OSTEOTOMY
FIGURE 6. Correlation between hard tissue change and soft tissue change.
Park and Hwang. Soft and Hard Tissue Changes After Segmental Osteotomy. J Oral Maxillofac Surg 2008.
Anterior segmental osteotomy, especially on the max-
illa, is not simple. Many modifications have been made
by many surgeons. Cohn-Stock5 originally introduced
vestibulopalatal osteotomy for the correction of progn-
athism, which consisted of retraction of the vestibular
incision and segmental bone cut. Wassmund7 intro-
duced palatal tunneling to palatal osteotomy for bodily
movement of the segment, without causing a deep over-
bite. Schuchardt12 performed the procedure in 2 stages
at a 4-week interval to prevent necrosis of the mobilized
segment. Wunderer8 improved the segmental osteot-
omy technique, obtaining better sight for the palatal
osteotomy and increased blood circulation through the
posterior nasal septal and nasopalatal artery by perform-
ing palatal incision. Nevertheless, many problems have
FIGURE 7. An illustration of horizontal and vertical bone cut in a
modified segmental osteotomy in the maxilla observed from the lateral
view.
Park and Hwang. Soft and Hard Tissue Changes After Segmental
Osteotomy. J Oral Maxillofac Surg 2008.
arisen. Bite was deepened because the vomer and nasal
septum were not detached and the osteotomized seg-
ment was just tipped backward. The 2-stage operation
was tedious for both patients and surgeons. There was
always a possibility of necrosis of not only bone but also
teeth at any time.
Such problems should be avoided, so the idea of a
modified segmental osteotomy technique developed.
This new technique requires a vestibular incision alone
from canine to canine. A vertical bone cut is performed
on the bicuspid extraction space, either first or second,
or even the first molar. Then, bicortical horizontal os-
teotomy between the canine root tip and the apertura
piriformis is carried out to connect the vertical osteoto-
mies on the right and left sides (Fig 7). Bicortical indi-
cates that a palatal bone cut is performed in 1 operation
with the facial horizontal osteotomy. However, it does
require dexterity of surgery and adequate armamentar-
ium.
There are many advantages with this new technique
compared with the conventional techniques. Bone re-
moval, including the vomer and nasal septum, which is
required for any directional movement of the osteoto-
mized segment, can be performed in full sight. The
possibility of necrosis is reduced because blood circula-
tion is guaranteed with intact palatal mucosa, including
palatal blood vessels. Nasal change can be minimized
with minimal retraction of the paranasal soft tissues.
This new technique also greatly saves operation time,
resulting in less postoperative stress.
There have been many reports in the literature of
hard and soft tissue changes after orthognathic surgery,
PARK AND HWANG
but few about the anterior segmental surgery of the
maxilla and mandible. First, this is because anterior seg-
mental osteotomy was rarely carried out on patients
with ordinary dentoalveolar protrusion in association
with the advance in orthodontic techniques, and Asians
generally have a greater tendency toward bimaxillary
protrusion than Caucasians, whereby so-called midface
(by Schwarz13) was considered normal. However, this is
now changing; many Asians regard retro-face (like Cau-
casian) as more beautiful and even their ideal type. At
present, demand for correction of bimaxillary or bial-
veolar protrusion is rapidly increasing. Second, anterior
segmental osteotomy was not applied to suitable cases,
resulting in dismay for both the patients and surgeons
and relegating this surgical technique to the back room.
Lines and Steinhauser,10 Lew et al,9 and Nadkarni11
reported profile changes following anterior segmental
osteotomy on the maxilla and mandible. The upper lip
to maxillary incisor retraction ratios were 0.5:1,10 0.43:
1,9 and 1:3,11 while the lower lip to mandibular incisor
retraction ratios were 0.75:1,10 0.71:1,9 and 2:3.11 These
ratios show that there were much smaller changes of
the soft tissue compared with that of this study. This
could be because of differences in the amount of pos-
terior movement of the upper anteriors, operative tech-
nique, lip thickness and lip strength, amount of fatty
tissue and musculature, and race. These factors must be
considered for future study. In addition to the sagittal
change of the upper and lower lips, the lip thickness
was clearly reduced and the philtrum length was in-
creased.4 However, care must be maintained in the
selection for this kind of surgery of patients who have
minimal vermilion border or long philtrum length.
While significant advances in the stability and predict-
ability of maxillary surgery have been made over the
years, minimal attention has been focused on the influ-
ence of maxillary surgery on the nose and facial soft
tissue. In this study on modified anterior segmental os-
teotomy, tissue dissection and horizontal bone cutting
were performed from the inferior aspect of the apertura
piriformis to minimize unfavorable nasal changes. The
alar base width was increased by 2.92%, based on the
inner intercanthal width, showing an actual increase of
1 mm. The nose inclination was increased by 1°, based
on the FH line, showing no clinically significant in-
crease. Changes in nasal form after anterior segmental
osteotomy could not be compared with those of other
methods because of the paucity of research on this
subject.
This study was a retrospective investigation of the soft
and hard tissue changes following anterior segmental
osteotomy on the maxilla and mandible in 30 adult
patients. The following results were obtained:
1. Through the modified segmental osteotomy
technique, the upper lip was moved backward
103
at a ratio of 67% to the change of the upper
incisor with the posterior movement of the an-
terior maxilla.
2. The lower lip was moved at a ratio of 89% to the
lower incisor.
3. The nasolabial angle was increased by an aver-
age of 14.1°.
4. Although the nasal change could be kept as
small as possible, slight widening of the nasal
width and anti-tip rotation of the nasal tip were
observed.
5. The philtrum length was increased, while the lip
thickness and lip width were decreased.
Anterior segmental osteotomy might be recom-
mended as the treatment modality of choice in patients
with bimaxillary and/or dentoalveolar protrusion. The
technique is simple, postoperative complications are
minimal, relapse is limited, and soft tissue changes in
response to surgery are more predictable.
Acknowledgments
The authors thank Prof Chang Bae, Prof Yoon-Ah Kook, and Dr
Sung-Min Kang for their advice and guidance throughout this in-
vestigation, and Dr Kwang Yoo Kim for writing the computer
programs used and for his help with the statistical analysis.
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