The pur pos e of t hi s s t udy wa s t o i nv e s t i g a t e c ha ng e s i n f a c i a l mor phol og y a f t e r pa r t i a l ma x i l l e c t omy a nd r e c ov e r y a f t e r de nt o- ma x i l l a r y pr os t he s i

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Fac i al Ae s t he t i c Anal y s i s o f Pr o s t he t i c Re c o v e r y af t e r Par t i al Maxi l l e c t o my Us i ng a No n- Co nt ac t 3 - Di me ns i o nal Di g i t i s e r

Tomoy uki Ka nbe � , Sa t os hi Yokoo � , Ma s a r u Og a wa � , Yu Ta ka y a ma � , Aki nor i Gomi � a nd Ta ka y a Ma ki g uc hi �

1 Department of Oral and Maxillofacial Surgery・Plastic Surgery,Gunma University Graduate School of Medicine,3-39-22 Showa-machi, Maebashi,Gunma 371-8511,Japan

Abstract

Background& Aims:

The pur pos e of t hi s s t udy wa s t o i nv e s t i g a t e c ha ng e s i n f a c i a l mor phol og y a f t e r pa r t i a l ma x i l l e c t omy a nd r e c ov e r y a f t e r de nt o- ma x i l l a r y pr os t he s i s pl a c e me nt .

Methods:

For f a c i a l mor phol og y me a s ur e - me nt s ,t he non- c ont a c t 3 - di me ns i ona l( 3 D)di g i t i s e r a nd t he a na l y t i c a l s of t wa r e we r e us e d f or 2 1 pa t i e nt s wi t h de f e c t s c l a s s i f i e d i nt o Cl a s s I or I I of t he Ar a ma ny c l a s s i f i c a t i on.

Results:

I t wa s qua nt i t a t i v e l y de mons t r a t e d t ha t f a c i a l de f or mi t i e s r e s ul t i ng f r om pa r t i a l ma x i l l e c t omy we r e due t o c onc a v i t i e s f r om t he s ubna s a l poi nt t o t he me nt ol a bi a l g r oov e i n t he v e r t i c a l r a ng e ,a nd f r om t he r e g i on a r ound t he na s a l a l a r t o t he a nt e r i or c he e k i n t he l a t e r a l r a ng e .Fa c i a l f e a t ur e s a nt e r ol a t e r a l l y e x pa nde d on t he de f e c t e d s i de i n v ol ume wi t h t he pr os t he s i s .Fa c i a l di s f i g ur e me nt e x t e nde d t o t he l owe r f a c e ,a nd i mpr ov e me nt of t he s e de f or mi t i e s wa s a l s o obs e r v e d wi t h t he pr os t he s i s .Us i ng t he non- c ont a c t 3 D di g i t i s e r ,t he di r e c t i on a nd a mount of mov e me nt of t he f a c i a l c ompone nt s wi t hi n t he mi d-a nd t he l owe r f a c e r e g i ons we r e 3 - di me ns i ona l l y de t e r mi ne d, e na bl i ng r a pi d a nd a c c ur a t e i de nt i f i c a - t i on of f a c i a l de f or mi t i e s , a nd r e c ov e r y of t he f a c i a l mor phol og y wi t h pr os t he s i s .

Conclusion:

Thi s i s t he f i r s t s t udy t o a na l ys e of pr os t he s i s - i nduc e d c ha ng e s i n f a c i a l mor phol og y a f t e r pa r t i a l ma x i l l e c t omy wi t h a non- c ont a c t 3 D di g i t i s e r .

I nt r o d uc t i o n

Mi df a c e de f or mi t i e s a f t e r ma x i l l e c t omy ma r ke dl y i nf l ue nc e pa t i e nt ’ s s oc i a l l i v e s .

�

Fa c i a l mor phol og y a nd f unc t i on a r e r e c ov e r e d by c ombi ni ng r e c ons t r uc - t i v e s ur g e r y

��

a nd

/

or de nt o- ma x i l l a r y pr os t he s i s

��

a f t e r ma x i l l e c t omy . The de nt o- ma x i l l a r y pr os t he s i s ma y be s i mpl y a dj us t e d a nd t hus a c c ommoda t e s f a c i a l c ha ng e s ov e r t i me

��

;howe v e r ,t he r e a r e no obj e c t i v e e v a l ua t i ons of t he a e s t he t i c e f f e c t s of t he s e pr os t he s e s . The a e s t he t i c g oa l of t he de nt o- ma x i l l a r y pr os t he s i s i s ba s e d on t he a e s t he t i c j udg me nt s of pa t i e nt s a nd phy s i - c i a ns ,a nd i n ma ny c a s e s ,t he s e g oa l s di f f e r .The r e f or e , a s i mpl e a nd obj e c t i v e me t hod f or e v a l ua t i ng f a c i a l mor phol og y i s ne c e s s a r y f or c r e a t i ng a c ommon v i e w- poi nt f or t he pa t i e nt a nd t r e a t i ng phy s i c i a n.

�

The pur pos e of t hi s s t udy wa s t o i nv e s t i g a t e c ha ng e s i n f a c i a l mor phol og y a f t e r pa r t i a l ma x i l - l e c t omy a nd r e c ov e r y a f t e r de nt o- ma x i l l a r y pr os t he s i s pl a c e me nt . We a l s o s oug ht t o e s t a bl i s h a n obj e c t i v e me t hod f or e v a l ua t i ng pr os t he s i s pl a c e me nt e f f e c t i v e - ne s s f r om a n a e s t he t i c v i e wpoi nt a s a pi l ot s t udy .

The non- c ont a c t 3 - di me ns i ona l( 3 D)di g i t i s e r i s a ne w pr e c i s e a na l y t i c a l a ppa r a t us us e d i n t he f i e l ds of or a l a nd ma x i l l of a c i a l s ur g e r y ,pl a s t i c a nd r e c ons t r uc - t i v e s ur g e r y ,a e s t he t i c s ur g e r y a nd de nt i s t r y .

��

Thi s i s t he f i r s t r e por t on f a c i a l mor phol og y c ha ng e s r e s ul t - i ng f r om de nt o- a l v e ol a r pr os t he s i s pl a c e me nt a f t e r pa r t i a l ma x i l l e c t omy a na l y s e d wi t h a non- c ont a c t 3 D di g i t i s e r .

Article Information

Key words:

dento-maxillary prosthesis, partial maxillectomy,

non-contact 3-dimensional digitiser, facial morphology,

principal component analysis

Publication history: Received: August 21,2017 Revised: September 29,2017 Accepted: October 3,2017

Corresponding author: Satoshi Yokoo

Department of Oral and Maxillofacial Surgery・Plastic Surgery,Gunma University Graduate School of Medicine, 3-39-22 Showa-machi,Maebashi,Gunma 371-8511,Japan Tel:＋81-27-220-8484

E-mail:syokoo＠gunma-u.ac.jp

Or i g i nal

(2)

Mat e r i al s and Me t ho d s

The Gunma Uni v e r s i t y Et hi c s Commi t t e e a p- pr ov e d a l l a s pe c t s of t hi s s t udy( No. 2 0 1 7

-

1 1 8 ) .

Fi f t y - e i g ht pa t i e nt s unde r we nt pa r t i a l ma x i l - l e c t omy f ol l owe d by de nt o- ma x i l l a r y pr os t he s i s t r e a t - me nt a t De pa r t me nt of Or a l a nd Ma x i l l of a c i a l Sur g e r y Gunma Uni v e r s i t y Hos pi t a l be t we e n 2 0 1 3 a nd 2 0 1 6 we r e i nc l ude d i n t hi s s t udy . The r e we r e 2 1 pa t i e nt s wi t h de f e c t s c l a s s i f i e d i nt o Cl a s s I or I I of t he Ar a ma ny c l a s s i f i c a t i on

��

( Ta bl e 1 a nd Fi g . 1 ) ,c ompr i s i ng 1 3

me n a nd 8 wome n,r a ng i ng i n a g e f r om 4 1 t o 9 1 y e a r s ( me di a n:7 0 y e a r s ol d) . The pr i ma r y di s e a s e wa s s qua mous c e l l c a r c i noma i n 1 8 pa t i e nt s ,ma l i g na nt me l a noma i n 2 ,a nd odont og e ni c my x oma i n one .The Ar a ma ny c l a s s i f i c a t i on wa s c l a s s I a nd I I i n 1 0 a nd 1 1 pa t i e nt s .The buc c a l muc os a wa s c onc omi t a nt l y r e s e c t - e d a nd r e c ons t r uc t e d by s ki n f l a p or s ki n g r a f t i ng i n a l l Cl a s s I pa t i e nt s .

Thi s s t udy e x c l ude d Cl a s s I I I t o I V of t he Ar a ma ny c l a s s i f i c a t i on f or c ompa r i s on of t he l a t e r a l i t y of t he de f e c t i v e s i de a nd t he nor ma l s i de .

Table 1 Patients

Case Age Sex Diagnosis maxillary

resection Aramany

classification Defect of

buccal mucosa Reconstruction of buccal mucosa

1 82 F SCC Partial � ＋ D-P※flap

2 69 M SCC Partial � － Skin graft

3 68 F SCC Partial � － Reefing

4 81 M SCC Partial � ＋ Skin graft

5 67 M Malignant melanoma Partial � － Forearm flap 6 65 M Malignant melanoma Partial � － Reefing

7 68 F SCC Partial � ＋ Forearm

10 63 M SCC Partial � ＋ Reefing

11 77 M SCC Partial � － Reefing

12 41 M Odontogenic Myxoma Partial � － Skin graft

14 80 F SCC Partial � ＋ Skin graft 15 91 M SCC Partial � ＋ Skin graft

20 62 F SCC Partial � ＋ Skin graft 21 74 F SCC Partial � － Skin graft

※ SCC:Squamous cell carcinoma,D-P:Deltopectoralis

Fig.1 Aramany classification

The Class I and II patients of Aramany classification were analysed. The buccal mucosa was concomitantly resected and reconstructed by skin flap or skin grafting in all Class I patients

Operative and prosthetic method for partial maxillectomy

We de f i ne d r e s e c t i on of t he ma x i l l a r y r e g i on l owe r t ha n t he i nf e r i or or bi t a l f or a me n a s pa r t i a l ma x i l - l e c t omy ,a nd r e s e c t i on i nc l udi ng t he i nf e r i or or bi t a l f or a me n c ons e r v i ng t he or bi t a l f l oor a s s ubt ot a l ma x i l - l e c t omy

�

( Fi g . 2 ) . Whe n t he s a f e t y ma r g i n of t he r e s e c t i on e x t e nds t o t he buc c a l muc os a ,s ki n f l a p t r a ns -

pl a nt a t i on or g r a f t i ng i s c ompl e t e d t o pr e v e nt pos - t ope r a t i v e s c a r c ont r a c t ur e s t ha t r e s ul t i n f a c i a l di s - f i g ur e me nt( Fi g . 3 ) . Pos t ope r a t i v e ma x i l l a r y de f e c t s a r e not c l os e d by r e c ons t r uc t i v e ma t e r i a l s( i . e .mus - c ul oc ut a ne ous f l a ps

��

) .I n our i ns t i t ut i on,a s a r ul e , t he de f e c t s a r e c l os e d by t he de nt o- ma x i l l a r y pr os t he s i s i n or de r t o di s c ov e r t umour r e c ur r e nc e a nd t o de a l wi t h c ha ng e s i n t he pos t ope r a t i v e f a c i a l a ppe a r a nc e i mme di a t e l y

��

( Fi g . 4 ) .

Reference points,lines,and planes

For f a c i a l mor phol og y me a s ur e me nt s ,t he non- c ont a c t 3 D di g i t i s e r Mor phe us 3 D ( Mor pe us ,Se on- g na m,Kor e a )wa s us e d. Thi s de v i c e s c a ns s ur f a c e s wi t h a s e mi c onduc t or l a s e r s l i t be a m a nd a c qui r e s i ma g e s i n t he f r ont a l a nd bi l a t e r a l 4 5

°

di r e c t i ons us i ng a s i ng l e CCD c a me r a . The s e i ma g e da t a i n t he 3 di r e c t i ons a r e t he n r e c ons t r uc t e d i nt o a 3 D i ma g e .The r e s ol ut i on wa s 0 . 2 mm,a nd t he a c qui s i t i on t i me wa s e i g ht s e c onds i n e a c h di r e c t i on.The pa t i e nt s a t on a c ha i r f or me a s ur e me nt s wi t h t he uppe r ha l f of t he body pos i t i one d v e r t i c a l l y r e l a t i v e t o t he f l oor .The pa t i e nt ’ s he a d wa s f i x e d on a he a d r e s t a t a pos i t i on t ha t mi ni mi s e d t he bl i nd a r e a of t he s l i t be a m,a nd t wo i ma g e pa t t e r ns( wi t h a nd wi t hout pr os t he s i s )we r e r e c or de d( Fi g . 5 ) .

I n t he a na l y s i s ,r e f e r e nc e poi nt s we r e s e t ba s e d on t he a nt hr opome t r i c l a ndma r ks

��

:t he uppe r f a c e ( a r ound t he e y e l i d) ,

entcanthion(

En)a nd

ectocanthion(

E) ;mi df a c e( a r ound t he na s a l a l a r ) ,

alare(

Al ) , a nd

subnasale

( Sn) ;l owe r f a c e ( a r ound t he l i ps ) ,

stomion

( St o) ,

labrale superius(

Ls ) ,

labrale inferius

( Li ) ,a nd

chelion(

Ch) .The f a c e wa s di v i de d i nt o t he de f e c t i v e s i de( D- s i de )a nd t he nor ma l s i de( N- s i de ) ( Fi g . 6 ) .

The n,t he c oor di na t e ax e s a nd r e f e r e nc e pl a ne s we r e e s t a bl i s he d.A s t r a i g ht l i ne pa s s i ng t hr oug h t he bi l a t e r a l En wa s s e t a s t he X- a x i s ,a nd t he mi dpoi nt be t we e n t he bi l a t e r a l En wa s de f i ne d a s t he c oor di na t e or i g i n poi nt ,O.The pl a ne e s t a bl i s he d by t he X- a x i s a nd Al on t he N- s i de wa s r e g a r de d a s t he f a c i a l f r ont a l pl a ne .A s t r a i g ht l i ne pa s s i ng t hr oug h O on t he f a c i a l

Fig.2 Operative procedure of partial maxillectomy and subtotal

maxillectomy

We defined resection of the maxillary region lower than the inferior orbital foramen as partial maxillectomy(A), and resection including the inferior orbital foramen con- serving the orbital floor as subtotal maxillectomy(B).

Fig.3 Reconstruction of defect of the buccal mucosa for safty margin of the tumour resection

When the safety margin of the resection extends to the buccal mucosa,skin flap transplantation(A:vascularised free forearm flap)or grafting(B)is completed to prevent postoperative scar contractures that result in facial disfigurement.

Fig.4 Prosthetic procedure for partial maxillectomy

For aesthetic change of facial morphology after maxillectomy,reliable 3D identification of defect-induced facial disfigurement and recovery by reconstructive surgery and/ or dento-maxillary prosthesis is important.(A):without prosthesis,(B)with prosthesis.

(A) (B)

(B) (A)

(3)

Mat e r i al s and Me t ho d s

The Gunma Uni v e r s i t y Et hi c s Commi t t e e a p- pr ov e d a l l a s pe c t s of t hi s s t udy( No. 2 0 1 7

-

1 1 8 ) .

Fi f t y - e i g ht pa t i e nt s unde r we nt pa r t i a l ma x i l - l e c t omy f ol l owe d by de nt o- ma x i l l a r y pr os t he s i s t r e a t - me nt a t De pa r t me nt of Or a l a nd Ma x i l l of a c i a l Sur g e r y Gunma Uni v e r s i t y Hos pi t a l be t we e n 2 0 1 3 a nd 2 0 1 6 we r e i nc l ude d i n t hi s s t udy . The r e we r e 2 1 pa t i e nt s wi t h de f e c t s c l a s s i f i e d i nt o Cl a s s I or I I of t he Ar a ma ny c l a s s i f i c a t i on

��

( Ta bl e 1 a nd Fi g . 1 ) ,c ompr i s i ng 1 3

me n a nd 8 wome n,r a ng i ng i n a g e f r om 4 1 t o 9 1 y e a r s ( me di a n:7 0 y e a r s ol d) . The pr i ma r y di s e a s e wa s s qua mous c e l l c a r c i noma i n 1 8 pa t i e nt s ,ma l i g na nt me l a noma i n 2 ,a nd odont og e ni c my x oma i n one .The Ar a ma ny c l a s s i f i c a t i on wa s c l a s s I a nd I I i n 1 0 a nd 1 1 pa t i e nt s .The buc c a l muc os a wa s c onc omi t a nt l y r e s e c t - e d a nd r e c ons t r uc t e d by s ki n f l a p or s ki n g r a f t i ng i n a l l Cl a s s I pa t i e nt s .

Thi s s t udy e x c l ude d Cl a s s I I I t o I V of t he Ar a ma ny c l a s s i f i c a t i on f or c ompa r i s on of t he l a t e r a l i t y of t he de f e c t i v e s i de a nd t he nor ma l s i de .

Table 1 Patients

Case Age Sex Diagnosis maxillary

resection Aramany

classification Defect of

buccal mucosa Reconstruction of buccal mucosa

1 82 F SCC Partial � ＋ D-P※flap

5 67 M Malignant melanoma Partial � － Forearm flap 6 65 M Malignant melanoma Partial � － Reefing

7 68 F SCC Partial � ＋ Forearm

12 41 M Odontogenic Myxoma Partial � － Skin graft

14 80 F SCC Partial � ＋ Skin graft 15 91 M SCC Partial � ＋ Skin graft

20 62 F SCC Partial � ＋ Skin graft 21 74 F SCC Partial � － Skin graft

※ SCC:Squamous cell carcinoma,D-P:Deltopectoralis

Fig.1 Aramany classification

The Class I and II patients of Aramany classification were analysed. The buccal mucosa was concomitantly resected and reconstructed by skin flap or skin grafting in all Class I patients

Operative and prosthetic method for partial maxillectomy

We de f i ne d r e s e c t i on of t he ma x i l l a r y r e g i on l owe r t ha n t he i nf e r i or or bi t a l f or a me n a s pa r t i a l ma x i l - l e c t omy ,a nd r e s e c t i on i nc l udi ng t he i nf e r i or or bi t a l f or a me n c ons e r v i ng t he or bi t a l f l oor a s s ubt ot a l ma x i l - l e c t omy

�

( Fi g . 2 ) . Whe n t he s a f e t y ma r g i n of t he r e s e c t i on e x t e nds t o t he buc c a l muc os a ,s ki n f l a p t r a ns -

pl a nt a t i on or g r a f t i ng i s c ompl e t e d t o pr e v e nt pos - t ope r a t i v e s c a r c ont r a c t ur e s t ha t r e s ul t i n f a c i a l di s - f i g ur e me nt( Fi g . 3 ) . Pos t ope r a t i v e ma x i l l a r y de f e c t s a r e not c l os e d by r e c ons t r uc t i v e ma t e r i a l s( i . e .mus - c ul oc ut a ne ous f l a ps

��

) .I n our i ns t i t ut i on,a s a r ul e , t he de f e c t s a r e c l os e d by t he de nt o- ma x i l l a r y pr os t he s i s i n or de r t o di s c ov e r t umour r e c ur r e nc e a nd t o de a l wi t h c ha ng e s i n t he pos t ope r a t i v e f a c i a l a ppe a r a nc e i mme di a t e l y

��

( Fi g . 4 ) .

Reference points,lines,and planes

For f a c i a l mor phol og y me a s ur e me nt s ,t he non- c ont a c t 3 D di g i t i s e r Mor phe us 3 D ( Mor pe us ,Se on- g na m,Kor e a )wa s us e d. Thi s de v i c e s c a ns s ur f a c e s wi t h a s e mi c onduc t or l a s e r s l i t be a m a nd a c qui r e s i ma g e s i n t he f r ont a l a nd bi l a t e r a l 4 5

°

di r e c t i ons us i ng a s i ng l e CCD c a me r a . The s e i ma g e da t a i n t he 3 di r e c t i ons a r e t he n r e c ons t r uc t e d i nt o a 3 D i ma g e .The r e s ol ut i on wa s 0 . 2 mm,a nd t he a c qui s i t i on t i me wa s e i g ht s e c onds i n e a c h di r e c t i on.The pa t i e nt s a t on a c ha i r f or me a s ur e me nt s wi t h t he uppe r ha l f of t he body pos i t i one d v e r t i c a l l y r e l a t i v e t o t he f l oor .The pa t i e nt ’ s he a d wa s f i x e d on a he a d r e s t a t a pos i t i on t ha t mi ni mi s e d t he bl i nd a r e a of t he s l i t be a m,a nd t wo i ma g e pa t t e r ns( wi t h a nd wi t hout pr os t he s i s )we r e r e c or de d( Fi g . 5 ) .

I n t he a na l y s i s ,r e f e r e nc e poi nt s we r e s e t ba s e d on t he a nt hr opome t r i c l a ndma r ks

��

:t he uppe r f a c e ( a r ound t he e y e l i d) ,

entcanthion(

En)a nd

ectocanthion(

E) ;mi df a c e( a r ound t he na s a l a l a r ) ,

alare(

Al ) , a nd

subnasale

( Sn) ;l owe r f a c e ( a r ound t he l i ps ) ,

stomion

( St o) ,

labrale superius(

Ls ) ,

labrale inferius

( Li ) ,a nd

chelion(

Ch) .The f a c e wa s di v i de d i nt o t he de f e c t i v e s i de( D- s i de )a nd t he nor ma l s i de( N- s i de ) ( Fi g . 6 ) .

The n,t he c oor di na t e ax e s a nd r e f e r e nc e pl a ne s we r e e s t a bl i s he d.A s t r a i g ht l i ne pa s s i ng t hr oug h t he bi l a t e r a l En wa s s e t a s t he X- a x i s ,a nd t he mi dpoi nt be t we e n t he bi l a t e r a l En wa s de f i ne d a s t he c oor di na t e or i g i n poi nt ,O.The pl a ne e s t a bl i s he d by t he X- a x i s a nd Al on t he N- s i de wa s r e g a r de d a s t he f a c i a l f r ont a l pl a ne .A s t r a i g ht l i ne pa s s i ng t hr oug h O on t he f a c i a l

Fig.2 Operative procedure of partial maxillectomy and subtotal

maxillectomy

We defined resection of the maxillary region lower than the inferior orbital foramen as partial maxillectomy(A), and resection including the inferior orbital foramen con- serving the orbital floor as subtotal maxillectomy(B).

Fig.3 Reconstruction of defect of the buccal mucosa for safty margin of the tumour resection

When the safety margin of the resection extends to the buccal mucosa,skin flap transplantation(A:vascularised free forearm flap)or grafting(B)is completed to prevent postoperative scar contractures that result in facial disfigurement.

Fig.4 Prosthetic procedure for partial maxillectomy

For aesthetic change of facial morphology after maxillectomy,reliable 3D identification of defect-induced facial disfigurement and recovery by reconstructive surgery and/ or dento-maxillary prosthesis is important.(A):without prosthesis,(B)with prosthesis.

(A) (B)

(B) (A)

(4)

f r ont a l pl a ne v e r t i c a l l y t o t he X- a x i s wa s de f i ne d a s t he Y- a x i s , a nd a s t r a i g ht l i ne pa s s i ng t hr oug h O pos i t i one d v e r t i c a l l y t o t he f a c i a l f r ont a l pl a ne wa s de f i ne d a s t he Z- a x i s .Onl y t he X- a x i s wa s c or r e c t e d t o be c ome a pos i t i v e v e c t or f r om t he N-t o D- s i de( Fi g . 7 ) .

Analysis of facial morphology

For a na l y s i s of f a c i a l mor phol og y ,t he a na l y t i c a l s of t wa r e 3 D- Rug l e 7( Me di c Eng i ne e r i ng Cor p, Ky ot o, J a pa n)wa s us e d.

A mi r r or i ma g e of t he N- s i de wa s pr e pa r e d a nd ma t c he d t o t he D- s i de , a nd t he f ol l owi ng a na l y s e s we r e c a r r i e d out( Fi g . 8 ) . Fi r s t ,t o i nv e s t i g a t e how t he D- s i de wi l l be c ha ng e d by pr os t he s i s pl a c e me nt ,t he

D- s i de da t a wi t hout pr os t he s i s we r e s upe r i mpos e d on t he D- s i de da t a wi t h pr os t he s i s .The di f f e r e nc e s i n t he c oor di na t e v a l ue s( x , y , z )of t he r e f e r e nc e poi nt s on t he uppe r f a c e ,mi df a c e ,a nd l owe r f ac e r e g i ons we r e de t e r - mi ne d, a nd t he di r e c t i on a nd a mount of mov e me nt wa s a na l y s e d.The a mount of mov e me nt wa s s i g ni f i c a nt i n ni ne i t e ms ,a nd t he s e i t e ms we r e s ubj e c t e d t o pr i nc i pa l c ompone nt a na l y s i s .

��

The Ma nnWhi t ne y U t e s t wa s us e d t o c ompa r e di f f e r e nc e s be t we e n 2 e x a mi na t i on i t e ms .A s i g ni f i c a nt di f f e r e nc e be t wwe n t he g r oups i f

Fig.5 Measurement method using the non-contact 3-D digitiser,Morpheus 3-D

Morpheus 3-D scanner(A)scans surfaces with a semiconductor laser slit beam and acquires images in the frontal and bilateral 45°directions using a single CCD camera.The patient sat on a chair for measurements with the upper half of the body positioned vertically relative to the floor.The patient’s head was fixed on a head rest at a position that minimised the blind area of the slit beam,and two image patterns(with and without prosthesis)were recorded(B).

Fig.6 Anthropological facial landmarks

Reference points,the upper face(around the eyelid),entcanthion(En)and ectocanthion(Ex);midface(around the nasal alar),alare(Al),andsub- nasale(Sn);lower face(around the lips),stomion(Sto),labrale superius (Ls),labrale inferious(Li),andchelion(Ch),were set based on the anth- ropometric landmarks(A). The face was divided into the defective side (D-side)and the normal side(N-side)(B).

Fig.7 Reference lines and planes

A straight line passing through the bilateral En was set as the X-axis,and the midpoint between the bilateral En was defined as the coordinate origin point,O.

The plane established by the X-axis and Al on the N-side was regarded as the facial frontal plane.A straight line passing through O on the facial frontal plane vertically to the X-axis was defined as the Y-axis, and a straight line passing through O positioned vertically to the facial frontal plane was defined as the Z-axis.

(A) (B)

t he t e s t s howe d a p- v a l ue l e s s t ha n 0 . 0 5 .I n a ddi t i on, us i ng t he s t a t i s t i c a l a na l y s i s s of t wa r e ,St a t f l e x v e r .6 ( Ar t e c h. Co. ,Lt d. ,Os a ka ,J a pa n) ,t he s ol ut i ons of c ha r a c t e r i s t i c e qua t i ons we r e de t e r mi ne d us i ng t he v a r i a nc e - c ov a r i a nc e ma t r i x pr e pa r e d by s t a nda r di z i ng t he v a r i a bl e s . The e i g e nv a l ue ,c ont r i but i on r a t i o, a c c umul a t e d c ont r i but i on r a t i o,a nd f a c t or l oa di ng we r e out put . The pr i nc i pa l c ompone nt s c or e was c a l c ul a t e d f r om t he pr oduc t of t he s t a nda r di s e d v a r i - a bl e s a nd f a c t or l oa di ng .

Ne x t ,t he r e c ov e r y of f a c i a l mor phol og y wa s i nv e s - t i g a t e d a s f ol l ows :1 )t he di s t a nc e a nd t he v ol ume of t he g a p be t we e n s upe r i mpos e d f a c i a l s ur f a c e g e ne r a t e d on t he D- s i de we r e a na l y s e d a s pr os t he s i s pl a c e me nt - i nduc e d c ha ng e s ;2 )t he N- s i de da t a wi t h a nd wi t hout pr os t he s i s we r e s upe r i mpos e d t o i nv e s t i g a t e t he i nf l u- e nc e of pr os t he s i s ,a nd 3 )t he D- s i de da t a wi t h pr os t h- e s i s we r e ma t c he d t o N- s i de da t a t o i nv e s t i g a t e r e c ov - e r y of f a c i a l a s y mme t r y r e s ul t i ng f r om pr os t he s i s pl a c e - me nt .

Re s ul t s

1.Direction and amount of facial component move- ment by dento-maxillary prosthesis

I n t he uppe r f a c e ,no s i g ni f i c a nt c ha ng e s we r e not e d a t t he

entcanthion(

En)or

ectocanthion(

Ex )on e i t he r t he D-or N- s i de s .At mi df a c e ,pr os t he s i s pl a c e - me nt s i g ni f i c a nt l y mov e d t he

subnasale(

Sn)a nd

alare

poi nt s on t he D- s i de( Al - D)t owa r d t he pos i t i v e s i de i n t he di r e c t i on of Z- a x i s .I n t he l owe r f a c e ,

the stomion

( St o)a nd t he

labrale superius

( Ls )s i g ni f i c a nt l y mov e d t owa r d t he pos i t i v e s i de i n t he di r e c t i ons of X-a nd Y- a x i s . The

chelion

,t he or a l c ommi s s ur e ,on t he D- s i de( Ch- D) , s i g ni f i c a nt l y mov e d t owa r d t he pos i t i v e s i de i n t he di r e c t i on of Y- a x i s( Ta bl e 2 ) .

The a mount of mov e me nt wa s s i g ni f i c a nt f or ni ne i t e ms ,a l l of whi c h we r e s ubj e c t e d t o pr i nc i pa l c ompo- ne nt a na l y s i s .The e i g e nv a l ue wa s 1 . 0 or g r e a t e r up t o t he 4 t h pr i nc i pa l c ompone nt ,a nd t he a c c umul a t e d c ont r i but i on r a t i o wa s 8 3

％.Thus

,t he f a c t or l oa di ng of t he 1 s t t o 4 t h pr i nc i pa l c ompone nt s wa s de t e r mi ne d. The a bs ol ut e v a l ue s of f a c t or l oa di ng s hi g he r t ha n 0 . 4 a r e s hown i n Ta bl e 3 .I n t he 1 s t pr i nc i pa l c ompone nt , t he f a c t or l oa di ng of t wo v a r i a bl e s wa s hi g h:pos i t i v e

Fig.8 Facial morphology analytical method

For analysis of facial morphology,the analytical software 3D-Rugle 7(Medic Engineering Corp,Kyoto,Japan)was used.A mirror image of the N-side was prepared and matched to the D-side,and some analyses were carried out.

Table 2 Change in anthropological facial profile

Point X Y Z

En-D 0.11±0.78 －0.07±0.96 0.19±0.57 En-I 0.09±0.69 －0.04±0.73 0.05±0.43 Ex-D －0.12±0.86 －0.14±0.89 0.15±1.02 Ex-I －0.08±0.79 0.17±0.55 0.03±0.76 Sn 0.29±0.81 0.21±1.49 2.13±2.48� Al-D －0.47±2.02 0.59±1.01 2.85±2.26��

Al-I 0.12±1.17 0.17±1.41 0.94±1.31 Sto 0.55±1.01� 1.59±2.32� 0.66±2.71 Ls 0.39±1.06 1.37±1.22�� 2.98±3.89��

Li 0.33±1.31 1.46±1.05�� 0.37±2.84 Ch-D 1.16±1.94 2.37±2.19�� 1.04±2.24 Ch-I －0.07±2.38 0.39±3.76 0.81±2.47

mean±standard deviation Significant difference�p＜0.05 ��p＜0.01

(5)

f r ont a l pl a ne v e r t i c a l l y t o t he X- a x i s wa s de f i ne d a s t he Y- a x i s , a nd a s t r a i g ht l i ne pa s s i ng t hr oug h O pos i t i one d v e r t i c a l l y t o t he f a c i a l f r ont a l pl a ne wa s de f i ne d a s t he Z- a x i s .Onl y t he X- a x i s wa s c or r e c t e d t o be c ome a pos i t i v e v e c t or f r om t he N-t o D- s i de( Fi g . 7 ) .

Analysis of facial morphology

For a na l y s i s of f a c i a l mor phol og y ,t he a na l y t i c a l s of t wa r e 3 D- Rug l e 7( Me di c Eng i ne e r i ng Cor p, Ky ot o, J a pa n)wa s us e d.

A mi r r or i ma g e of t he N- s i de wa s pr e pa r e d a nd ma t c he d t o t he D- s i de , a nd t he f ol l owi ng a na l y s e s we r e c a r r i e d out( Fi g . 8 ) . Fi r s t ,t o i nv e s t i g a t e how t he D- s i de wi l l be c ha ng e d by pr os t he s i s pl a c e me nt ,t he

D- s i de da t a wi t hout pr os t he s i s we r e s upe r i mpos e d on t he D- s i de da t a wi t h pr os t he s i s .The di f f e r e nc e s i n t he c oor di na t e v a l ue s( x , y , z )of t he r e f e r e nc e poi nt s on t he uppe r f a c e ,mi df a c e ,a nd l owe r f ac e r e g i ons we r e de t e r - mi ne d, a nd t he di r e c t i on a nd a mount of mov e me nt wa s a na l y s e d.The a mount of mov e me nt wa s s i g ni f i c a nt i n ni ne i t e ms ,a nd t he s e i t e ms we r e s ubj e c t e d t o pr i nc i pa l c ompone nt a na l y s i s .

��

The Ma nnWhi t ne y U t e s t wa s us e d t o c ompa r e di f f e r e nc e s be t we e n 2 e x a mi na t i on i t e ms .A s i g ni f i c a nt di f f e r e nc e be t wwe n t he g r oups i f

Fig.5 Measurement method using the non-contact 3-D digitiser,Morpheus 3-D

Morpheus 3-D scanner(A)scans surfaces with a semiconductor laser slit beam and acquires images in the frontal and bilateral 45°directions using a single CCD camera.The patient sat on a chair for measurements with the upper half of the body positioned vertically relative to the floor.The patient’s head was fixed on a head rest at a position that minimised the blind area of the slit beam,and two image patterns(with and without prosthesis)were recorded(B).

Fig.6 Anthropological facial landmarks

Reference points,the upper face(around the eyelid),entcanthion(En)and ectocanthion(Ex);midface(around the nasal alar),alare(Al),andsub- nasale(Sn);lower face(around the lips),stomion(Sto),labrale superius (Ls),labrale inferious(Li),andchelion(Ch),were set based on the anth- ropometric landmarks(A). The face was divided into the defective side (D-side)and the normal side(N-side)(B).

Fig.7 Reference lines and planes

A straight line passing through the bilateral En was set as the X-axis,and the midpoint between the bilateral En was defined as the coordinate origin point,O.

The plane established by the X-axis and Al on the N-side was regarded as the facial frontal plane.A straight line passing through O on the facial frontal plane vertically to the X-axis was defined as the Y-axis, and a straight line passing through O positioned vertically to the facial frontal plane was defined as the Z-axis.

(A) (B)

t he t e s t s howe d a p- v a l ue l e s s t ha n 0 . 0 5 .I n a ddi t i on, us i ng t he s t a t i s t i c a l a na l y s i s s of t wa r e ,St a t f l e x v e r .6 ( Ar t e c h. Co. ,Lt d. ,Os a ka ,J a pa n) ,t he s ol ut i ons of c ha r a c t e r i s t i c e qua t i ons we r e de t e r mi ne d us i ng t he v a r i a nc e - c ov a r i a nc e ma t r i x pr e pa r e d by s t a nda r di z i ng t he v a r i a bl e s . The e i g e nv a l ue ,c ont r i but i on r a t i o, a c c umul a t e d c ont r i but i on r a t i o,a nd f a c t or l oa di ng we r e out put . The pr i nc i pa l c ompone nt s c or e was c a l c ul a t e d f r om t he pr oduc t of t he s t a nda r di s e d v a r i - a bl e s a nd f a c t or l oa di ng .

Ne x t ,t he r e c ov e r y of f a c i a l mor phol og y wa s i nv e s - t i g a t e d a s f ol l ows :1 )t he di s t a nc e a nd t he v ol ume of t he g a p be t we e n s upe r i mpos e d f a c i a l s ur f a c e g e ne r a t e d on t he D- s i de we r e a na l y s e d a s pr os t he s i s pl a c e me nt - i nduc e d c ha ng e s ;2 )t he N- s i de da t a wi t h a nd wi t hout pr os t he s i s we r e s upe r i mpos e d t o i nv e s t i g a t e t he i nf l u- e nc e of pr os t he s i s ,a nd 3 )t he D- s i de da t a wi t h pr os t h- e s i s we r e ma t c he d t o N- s i de da t a t o i nv e s t i g a t e r e c ov - e r y of f a c i a l a s y mme t r y r e s ul t i ng f r om pr os t he s i s pl a c e - me nt .

Re s ul t s

1.Direction and amount of facial component move- ment by dento-maxillary prosthesis

I n t he uppe r f a c e ,no s i g ni f i c a nt c ha ng e s we r e not e d a t t he

entcanthion(

En)or

ectocanthion(

Ex )on e i t he r t he D-or N- s i de s .At mi df a c e ,pr os t he s i s pl a c e - me nt s i g ni f i c a nt l y mov e d t he

subnasale(

Sn)a nd

alare

poi nt s on t he D- s i de( Al - D)t owa r d t he pos i t i v e s i de i n t he di r e c t i on of Z- a x i s .I n t he l owe r f a c e ,

the stomion

( St o)a nd t he

labrale superius

( Ls )s i g ni f i c a nt l y mov e d t owa r d t he pos i t i v e s i de i n t he di r e c t i ons of X-a nd Y- a x i s . The

chelion

,t he or a l c ommi s s ur e ,on t he D- s i de( Ch- D) , s i g ni f i c a nt l y mov e d t owa r d t he pos i t i v e s i de i n t he di r e c t i on of Y- a x i s( Ta bl e 2 ) .

The a mount of mov e me nt wa s s i g ni f i c a nt f or ni ne i t e ms ,a l l of whi c h we r e s ubj e c t e d t o pr i nc i pa l c ompo- ne nt a na l y s i s .The e i g e nv a l ue wa s 1 . 0 or g r e a t e r up t o t he 4 t h pr i nc i pa l c ompone nt ,a nd t he a c c umul a t e d c ont r i but i on r a t i o wa s 8 3

％.Thus

,t he f a c t or l oa di ng of t he 1 s t t o 4 t h pr i nc i pa l c ompone nt s wa s de t e r mi ne d.

The a bs ol ut e v a l ue s of f a c t or l oa di ng s hi g he r t ha n 0 . 4 a r e s hown i n Ta bl e 3 .I n t he 1 s t pr i nc i pa l c ompone nt , t he f a c t or l oa di ng of t wo v a r i a bl e s wa s hi g h:pos i t i v e

Fig.8 Facial morphology analytical method

For analysis of facial morphology,the analytical software 3D-Rugle 7(Medic Engineering Corp,Kyoto,Japan)was used.A mirror image of the N-side was prepared and matched to the D-side,and some analyses were carried out.

Table 2 Change in anthropological facial profile

Point X Y Z

En-D 0.11±0.78 －0.07±0.96 0.19±0.57 En-I 0.09±0.69 －0.04±0.73 0.05±0.43 Ex-D －0.12±0.86 －0.14±0.89 0.15±1.02 Ex-I －0.08±0.79 0.17±0.55 0.03±0.76 Sn 0.29±0.81 0.21±1.49 2.13±2.48� Al-D －0.47±2.02 0.59±1.01 2.85±2.26��

Al-I 0.12±1.17 0.17±1.41 0.94±1.31 Sto 0.55±1.01� 1.59±2.32� 0.66±2.71 Ls 0.39±1.06 1.37±1.22�� 2.98±3.89��

Li 0.33±1.31 1.46±1.05�� 0.37±2.84 Ch-D 1.16±1.94 2.37±2.19�� 1.04±2.24 Ch-I －0.07±2.38 0.39±3.76 0.81±2.47

mean±standard deviation Significant difference�p＜0.05 ��p＜0.01

(6)

mov e me nt s of t

he labrale superius(

Ls )i n t he i n t he di r e c t i on of Z- a x i s a nd of t he

chelion on

t he D- s i de ( Ch- D)i n t he di r e c t i on of Y- a x i s .I n t he 2 nd pr i nc i pa l c ompone nt , f a c t or l oa di ng of t hr e e v a r i a bl e s we r e hi g h:

pos i t i v e mov e me nt s of t he

stomion(

St o)i n t he di r e c - t i ons of X-a nd Y- a x i s a nd pos i t i v e mov e me nt of t he

labrale inferius

( Li )i n t he i n t he di r e c t i on of Y- a x i s . I n t he 3 r d pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of onl y one v a r i a bl e ,pos i t i v e mov e me nt of t he

subnasale

( Sn)i n t he i n t he di r e c t i on of Z- a x i s ,wa s hi g h.I n t he 4 t h pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of t wo v a r i a bl e s wa s hi g h:pos i t i v e mov e me nt s of t he

alare

on t he D- s i de( Al - D)i n t he i n t he di r e c t i on of Z- a x i s a nd t he

stomion

( St o)i n t he i n t he di r e c t i on of X- a x i s . ( Ta bl e 3 )

2.Recovery of facial concavity by dento-maxillary prosthesis

The di s t a nc e of t he g a ps be t we e n t he s upe r - i mpos e d 3 - D da t a( ma x i mum a nd mi ni mum di s t a nc e s be t we e n t he s upe r i mpos e d s ur f a c e s ) a nd v ol ume c ha ng e s we r e a na l y s e d. The ma x i mum di s t a nc e be t we e n t he s upe r i mpos e d s ur f a c e s a nd v ol ume c ha ng e a f t e r pr os t he s i s pl a c e me nt we r e s i g ni f i c a nt l y g r e a t e r on t he D- s i de .No s i g ni f i c a nt di f f e r e nc e s we r e not e d on t he N- s i de be t we e n wi t h a nd wi t hout pr os t he s i s c ondi - t i ons or be t we e n t he D-a nd N- s i de s dur i ng pr os t he s i s pl a c e me nt( Ta bl e 4 ) .

Di s c us s i o n

1.Usefulness of the non-contact 3-D digitiser,and objectives,and methods of this study

For a e s t he t i c c ha ng e of f a c i a l mor phol og y a f t e r

ma x i l l e c t omy ,r e l i a bl e 3 D i de nt i f i c a t i on of de f e c t - i nduc e d f a c i a l di s f i g ur e me nt a nd r e c ov e r y by r e c on- s t r uc t i v e s ur g e r y a nd

/

or de nt o- ma x i l l a r y pr os t he s i s i s i mpor t a nt .

��

Pr e v i ous l y ,f a c i a l mor phol og y me a - s ur e me nt da t a we r e ma i nl y 2 - di me ns i ona l .

��

St one r

��

wa s one of t he f i r s t t o pr e s e nt a n i ma g e - ba s e d a na l y s i s f or s of t t i s s ue di a g nos i s .Re c e nt a dv a nc e s i n 3 D- CT a nd 3 D- MR t e c hnol og i e s ha v e a i de d i n a c hi e v - i ng t he s e obj e c t i v e s . Howe v e r ,pr obl e ms ,s uc h a s e x pos ur e of X- r a y s ,de nt a l me t a l a r t e f a c t s ,a nd a c qui s i - t i on t i me ,r e ma i n a s di s a dv a nt a g e s . To ov e r c ome t he s e ,ma ny r e por t e d ma nua l me t hods e x s i s t f or f a c i a l s of t t i s s ue a na l y s i s . The s e me t hods qua nt i t a t i v e l y a na l y s e f a c i a l mor phol og y c ha ng e s ,( e . g . ,t he f a c i a l i mpr e s s i on me t hod,

��

di r e c t me a s ur e me nt of t he body ,

��

s t e r e os c opi c phot og r a phy ,

��

a nd moi r � t e opog - r a phy

��

) ,but t he s e a r e not wi de l y e mpl oy e d be c a us e t he y ar e c ompl e x, i nc ons i s t e nt ac c ur ac y, r e - pr oduc i bi l i t y a nd i nj ur i ous pr ope r t i e s .

Re c e nt l y ,a ne w a nd pr e c i s e a na l y t i c a l a ppa r a t us , t he non- c ont a c t 3 D di g i t i s e r ,i s f r e que nt l y us e d i n t he f i e l ds of or a l a nd ma x i l l of a c i a l s ur g e r y ,pl a s t i c a nd r e c ons t r uc t i v e s ur g e r y ,a e s t he t i c s ur g e r y ,a nd de n- t i s t r y .

��

The Mor phe us 3 D i n t hi s s t udy s c a ns s ur - f a c e s wi t h a s e mi c onduc t or l a s e r s l i t be a m,a nd a c qui r e s i ma g e s i n t he f r ont a l a nd bi l a t e r a l 4 5

°

di r e c - t i ons us i ng a s i ng l e CCD c a me r a .The s e i ma g e da t a i n t he 3 di r e c t i ons a r e r e c ons t r uc t e d i nt o a 3 D i ma g e .The r e s ol ut i on i s 0 . 2 mm,t he a c qui s i t i on t i me wa s e i g ht s e c onds i n e a c h di r e c t i on,a nd a l l pr obl e ms wi t h e x po- s ur e of X- r a y s ,de nt a l me t a l a r t e f a c t s ,a c qui s i t i on t i me , a nd ope r a t i ona l i s s ue r e l a t i ng t o 3 D- CT a nd

/

or 3 D- MR we r e s ol v e d by t hi s nov e l t e c hnol og y .

The c l i ni c a l us e f ul ne s s of r e pr oduc i ng f a c i a l

Table 3 Principal component analysis

Point Comp.1 Comp.2 Comp.3 Comp.4

Sn(Z) 0.2500 0.0383 0.6488 0.3249 AlD(Z) 0.2326 －0.1673 －0.3238 0.6726 Sto(X) －0.0115 0.4989 －0.1873 0.4664 Sto(Y) －0.2391 0.5322 －0.3780 －0.0333 Ls(Y) 0.3910 0.2820 0.1863 －0.2625 Ls(Z) 0.4668 －0.2429 －0.3411 －0.1268 Li(Y) 0.3011 0.4930 0.0048 －0.2691 ChD(Y) 0.4963 0.1579 0.0694 0.1499 ChD(Z) 0.3440 －0.1786 －0.3746 －0.2089 eigenvalue 2.8344 1.9905 1.4006 1.1884 contribution ratio 0.3149 0.2212 0.1556 0.1320 accumulated contribution ratio 0.3149 0.5316 0.6917 0.8283

Table 4 Recovery of facial concavity by dento-maxillary prosthesis Maximum distance

(mm) Minimum distance

(mm) Change in volume (mm�) D-side with and without prosthesis 9.08±4.78� -1.52±0.63 5.70±3.74� N-side with and without prosthesis 1.61±0.91 -1.77±0.69 0.14±0.82 N-and D-sides with prosthesis 2.98±2.04 -2.33±1.63 -0.88±1.15

mean±standard deviation Significant difference ＊＜0.05

mor phol og y by l a s e r s c a nni ng ha s be e n de mons t r a t e d i n ma ny s t udi e s .

��

The i mpor t a nt poi nt of l a s e r s c a nni ng i s a c qui s i t i on of hi g h- qua l i t y t hr e e - di me ns i ona l f a c i a l i ma g e s . Body mov e me nt - i nduc e d di s t or t i on of i ma g e s wa s a pr obl e m wi t h pr e v i ous - l a s e r - s c a nni ng de v i c e s ,but t he a c qui s i t i on t i me of Mor phe us 3 D i s e i g ht s e c onds pe r di r e c t i on a nd a t ot a l t we nt y - f our s e c onds f or t hr e e di r e c t i ons ,whi c h i s v e r y s hor t ,t he r e by s ol v i ng t hi s pr obl e m. Howe v e r ,bl a c k a nd br own e y e l a s he s a nd e y e br ows a bs or b t he l a s e r be a m,r e s ul t i ng i n e mpt y s pa c e s i n t he a r e a a r ound t he e y e l a s he s a nd e y e br ows .Thi s we a kne s s i n r e pr oduc i ng t he r e g i ons a r ound t he e y e l i ds( uppe r f a c e )ma y be a di s a dv a nt a g e .To s uppl e me nt t hi s di s a dv a nt a g e ,i t i s ne c e s s a r y t o r e pe a t s c a nni ng a s ne e de d whe n a de f e c t i s g e ne r a t e d i n t he s c a nne d i ma g e .We be l i e v e t ha t wi t h t he r a pi d de v e l opme nt of t he l a s e r s c a nni ng t e c hnol - og y ,a f a c e wi t h f a nt a s t i c de t a i l s wi l l be pr ov i de d a nd e x i s t i ng dr a wba c ks wi l l be e a s i l y r e s ol v e d i n t he ne a r f ut ur e .

2.Interpretation of the results of principal component analysis and recovery of facial concavity by dento-maxillary prosthesis

The c oor di na t e v a l ue s( X,Y,Z)we r e me a s ur e d a t t he r e f e r e nc e poi nt s t hr oug hout t he uppe r f a c e ,mi d- f a c e ,a nd l owe r f a c e wi t h a nd wi t hout de nt o- ma x i l l a r y pr os t he s i s . The c oor di na t e v a l ue s a t e a c h r e f e r e nc e poi nt wi t hout pr os t he s i s we r e s ubt r a c t e d f r om t hos e wi t h pr os t he s i s ,a nd t he di r e c t i on a nd a mount of mov e me nt we r e a na l y s e d. Si g ni f i c a nt c ha ng e s i n t he a mount of mov e me nt we r e not e d i n ni ne i t e ms ,a nd t he s e i t e ms we r e s ubj e c t e d t o pr i nc i pa l c ompone nt a na l y s i s . I n t he pr i nc i pa l c ompone nt a na l y s i s ,whe n t he a c c umul a t e d c ont r i but i on r a t i o of a mi ni mum numbe r of pr i nc i pa l c ompone nt s a ppr oa c he d 1 0 0

％,i

t wa s i ndi c a t e d ‘ f a v our a bl e me ani ngf ul ne s s was g i v e n’ .

��

The ni ne me a s ur e me nt i t e ms we r e s umma r - i s e d i nt o f our pr i nc i pa l c ompone nt s ,a nd t he a c - c umul a t e d c ont r i but i on r a t i o wa s 8 3

％,i

ndi c a t i ng t ha t

mor e t ha n 8 0

％

of a l l da t a we r e a bs or be d,ba s e d on whi c h,t he r e s ul t s of t hi s a na l y s i s we r e j udg e d a s s i g ni f - i c a nt .

I n t he 1 s t pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of t wo v a r i a bl e s ,pos i t i v e mov e me nt s of t he

labrale superius

( Ls )i n t he di r e c t i on of Z- a x i s a nd

chelion

on t he D- s i de( Ch- D)i n t he di r e c t i on of Y- a x i s ,we r e hi g h.Thi s ma y be t he pr i nc i pa l c ompone nt i ndi c a t i ng pr os t he s i s pl a c e me nt - i nduc e d mov e me nt of t he uppe r l i p a nd a nt e r i or c he e k t owa r d t he a nt e r os upe r i or di r e c - t i on. I n t he 2 nd pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of t hr e e v a r i a bl e s ,pos i t i v e mov e me nt s of t he

stomion(

St o)i n t he di r e c t i ons of X-a nd Y- a x i s a nd t he

labrale inferious(

Li )i n t he di r e c t i ons of Y- a x i s , we r e hi g h. Thi s ma y be t he pr i nc i pa l c ompone nt i ndi c a t i ng c ha ng e s i n t he l owe r l i p a nd me nt ol a bi a l g r oov e c ons t i t ut i ng of t he l owe r f a c e wi t h mov e me nt of t he uppe r l i p t owa r d t he s i de of pr os t he s i s pl a c e me nt . I n t he 3r d pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of one v a r i a bl e ,pos i t i v e mov e me nt of t he

subnasale

( Sn) i n t he i n t he di r e c t i ons of Z- a x i s ,wa s hi g h,i ndi c a t i ng t ha t t hi s wa s t he pr i nc i pa l c ompone nt of f or wa r d mov e me nt of t he s ubna s a l poi nt .I n t he 4 t h pr i nc i pa l c ompone nt ,f a c t or l oa di ng of t wo v a r i a bl e s ,pos i t i v e mov e me nt s of t he

alare(

Al - D)on t he D- s i de i n t he di r e c t i on of Z- a x i s a nd t he

stomion(

St o)i n t he di r e c - t i on of X- a x i s we r e hi g h,i ndi c a t i ng t ha t pr os t he s i s pl a c e me nt - i nduc e d f or wa r d mov e me nt of t he na s a l a l a r a nd mov e me nt of t he uppe r a nd l owe r l i ps t owa r d t he s i de of pr os t he s i s pl a c e me nt we r e t he pr i nc i pa l c ompo- ne nt s .

The pr i nc i pa l c ompone nt a na l y s i s de mons t r a t e d t ha t f a c i a l mor phol og y wi t h de f e c t of Ar a ma ny c l a s s i f i - c a t i on Cl a s s I or I I ma i nl y r e c ov e r e d a t t he uppe r l a bi a l ,na s a l a l a r ,a nd s ubna s a l poi nt s ,i . e .i n t he mi df a c e r e g i on,a nd t he r e c ov e r y of t he l owe r l i p a nd me nt ol a bi a l g r oov e ,i .e .i n t he l owe r f a c e wa s a ddi - t i ona l .The s e c ha ng e s we r e due t o uppe r a nd f or wa r d mov e me nt of f a c i a l s of t t i s s ue s e x pl a i ni ng a ppr ox i - ma t e l y 8 0

％

of ov e r a l l c ha ng e s . Fur t he r mor e ,t he

Fig.9 Summary of recovery of facial appearance

Aramany’s Classification I and II facial deformities formed by partial maxillectomy (A),and summary of recovery of facial appearance with dento-maxillary prosthesis placement(B).

(B) (A)

(7)

mov e me nt s of t

he labrale superius(

Ls )i n t he i n t he di r e c t i on of Z- a x i s a nd of t he

chelion on

t he D- s i de ( Ch- D)i n t he di r e c t i on of Y- a x i s .I n t he 2 nd pr i nc i pa l c ompone nt , f a c t or l oa di ng of t hr e e v a r i a bl e s we r e hi g h:

pos i t i v e mov e me nt s of t he

stomion(

St o)i n t he di r e c - t i ons of X-a nd Y- a x i s a nd pos i t i v e mov e me nt of t he

labrale inferius

( Li )i n t he i n t he di r e c t i on of Y- a x i s . I n t he 3 r d pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of onl y one v a r i a bl e ,pos i t i v e mov e me nt of t he

subnasale

( Sn)i n t he i n t he di r e c t i on of Z- a x i s ,wa s hi g h.I n t he 4 t h pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of t wo v a r i a bl e s wa s hi g h:pos i t i v e mov e me nt s of t he

alare

on t he D- s i de( Al - D)i n t he i n t he di r e c t i on of Z- a x i s a nd t he

stomion

( St o)i n t he i n t he di r e c t i on of X- a x i s . ( Ta bl e 3 )

2.Recovery of facial concavity by dento-maxillary prosthesis

The di s t a nc e of t he g a ps be t we e n t he s upe r - i mpos e d 3 - D da t a( ma x i mum a nd mi ni mum di s t a nc e s be t we e n t he s upe r i mpos e d s ur f a c e s ) a nd v ol ume c ha ng e s we r e a na l y s e d. The ma x i mum di s t a nc e be t we e n t he s upe r i mpos e d s ur f a c e s a nd v ol ume c ha ng e a f t e r pr os t he s i s pl a c e me nt we r e s i g ni f i c a nt l y g r e a t e r on t he D- s i de .No s i g ni f i c a nt di f f e r e nc e s we r e not e d on t he N- s i de be t we e n wi t h a nd wi t hout pr os t he s i s c ondi - t i ons or be t we e n t he D-a nd N- s i de s dur i ng pr os t he s i s pl a c e me nt( Ta bl e 4 ) .

Di s c us s i o n

1.Usefulness of the non-contact 3-D digitiser,and objectives,and methods of this study

For a e s t he t i c c ha ng e of f a c i a l mor phol og y a f t e r

ma x i l l e c t omy ,r e l i a bl e 3 D i de nt i f i c a t i on of de f e c t - i nduc e d f a c i a l di s f i g ur e me nt a nd r e c ov e r y by r e c on- s t r uc t i v e s ur g e r y a nd

/

or de nt o- ma x i l l a r y pr os t he s i s i s i mpor t a nt .

��

Pr e v i ous l y ,f a c i a l mor phol og y me a - s ur e me nt da t a we r e ma i nl y 2 - di me ns i ona l .

��

St one r

��

wa s one of t he f i r s t t o pr e s e nt a n i ma g e - ba s e d a na l y s i s f or s of t t i s s ue di a g nos i s .Re c e nt a dv a nc e s i n 3 D- CT a nd 3 D- MR t e c hnol og i e s ha v e a i de d i n a c hi e v - i ng t he s e obj e c t i v e s . Howe v e r ,pr obl e ms ,s uc h a s e x pos ur e of X- r a y s ,de nt a l me t a l a r t e f a c t s ,a nd a c qui s i - t i on t i me ,r e ma i n a s di s a dv a nt a g e s . To ov e r c ome t he s e ,ma ny r e por t e d ma nua l me t hods e x s i s t f or f a c i a l s of t t i s s ue a na l y s i s . The s e me t hods qua nt i t a t i v e l y a na l y s e f a c i a l mor phol og y c ha ng e s ,( e . g . ,t he f a c i a l i mpr e s s i on me t hod,

��

di r e c t me a s ur e me nt of t he body ,

��

s t e r e os c opi c phot og r a phy ,

��

a nd moi r � t e opog - r a phy

��

) ,but t he s e a r e not wi de l y e mpl oy e d be c a us e t he y ar e c ompl e x, i nc ons i s t e nt ac c ur ac y, r e - pr oduc i bi l i t y a nd i nj ur i ous pr ope r t i e s .

Re c e nt l y ,a ne w a nd pr e c i s e a na l y t i c a l a ppa r a t us , t he non- c ont a c t 3 D di g i t i s e r ,i s f r e que nt l y us e d i n t he f i e l ds of or a l a nd ma x i l l of a c i a l s ur g e r y ,pl a s t i c a nd r e c ons t r uc t i v e s ur g e r y ,a e s t he t i c s ur g e r y ,a nd de n- t i s t r y .

��

The Mor phe us 3 D i n t hi s s t udy s c a ns s ur - f a c e s wi t h a s e mi c onduc t or l a s e r s l i t be a m,a nd a c qui r e s i ma g e s i n t he f r ont a l a nd bi l a t e r a l 4 5

°

di r e c - t i ons us i ng a s i ng l e CCD c a me r a .The s e i ma g e da t a i n t he 3 di r e c t i ons a r e r e c ons t r uc t e d i nt o a 3 D i ma g e .The r e s ol ut i on i s 0 . 2 mm,t he a c qui s i t i on t i me wa s e i g ht s e c onds i n e a c h di r e c t i on,a nd a l l pr obl e ms wi t h e x po- s ur e of X- r a y s ,de nt a l me t a l a r t e f a c t s ,a c qui s i t i on t i me , a nd ope r a t i ona l i s s ue r e l a t i ng t o 3 D- CT a nd

/

or 3 D- MR we r e s ol v e d by t hi s nov e l t e c hnol og y .

The c l i ni c a l us e f ul ne s s of r e pr oduc i ng f a c i a l

Table 3 Principal component analysis

Point Comp.1 Comp.2 Comp.3 Comp.4

Sn(Z) 0.2500 0.0383 0.6488 0.3249 AlD(Z) 0.2326 －0.1673 －0.3238 0.6726 Sto(X) －0.0115 0.4989 －0.1873 0.4664 Sto(Y) －0.2391 0.5322 －0.3780 －0.0333 Ls(Y) 0.3910 0.2820 0.1863 －0.2625 Ls(Z) 0.4668 －0.2429 －0.3411 －0.1268 Li(Y) 0.3011 0.4930 0.0048 －0.2691 ChD(Y) 0.4963 0.1579 0.0694 0.1499 ChD(Z) 0.3440 －0.1786 －0.3746 －0.2089 eigenvalue 2.8344 1.9905 1.4006 1.1884 contribution ratio 0.3149 0.2212 0.1556 0.1320 accumulated contribution ratio 0.3149 0.5316 0.6917 0.8283

Table 4 Recovery of facial concavity by dento-maxillary prosthesis Maximum distance

(mm) Minimum distance

(mm) Change in volume (mm�) D-side with and without prosthesis 9.08±4.78� -1.52±0.63 5.70±3.74� N-side with and without prosthesis 1.61±0.91 -1.77±0.69 0.14±0.82 N-and D-sides with prosthesis 2.98±2.04 -2.33±1.63 -0.88±1.15

mean±standard deviation Significant difference ＊＜0.05

mor phol og y by l a s e r s c a nni ng ha s be e n de mons t r a t e d i n ma ny s t udi e s .

��

The i mpor t a nt poi nt of l a s e r s c a nni ng i s a c qui s i t i on of hi g h- qua l i t y t hr e e - di me ns i ona l f a c i a l i ma g e s . Body mov e me nt - i nduc e d di s t or t i on of i ma g e s wa s a pr obl e m wi t h pr e v i ous - l a s e r - s c a nni ng de v i c e s ,but t he a c qui s i t i on t i me of Mor phe us 3 D i s e i g ht s e c onds pe r di r e c t i on a nd a t ot a l t we nt y - f our s e c onds f or t hr e e di r e c t i ons ,whi c h i s v e r y s hor t ,t he r e by s ol v i ng t hi s pr obl e m. Howe v e r ,bl a c k a nd br own e y e l a s he s a nd e y e br ows a bs or b t he l a s e r be a m,r e s ul t i ng i n e mpt y s pa c e s i n t he a r e a a r ound t he e y e l a s he s a nd e y e br ows .Thi s we a kne s s i n r e pr oduc i ng t he r e g i ons a r ound t he e y e l i ds( uppe r f a c e )ma y be a di s a dv a nt a g e .To s uppl e me nt t hi s di s a dv a nt a g e ,i t i s ne c e s s a r y t o r e pe a t s c a nni ng a s ne e de d whe n a de f e c t i s g e ne r a t e d i n t he s c a nne d i ma g e .We be l i e v e t ha t wi t h t he r a pi d de v e l opme nt of t he l a s e r s c a nni ng t e c hnol - og y ,a f a c e wi t h f a nt a s t i c de t a i l s wi l l be pr ov i de d a nd e x i s t i ng dr a wba c ks wi l l be e a s i l y r e s ol v e d i n t he ne a r f ut ur e .

2.Interpretation of the results of principal component analysis and recovery of facial concavity by dento-maxillary prosthesis

The c oor di na t e v a l ue s( X,Y,Z)we r e me a s ur e d a t t he r e f e r e nc e poi nt s t hr oug hout t he uppe r f a c e ,mi d- f a c e ,a nd l owe r f a c e wi t h a nd wi t hout de nt o- ma x i l l a r y pr os t he s i s . The c oor di na t e v a l ue s a t e a c h r e f e r e nc e poi nt wi t hout pr os t he s i s we r e s ubt r a c t e d f r om t hos e wi t h pr os t he s i s ,a nd t he di r e c t i on a nd a mount of mov e me nt we r e a na l y s e d. Si g ni f i c a nt c ha ng e s i n t he a mount of mov e me nt we r e not e d i n ni ne i t e ms ,a nd t he s e i t e ms we r e s ubj e c t e d t o pr i nc i pa l c ompone nt a na l y s i s . I n t he pr i nc i pa l c ompone nt a na l y s i s ,whe n t he a c c umul a t e d c ont r i but i on r a t i o of a mi ni mum numbe r of pr i nc i pa l c ompone nt s a ppr oa c he d 1 0 0

％,i

t wa s i ndi c a t e d ‘ f a v our a bl e me ani ngf ul ne s s was g i v e n’ .

��

The ni ne me a s ur e me nt i t e ms we r e s umma r - i s e d i nt o f our pr i nc i pa l c ompone nt s ,a nd t he a c - c umul a t e d c ont r i but i on r a t i o wa s 8 3

％,i

ndi c a t i ng t ha t

mor e t ha n 8 0

％

of a l l da t a we r e a bs or be d,ba s e d on whi c h,t he r e s ul t s of t hi s a na l y s i s we r e j udg e d a s s i g ni f - i c a nt .

I n t he 1 s t pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of t wo v a r i a bl e s ,pos i t i v e mov e me nt s of t he

labrale superius

( Ls )i n t he di r e c t i on of Z- a x i s a nd

chelion

on t he D- s i de( Ch- D)i n t he di r e c t i on of Y- a x i s ,we r e hi g h.Thi s ma y be t he pr i nc i pa l c ompone nt i ndi c a t i ng pr os t he s i s pl a c e me nt - i nduc e d mov e me nt of t he uppe r l i p a nd a nt e r i or c he e k t owa r d t he a nt e r os upe r i or di r e c - t i on. I n t he 2 nd pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of t hr e e v a r i a bl e s ,pos i t i v e mov e me nt s of t he

stomion(

St o)i n t he di r e c t i ons of X-a nd Y- a x i s a nd t he

labrale inferious(

Li )i n t he di r e c t i ons of Y- a x i s , we r e hi g h. Thi s ma y be t he pr i nc i pa l c ompone nt i ndi c a t i ng c ha ng e s i n t he l owe r l i p a nd me nt ol a bi a l g r oov e c ons t i t ut i ng of t he l owe r f a c e wi t h mov e me nt of t he uppe r l i p t owa r d t he s i de of pr os t he s i s pl a c e me nt . I n t he 3r d pr i nc i pa l c ompone nt ,t he f a c t or l oa di ng of one v a r i a bl e ,pos i t i v e mov e me nt of t he

subnasale

( Sn) i n t he i n t he di r e c t i ons of Z- a x i s ,wa s hi g h,i ndi c a t i ng t ha t t hi s wa s t he pr i nc i pa l c ompone nt of f or wa r d mov e me nt of t he s ubna s a l poi nt .I n t he 4 t h pr i nc i pa l c ompone nt ,f a c t or l oa di ng of t wo v a r i a bl e s ,pos i t i v e mov e me nt s of t he

alare(

Al - D)on t he D- s i de i n t he di r e c t i on of Z- a x i s a nd t he

stomion(

St o)i n t he di r e c - t i on of X- a x i s we r e hi g h,i ndi c a t i ng t ha t pr os t he s i s pl a c e me nt - i nduc e d f or wa r d mov e me nt of t he na s a l a l a r a nd mov e me nt of t he uppe r a nd l owe r l i ps t owa r d t he s i de of pr os t he s i s pl a c e me nt we r e t he pr i nc i pa l c ompo- ne nt s .

The pr i nc i pa l c ompone nt a na l y s i s de mons t r a t e d t ha t f a c i a l mor phol og y wi t h de f e c t of Ar a ma ny c l a s s i f i - c a t i on Cl a s s I or I I ma i nl y r e c ov e r e d a t t he uppe r l a bi a l ,na s a l a l a r ,a nd s ubna s a l poi nt s ,i . e .i n t he mi df a c e r e g i on,a nd t he r e c ov e r y of t he l owe r l i p a nd me nt ol a bi a l g r oov e ,i .e .i n t he l owe r f a c e wa s a ddi - t i ona l .The s e c ha ng e s we r e due t o uppe r a nd f or wa r d mov e me nt of f a c i a l s of t t i s s ue s e x pl a i ni ng a ppr ox i - ma t e l y 8 0

％

of ov e r a l l c ha ng e s . Fur t he r mor e ,t he

Fig.9 Summary of recovery of facial appearance

Aramany’s Classification I and II facial deformities formed by partial maxillectomy (A),and summary of recovery of facial appearance with dento-maxillary prosthesis placement(B).

(B) (A)

(8)

a na l y s i s of t he s upe r i mpos e d 3 - D da t a i ndi c a t e d t ha t pr os t he s i s pl a c e me nt r e t ur ne d t he D- s i de c ont our t o a s t a t e c ompa r a bl e wi t h t ha t of t he N- s i de , i . e . , s y mme t r i - c a l .

Ov e r a l l ,i t wa s qua nt i t a t i v e l y de mons t r a t e d t ha t f a c i a l de f or mi t i e s r e s ul t i ng f r om pa r t i a l ma x i l l e c t omy we r e due t o c onc a v i t i e s f r om t he s ubna s a l poi nt t o t he me nt ol a bi a l g r oov e i n t he v e r t i c a l r a ng e ,a nd f r om t he r e g i on a r ound t he na s al a l a r t o t he a nt e r i or c he e k i n t he l a t e r a l r a ng e . Fa c i a l f e a t ur e s a nt e r ol a t e r a l l y e x pa nde d on t he D- s i de i n v ol ume wi t h t he pr os t he s i s . I nt e r e s t i ng l y ,f a c i a l di s f i g ur e me nt e x t e nde d t o t he l owe r f a c e i n pa t i e nt s wi t h t he de f e c t s of Ar a ma ny c l a s s i f i c a t i on Cl a s s I a nd I I ,a nd i mpr ov e me nt of t he s e de f or mi t i e s wa s a l s o obs e r v e d wi t h t he pr os t he s i s( Fi g . 9 ) .

Us i ng t he non- c ont a c t 3 D di g i t i s e r ,t he di r e c t i on a nd a mount of mov e me nt of t he f a c i a l c ompone nt s wi t hi n t he mi d-a nd t he l owe r f a c e r e g i ons we r e 3 - di me ns i ona l l y de t e r mi ne d, e na bl i ng r a pi d a nd a c c ur a t e i de nt i f i c a t i on of f a c i a l de f or mi t i e s i nduc e d by t he de f e c t s of Ar a ma ny Cl a s s I a nd I I ,a nd r e c ov e r y of t he f a c i a l mor phol og y wi t h pr os t he s i s .

3.Usefulness and limitations of dento-maxillary prosthesis

Thi s s t udy de mons t r a t e d t ha t de nt o- ma x i l l a r y pr os t he s i s pl a c e me nt i s a pr omi s i ng me t hod f or a e s - t he t i c r e c ov e r y of t he de f e c t s of Ar a ma ny c l a s s i f i c a t i on Cl a s s I or I I ;howe v e r ,t he y ha v e l i mi t e d us e f ul ne s s f or de f e c t s r e s ul t i ng f r om t ot a l ma x i l l e c t omy( Fi g . 1 0( A) ) . Re c ov e r y of t he or bi t a l r i m,i .e . ,c onc a v i t y of t he s ubc i l l i a r y r e g i on,wi t h de nt o- ma x i l l a r y pr os t he s i s i s i mpos s i bl e ,a s s hown i n Fi g . 1 0( B)( C) .I n s uc h c a s e s , r e c ons t r uc t i on wi t h a ur i c ul a r or c os t al c a r t i l a g e g r a f t - i ng i s e s s e nt i a l ,a nd s i g ni f i c a nt f or de t e r mi ni ng a n a e s t he t i c r e c ons t r uc t i on a f t e r t ot a l ma x i l l e c t omy .

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Co nc l us i o n

Us i ng a non- c ont a c t 3 D di g i t i s e r , pa r t i a l ma x i l l e c t omy -a nd de nt o- ma x i l l a r y pr os t he s i s - i nduc e d f a c i a l mor phol og y c ha ng e s we r e obj e c t i v e l y e v a l ua t e d.

Thi s s t udy ma y s e r v e a s a n i nde x f or de c i di ng on pr os t he s i s mor phol og y ,i . e . ,a n i nde x us e d by phy s i - c i a ns a nd pa t i e nt s t o a r r i v e a t a c ommon g oa l .Thi s i s t he f i r s t s t e p t owa r d our f i na l obj e c t i v e of pr a c t i c a l us e a s a n e v a l ua t i on t ool .Thi s i s t he f i r s t s t udy t o a na l y s e of pr os t he s i s - i nduc e d c ha ng e s i n f a c i a l mor phol og y

Fig.10 Limitations of the dento-maxillary prosthesis

((A)Total maxillectomy,(B)Reconstruction with free rectus abdominis musculocutaneous flap,(C)Dento-maxillary prosthesis)

Dento-maxillary prosthesis has limited usefulness for defects resulting from total maxillectomy.Recovery of the orbital rim,i. e.,concavity of the subcilliary region,with dento-maxillary prosthesis is impossible.In such cases,reconstruction with auricular or costal cartilage grafting is essential,and significant for determining an aesthetic reconstruction after total maxillectomy.

(A)

a f t e r pa r t i a l ma x i l l e c t omy wi t h a non- c ont a c t 3 D di g i t i s e r .

As t he f a c i a l i mpr e s s i ons v a r y de pe ndi ng on t he pr e f e r e nc e s a nd ot he r f a c t or s ,s i mpl y a c hi e v i ng l a t e r a l s y mme t r y i s not s uf f i c i e nt . Fur t he r s t udi e s s houl d e x a mi ne t he a mount of f a c i a l or g a ni s a t i ona l c ha ng e s t ha t a r e obj e c t i v e l y a nd s ubj e c t i v e l y f a v our a bl e .

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Re f e r e nc e s

1.Yokoo S,Kurita T.Oral and maxillofacial reconstruction.

In:Kirita T,Omura K (eds).Oral Cancer-Diagnosis and Therapy-.Tokyo:Springer 2015:231-272.

2.Granick MS,Ramasasty SS,Newton ED,et al.Reconstruc- tion of complex maxillectomy defects with the scapular-free flap.Head Neck 1990;12:377-385.

3.Baj A,Youssef DA,Monteverdi R,et al.Reconstruction of partial maxillectomy defects with the double-barrel fibula free flap.Acta Otorhinolaryngol Ital 2010;30:299-302. 4.Lansford CD,Futran ND,Izzard ME. Reconstruction of

maxilla.In:Werning JW(ed). Oral Cancer. New York:

Thieme,2007:226-236.

5.Kosaka M,Sumita YI,Otomura T,et al. Differences of salivary cortisol levels between long-term and short-term wears of dento-maxillary prosthesis due to head and neck cancer resection.J Prosthodont Res 2014;58:41-47. 6.Aimaijiang Y,Otomura T,Taniguchi H. Relationships

between perceived chewing ability,objective masticatory function and oral health-related quality of life in man- dibulectomy or glossectomy patients with a dento-maxillary prosthesis.J Prosthodont Res 2016;60:92-97.

7.Martin JW,Lemon JC,Chambers MS. Oral prosthetic rehabilitation. In:Werning JW(ed). Oral Cancer. New York:Thieme,2007:278-287.

8.Conroy BF,Branemark PI,Blenkinsopp PT. Prosthetic restoration and rehabilitation of the orofacial cancer patient.In:Shah JP,Johnson NW,Batsakis JG (eds).Oral Cancer.London,Informa Healthcare,2011:401-457. 9.Hajeer MY,Millett DT,Ayoub AF,et al.Application of

3D imaging in orthodontics.part I. J Orthod 2004;31: 62-70.

10.Taghizadeh F,Leibowitz A,Ramiretz P,et al.Combining facelift with SmartLipo 1064-nm system technique overview and retrospective analysis of 56 patients. J Cosmet Laser Ther 2016;17:80-85.

11.Zhang Y,Zhang L,Sun X,et al. Evaluation of lower blepharoplasty treated the SmartLipo 1064-nm system and its clinical implication:A retrospective review. J Cosmet Laser Ther 2016;18:376-380.

12.Santler G,Karcher H,Ruda C.Indications and limitations of three-dimensional models in craniofacial surgery. J Craniomaxillofac Surg 1998;26:11-16.

13.Gaggl A,Schlters G,Santler G,et al.Clinical and magnetic resonance findings in the temporomandibular joints of patients before and after orthognathic surgery. Br J Oral Maxillofac Surg 1999;37:41-45.

14.Ploder O,Klug C,Backfrider W,et al.2D-and 3D-based measurements of orbital floor fractures from CT scans. J Craniomaxillofacial Surg 2002;30:153.

15.Aramany MA. Basic principles of obturator design for partially edentulous patients. Paer I:classification. J Prosthet Dent 1978;40:554-557.

16.Armary MA. Basic principles of obturator design for partially edentulous patients.Paer II:design principles.J Prosthet Dent 1978;40:656-662.

17.Konno A,Okamoto Y,Hanazawa S,et al.Analysis of the

long-term results of our combination therapy for maxillary cancer with particular reference to treatment od T4 and N1-3 maxillary cancer,Auris Nasus Larynx 1985;2:147-155. 18.Sakai S,Kubo T,Mori N,et al.A study of the late effects

of radiotherapy and operation on patients with maxillary cancer.Cancer 1988;62:2114-2117.

19.Gwilliam JR,Cunningham SJ,Huston T.Reproducibility of soft tissue landmarks on three-dimensional facial scan. Eur J Orthod 2006;28:408-415.

20.Powell N,Humphreus B.Proportions of the aesthetic face. New York:Thime-Stratton Inc,1984:1-11.

21.Naini FB.Clinical diagnostic records,natural head position a d craniofacial anthropometry.In:Facial aesthetics. Oxford:Wiley-Blackwell,2011:71-85.

22.Masui I,Honda T,Ishii H,et al.An analysis of soft tissue profile changes following mndiular set back using principal component analysis.Jpn J Jaw Deform 1994;4:26-36. 23.Yokoo S,Komori T,Watatani S,et al.Aesthetic changes

in lateral lip profile after sagittal split ramus osteotomy -Inplication for informed consent-.Asian J Oral maxillofac Surg 2002;14:70-77.

24.Lin SY,White GE.Mandibular position and head posture as a function of eye dominance.J Clin Pediat Dent 1996;20: 133-140.

25.Jeffrey WB,Steven JL.Evaluation of dental midline position.Semin Oethod 1998;4:146-152.

26.Ferrario VF,Sforza C,Serrao G,et al. A direct in vivo measurement of the three-dimensional orientation of the occlusal plane and of the saggital discrepancy of the jaws. Clin Orthod Res 2000;3:15-22.

27.Harnet JC,Lombardi T,Maniere-Ezvan A,et al.Transver- sal craniofacial growth evaluated on children dry skulls using V2 and V3 canal openings as references.Surg Radiol Anat 2013;35:757-763.

28.Krimmel M,Breidt M,Bacher M,et al.Three-dimensional normal facial growth birth to the age of 7 years. Plast Reconstr Surg 2015;136:490e-501e.

29.Bergmann RT,Waschak J,Borzabadi-Farahani A,et al. Longitudinal study of cephalometric soft tissue profile traits between the age of 6 and 18 years.Angle Orthod 2014;84: 48-55.

30.Stoner MM.A photometric analysis of the facial profile:a method of assessing facial change induced by orthodontic treatment.Am J Orthod 1955;41:453-469.

31.Tanaka Y,Gold H,Pruzansky S. New facial impression technique in maxillofacial. Maxillofac Prosthet 1979;2: 11-14.

32.Farkas LG.Anthropometry of the attractive North Amer- ican Caucasian face.In:Head and face,2��ed.Raven Press 1994,159-183.

33.Ras F,Habets L,van Ginkel FC,et al.Quantification of facial morphology using stereophotogrametry- demonstration of a new concept.J Dent 1996;24:369-374. 34.Kawai T,Natsume N,Shibata H,et al.Three-dimensional analysis of facial morphology usung moir� setripes Part II. Analysis of normal adult.Int J Oral Maxillofac Surg 1990; 19:359-362.

35.McCance AM,Moss JP,Fright WR,et al. A three- dimensional analysis of soft and hard tissue changes following bimaxillary surgery.Br J Oral Maxillofac Surg 1992;30: 221-232.

36.McCance AM,Moss JP,Fright WR,et al. A three- dimensional analysis of 16 skeletal class III patients following bimaxillary surgery.Br J Oral Maxillofac Surg 1992;30: 221-232.

37.Morris DO,Illing HM,Lee RT.A prospective evaluation of Bass,Bionator and Twin Block appliance.Part II-The soft tissues.Eur J Orthod 1998;20:663-684.