MozÏ nosti prïedpoveï di a zobrazenõâ leâcï ebnyâ ch zmeïn Accuracy of prediction and imaging of therapeutic changes

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1 MozÏ nosti prïedpoveï di a zobrazenõâ leâcï ebnyâ ch zmeïn Accuracy of prediction and imaging of therapeutic changes MUDr.Sylvie SaifrtovaÂ, MUDr.Hana TycovaÂ, MUDr.Rene FoltaÂn Ortodonticke oddeï lenõâ, Stomatologicka klinika1. LF UK avfn v Praze Department of Orthodontics, Clinic of Dental Medicine, 1st Medical Faculty of Charles University in Prague Souhrn CõÂlem teâ to praâ ce je shrnout soucï asneâ poznatky o mozï nosti prïedpoveïdileâcï ebnyâch zmeï n u ortodontickyâchpacientuê av praxi zhodnotit prïesnost pocï õâta cï ovyâ ch modelacõâ u pacientuê leâ cï enyâ ch kombinovanou metodou ortodonticko-chirurgickou pomocõâ modelacï nõâho programu Dolphin Imaging (verze 10.0). Do hodnoceneâ ho souboru bylo zarïazeno 29 pacientuê s kombinovanou ortodonticko-chirurgickou leâcï bou. Typ operace prïi vyâbeï ru nerozhodoval. VsÏ ichni pacienti meï li ukoncï enyâ ruê st. Byl porovnaâ n model vyâsledku operace vytvorïenyâ v programu Dolphin Imaging se skutecï nyâ m vyâ sledkem leâ cï by. NejlepsÏ õâ prïedpoveï d'vyâ sledku vysï la u bimaxilaâ rnõâch vyâ konuê,meâ neï prïesnaâ bylau posunuê dolnõâ cï elisti anejmeâ neï prïesnaâ u posunuê hornõâ cï elisti. CelkoveÏ lze rïõâci, zïe prïedpoveï d'bylahodnocenasubjektivneï jako dobraâ v 90% prïõâpaduê (Ortodoncie 2008, 17, cï. 1, s ). Abstract The aim of the work is to make a survey of prediction reliability and to assess the accuracy of computer simulations (performed with the Dolphin Imaging 10.0 software) in patients with a combined orthodontic-surgical treatment. The sample included 29 patients with an orthognathic surgery treatment. The type of operation was not relevant for the study. In all the patients the growth was finished. The model of the surgical result created by Dolphin Imaging software was compared with the actual therapeutic outcome. The most reliable prediction was recorded in bimaxillary operations; the prediction was less reliable in case of movements of the mandible, and the least reliable in case of the maxilla movements. The prediction was subjectively considered as good in 90% of the cases monitored (Ortodoncie 2008, 17, No. 1, p ). KlõÂcÏ ovaâ slova: Visualized Treatment Objectives, Dolphin Imaging Key Words: Visualized Treatment Objectives, Dolphin Imaging U vod Visualized Treatment Objectives (VTO) je technika modelace leâ cï ebnyâ ch zmeï n.tuto metodu muê zï eme pouzï õât u plaâ novaânõâleâcï by jak u pacientuê, kterïõâ budou leâcï eni pouze ortodonticky, tak u pacientuê, kterïõâ podstoupõâ kombinovanou ortodonticko-chirurgickou leâcï bu [ 1]. U pacienta po skoncï enõâ ruê stu, kteryâ jeleâcï en pouze ortodonticky, naâ m VTO znaâ zornï uje pouze pohyby zubuê ananeï navazujõâcõâ zmeï ny profilu. U pacientuê s kombinovanou ortodonticko - chirurgickou leâcï bou Introduction Visualized Treatment Objectives - VTO is a technique used for simulation of changes resulting from the treatment. The technique may be used in the treatment planning in both orthodontic patients only and patients with a combined orthognathic treatment [1]. In patients with a finished growth, treated as orthodontic patient only, VTO represents only movements of teeth and accompanying profile changes. In patients with combined (orthodontic-surgical) treatment 36

2 rocïnõâk17 naâ m VTO pomaâhaâ plaâ novat posuny kostõâ a je nezbytnaâ pro tvorbu leâcï ebneâ ho plaâ nu [2]. Existuje celkem 5 metod plaâ novaâ nõâ a vizualizace leâcï ebnyâ ch zmeï n (VTO). 1. manuaâ lnõâ technikapomocõâ acetaâ tovyâ ch foliõâ popsanaâ Cohenem, McNeillem ahendersonem [6]. 2. manipulace s fotografiemi pacienta v grafickyâch programech (Photoshop, Powerpoint aj.) 3. pocï õâta cï ovyâ software, s jehozï pomocõâ lze namodelovat profil meï kkyâ ch tkaâ nõâ dõâky pohybu digitalizovanyâch struktur nadaâ lkoveâ m rtg snõâmku 4. pocï õâta cï ovyâ software, kteryâ dokaâ zï e do modelace zacï lenit i fotografie pacienta (Videoimaging) 5. 3D pocï õâta cï ovaâ technologie pro plaâ novaâ nõâ amodelaci chirurgickyâch zmeïn PrvnõÂ trïi metody jsou v soucï asnosti jizï meâneï vyuzïõâvaneâ, metodacï õâslo cï tyrïi je v soucï asneâ dobeï nejrozsïõârïeneïjsï õâ ametodapeï t je ve vyâvoji ajesïteï nenõâ beïzïneï dostupnaâ v klinickeâ praxi. V teâ to praâ ci se veï nujeme hodnocenõâ metody cï õâslo cï tyrïi. Tato technika prïedstavuje spojenõâ digitalizovaneâho kefalometrickeâ ho snõâmku s profilovou fotografiõâ pacienta[3]. Velikost posunu meï kkyâ ch tkaâ nõâ v zaâ vislosti naposunu kostõâ je odvozen nazaâ kladeï algoritmuê specifickyâ ch pro danyâ software.vyâ slednaâ prïedpoveï d' je viditelnaâ nafotografii. To prïinaâ sï õâ dveï vyâ hody: 1) posiluje se komunikace mezi leâkarïem apacientem prïi stanovenõâ cõâluê beï hem kombinovaneâ ortodonticko-chirurgickeâ terapie a pacient maâ tak mozï nost volby mezi navrhovanyâmi plaâny 2) vyâ razneï se ulehcï õâ mozï nost rozhodovaâ nõâ; ortodontistaachirurg majõâ k dispozici obraâ zek, se kteryâm mohou manipulovat; mohou se tak shodnout na plaâ novaneâ m vzhledu meï kkyâch tkaâ nõâ. Mohou naprï. porovnat vyâ slednyâ profil u pacienta se III. Angleovou trïõâdou, pokud se bude deï lat pouze posun maxily doprïedu (Le- Fort I osteotomie) nebo se naopak provede posun mandibuly vzad (mandibulaâ rnõâ setback). NavõÂc naâm modelace pomuêzïe prïi rozhodnutõâ, zdabudou nutneâ jesï teï prïõâdatneâ vyâ kony nameï kkyâ ch tkaâ nõâch [4]. Podle Sarvera [5] prïi plaâ novaâ nõâ nejvõâce zaâ lezïõâ nazkusï enostech leâ ka rïe tvorïõâcõâho plaâ n se zvolenyâ m softwarem. DalsÏ õâm probleâ mem je prïedpoveïd'ruê stu u rostoucõâch pacientuê, kteraâ vyâ razneï komplikuje tvorbu prïedpoveï di. Tvorbamodelu leâ cï ebnyâ ch zmeï n probõâhaâ v neï kolika krocõâch: 1a) oblicï ejovaâ analyâza- prïi pohledu zeprïedu, z profilu apoloprofilu (45 ) hodnotõâme vztahy tvrdyâch ameï k- kyâch tkaânõâ VTO makes it possible to plan bone movements, and is necessary for the treatment planning [2]. There are 5 methods of treatment planning and visualization of treatment changes: 1. manual tracing using acetate film, described by Cohen, McNeill and Henderson [6] 2. adjustment of patients' photographs in graphic software (Photoshop, Powerpoint, etc.) 3. PC software enabling to simulate soft tissues profile by means of the movement of digitalized structures in cephalometric picture 4. PC software that is able to make the patient's photographs a part of the model (Videoimaging) 5. 3D computer technique for planning and simulation of changes resulting from surgery The first three approaches are less used nowadays, the technique 4 is used most frequently, and the last method has been still developing, and is not common in clinical practice yet. This study focuses on the fourth method. The method represents the connection of adigitalized cephalogram with a profile photograph [3]. The extent of soft tissues movement depending on the bone movement is inferred according to algorithms specific for the given software. The resulting prediction is visualized as a photograph. Thus: 1) the communication between a physician and apatient in discussing the objectives of the combined therapy is more important, the patient can choose between the treatment plans suggested; 2) it is easier to make decisions: an orthodontist and a surgeon can use an image, may manipulate with the image and discuss the soft tissue appearance. They can e.g. compare the resulting profile in a patient with Angle Class III in case they just move the maxilla forward (Le Fort I osteotomy), or in case they move the mandible backward (mandible setback). Moreover, the simulation helps us to decide whether additional management of soft tissues is required [4]. According to Sarver [5] in treatment planning the physician's experience with the software is the most important. In growing patients, the prediction of treatment outcomes is complicated by the estimate of growth. Model (simulation) of treatment outcomes includes several steps: 1a) face analysis - en face, profile, semi-profile (45 ); relationship of hard and soft tissues are evaluated 1b) model analysis - Angle Class classification, position of incisors assessment 1c) cephalometric analysis 37

3 1b) analyâza modelu - klasifikace podle AngleovyÂch trïõâd, hodnotõâme postavenõâ rïezaâkuê 1c) kefalometrickaâ analyâza 2. modelace plaâ novanyâch leâcï ebnyâch zmeïn V soucï asneâ dobeï je natrhu sï est pocïõâtacï ovyâch programuê, ktereâ umozïnï ujõâ plaâ novaânõâleâcï ebnyâch zmeï n pomocõâ metody videoimaging : 1. Dentofacial Planner Plus (Dentofacial Software, Toronto, Canada) 2. Dolphin Imaging (Dolphin Imaging, Santa Barbara, CA, USA) 3. Orthoplan 4. Quick Ceph Image (Quick Ceph System, San Diego, Kalifornia) 5. Vistadent 6. Opal ( Orthognatic Prediction Analysis) V zaâ sadeï jsou rozdõâly mezi jednotlivyâ mi programy zpuê sobeny rozdõâly v algoritmech na vyâ pocï et posunu meï kkyâ ch tkaâ nõâ v zaâ vislosti naposunu kostõâ. DalsÏ õâ rozdõâly muê zï e zaprïõâcï init zpuê sob propojenõâ fotografie a kefalometrickeâ ho snõâmku, zkreslenõâ kefalometrickeâ ho snõâmku av neposlednõâ rïadeï takeâ chybaleâkarïe, kteryâ simulaci provaâ dõâ [7, 8, 9,10]. Obvykle se meï kkeâ tkaâneï posunujõâ v urcï iteâ m procentu posunu kostõâ [11]. pohyb prïedozadnõâ posun rïezaâkuê vertikaâ lnõâ posun rïezaâkuê posun DCÏ vprïed HCÏ doprïedu DCÏ dozadu zmeïnameï kkyâch tkaânõâ % minimaâ lnõâ brada 1:1, dolnõâ ret % pohybu kosti lehce se zvedne sï picï kanosu, hornõâ ret - 60 % posunu rïezaâkuê ; zkraâ tõâ se o 1-2 mm brada 1:1, dolnõâ ret 60 % posunu kosti Propojenõ fotografie a kefalometrickeâ ho snõâmku je zalozï eno naprïekrytõâ boduê, ktereâ jsou shodneâ naobou. Materia l a metodika Do studie bylo zarïazeno celkem 29 pacientuê (20 zïen a9 muzïuê ) s kombinovanou ortodonticko-chirurgickou leâ cï bou, operovanyâch na luê zï koveâ m oddeï lenõâ Stomatologicke kliniky 1. LF UK avfn v Praze v obdobõâ Typ operace prïi vyâbeï ru nerozhodoval. VsÏ ichni pacienti meï li kompletnõâ dokumentaci: 1. kefalometrickyâ snõâmek s cï itelnyâm profilem meïkkyâ ch tkaâ nõâ a meï rïõâtkem zhotovenyâ po ortodontickeâ dekompenzaci 2. profilovou fotografii zhotovenou po dekompenzaci 3. kefalometrickyâ snõâmek s cï itelnyâm profilem meïkkyâch tkaânõâameïrïõâtkem zhotovenyâ po operaci 4. profilovou fotografii zhotovenou cca 6 meï sõâcuê po operaci ( vyloucï enõâ otokuê) 2) simulation of the planned treatment changes Currently, there are six PC softwares for the treatment planning via videoimaging: 1. Dentofacial Planner Plus (Dentofacial Software, Toronto, Canada) 2. Dolphin Imaging (Dolphin Imaging, Santa Barbara, CA, USA) 3. Orthoplan 4. Quick Ceph Image (Quick Ceph System, San Diego, CA, USA) 5. Vistadent 6. Opal (Orthognathic Prediction Analysis) Basic distinctions between the softwares are characterized by the different algorithms used to calculate the soft tissues movement depending on the bone movement. Other differences may be seen in the method of projection of a photograph in a cephalogram, cephalogram distortion, and - of course - the error of a physician performing the simulation [7, 8, 9, 10]. Soft tissues are usually moved in some proportion to the bone movement [11]. Movement Change of soft tissues Anterior-posterior 60-70% of the movement movement of incisors Vertical movement of minimum incisors Mandible anterior movement Maxilla forward Mandible backward Chin 1:1, lower lip 60-70% of the bone movement Only slight elevation of the tip of a nose, upper lip - 60% of incisors movement, reduced by 1-2 mm Chin 1:1, lower lip 60% of the bone movement Integration of a photograph and cephalogram is based on superimposition of points common to both. Material and method The sample included 29 patients (20 females and 9 males) with a combined orthodontic-surgical treatment operated in the Clinic of Dental Medicine, 1st Medical Faculty of Charles University and University Hospital in Prague between the years 2004 and The type of surgery was not relevant for our research. All the patients had a complete records: 1. cephalogram with a legible profile of soft tissues and scale made after orthodontic decompensation 2. profile photograph made after decompensation 3. cephalogram with a legible profile of soft tissues and scale made after the surgery 4. profile photograph made approximately 6 months after the surgery (without oedema) 38

4 rocïnõâk17 Obr.1: Postup prïekrytõâ kefalometrickeâ ho snõâmku s profilovou fotografiõâ pacienta. Fig.1: The way of superimposition of a cephalogram with a patient's profile picture. Obr.2: Uka zka meïrïenõâ na profilu pacienta Fig.2: Measurements in the patient's profile VsÏ ichni pacienti byli dospeï lõâ, takzïe prïi tvorbeï modelace plaâ novaneâhovyâsledku jsme zcelavyloucï ili ruê st. Pro digitalizaci kefalometrickyâ ch snõâmkuê bylo pouzï ito celkem 45 boduê natvrdyâch ameï kkyâ ch tkaâ nõâch. Na sledneï byly snõâmky v programu Dolphin imaging (verze 10.0) prïekryty s profilovou fotografiõâ pacienta pomocõâ boduê subnasale a glabella na meï kkyâch tkaânõâch (Obr. 1). All the patients were adult persons in order to eliminate growth factors during the simulation of the planned outcomes. For cephalogram digitalization 45 points in hard and soft tissues were used. With the help of Dolphin Imaging 10.0 the cephalograms were superimposed with aprofile photograph of apatient - the decisive points were subnasale and glabella in soft tissues (Fig. 1). 39

5 PrÏi hodnocenõâ prïesnosti plaâ novaâ nõâ leâ cï ebnyâ ch zmeï n je trïebavyloucï it chybu chirurga, proto byla modelace na snõâmku po dekompenzaci provedena po registraci reaâ lnyâch posunuê tvrdyâch tkaâ nõâ. Tyto posuny byly registrovaâ ny po prïekrytõâ kefalometrickyâ ch snõâmkuê po dekompenzaci a po operaci. PrÏekrytõ bylo provedeno prïes S-N linii opeï t v programu Dolphin imaging. Po zaznamenaâ nõâ zmeï n bylo mozïneâ proveâ st vlastnõâ modelaci na snõâmku po dekompenzaci prïekryteâ m fotografiõâ. Model byl naâ sledneï porovnaânsvyâsledkem. Pro hodnocenõâ prïesnosti modelace jsme nebrali vuâ vahu velikost posunu kostõâ. Namodelu aprïekryteâ m snõâmku s fotografiõâ po operaci byly zakresleny koordinaâtyxay. Ose X odpovõâdala linie S-N a ose Y linie kolmaâ na osu X prochaâ zejõâcõâ bodem N (Obr. 2). Bylo zvoleno celkem sedm boduê nameï kkyâch tkaânõâch: 1. sï picï ka nosu ( pronasale) 2. subnasale 3. bod A nameï kkyâch tkaânõâch 4. nejvõâce prominujõâcõâ bod hornõâho rtu (labrale superior) 5. nejvõâce prominujõâcõâ bod dolnõâho rtu (labrale inferior) 6. bod B nameï kkyâch tkaânõâch 7. pogonion Vlastnõ meï rïenõâ bylo provedeno tak, zï e ze zvolenyâch sedmi boduê byly naryâsovaâ ny kolmice ke koordinaâteïy avyâ slednaâ vzdaâ lenost zmeï rïenav milimetrech. Pokud zvolenyâ bod lezïelprïed liniõâ, bylahodnotapozitivnõâ, pokud byl zanõâ, bylahodnotanegativnõâ. Pacienti byly rozdeï leni do trïõâ skupin dle typu operace: 1. monomaxilaâ rnõâ vyâkon nadolnõâ cï elisti (MD) - 5 pacientuê 2. monomaxilaâ rnõâ vyâkon nahornõâ cï elisti (MX) - 11 pacientuê 3. bimaxilaâ rnõâ vyâkon (BIMAX) - 13 pacientuê PrÏi hodnocenõâ prïesnosti modelace u pacientuê kterïõâ meï li genioplastiku byl bod pogonion hodnocen zvlaâsït' ( MX+B - 2 pacienti; BIMAX+B - 9 pacientuê). CõÂlem bylo, aby se zmeïrïeneâ vzdaâ lenosti namodelu a fotografii po operaci co nejvõâce shodovaly. Vy sledky byly zaneseny do tabulek. U 20 pacientuê bylanaâ sledneï meï rïenõâ zopakovaâ nak vyâ pocï tu chyby meïrïenõâ. Ke statistickeâ mu zpracovaâ nõâ vyâ sledkuê byl pouzï it StudentuÊ v t-test nahladineï vyâ znamnosti VyÂsledky byly zpracovaâ ny tabulkoveï a do grafu s vyznacï enõâm statisticky signifikantnõâch rozdõâluê mezi modelacõâ avyâ sledkem sï ipkou. To evaluate the accuracy in treatment outcomes planning it is necessary to eliminate a surgeon's error. Therefore, the simulation was performed in the cephalogram made after decompensation according the real movements of hard tissues. The movements were registered after superimposition of cephalograms taken after decompensation and after surgery. The superimposition was performed by means of S-N line with Dolphin Imaging software. The simulation was compared with the actual outcome. For the assessment of simulation accuracy the extent of bone movement was not taken into consideration. In the model and in the superimposed cephalogram with a photograph after the surgery the coordinates X and Y were traced. X corresponded to S-N line, and Y corresponded to the line perpendicular to X and running through the N point (Fig. 2). In soft tissues the following seven points were chosen: 1. tip of a nose (pronasale) 2. subnasale 3. point A in soft tissues 4. the most prominent point of the upper lip (labrale superior) 5. the most prominent point of the lower lip (labrale inferior) 6. point B in soft tissues 7. pogonion From the seven points given above there were drawn perpendicular lines to the coordinate Y and the distance was measured in millimeters. In case the given point was before the line, the value was positive, in case it was behind the line, the value was negative. The patients were divided into three groups depending on the surgery: 1. monomaxillary surgery of the mandible (MD) - 5 patients 2. monomaxillary surgery of the maxilla (MX) - 11 patients 3. bimaxillary surgery (BIMAX) - 13 patients To evaluate the accuracy of simulation in patients with genioplastics the pogonion was assessed separately (MX+B - 2 patients; BIMAX+B - 9 patients). The measured distance in the model and in the photograph taken after the surgery should be as close as possible. The results are represented in tables. In 20 patients the measurements were repeated to calculate the measurement error. The results were statistically processed with the Student t-test, the level of significance The results were represented in tables and charts, statisti- 40

6 rocïnõâk17 Vy sledky U monomaxilaâ rnõâch vyâ konuê nahornõâ cï elisti vysï el statisticky vyâ znamnyâ rozdõâl mezi modelem avyâ sledkem celkem v peï ti bodech ( pronasale, subnasale, A, labrale sup., labrale inf.). Shoda byla v bodech B a pogonion nameï kkyâ ch tkaâ nõâch. U monomaxilaâ rnõâch vyâ konuê nadolnõâ cï elisti byly statisticky signifikantnõâ rozdõâly v bodech subnasale, labrale inferior a pogonion. Shoda byla ve 4 ostatnõâch bodech (pronasale, A, labrale sup., B). U bimaxilaâ rnõâch vyâ konuê byl statisticky signifikantnõâ rozdõâl pouze v bodeï labrale superior. Shoda byla ve cally significant difference between the simulation and the outcome was marked with an arrow. Results In monomaxillary surgery of the maxilla the statistically significant difference between the simulation and the real outcome was recorded in five points (pronasale, subnasale, A, labrale sup., labrale inf.). Agreement was found in points B and pogonion in soft tissues. In monomaxillary surgery of the lower jaw the statistically significant difference was recorded in subnasale, labrale inferior and pogonion. Agreement was proved in the other 4 points (pronasale, A, labrale sup., B). Tabulka 1: VyÂsledky meïrïenõâ pro body pronasale (tip of the nose); subnasale a bod A na meï kkyâch tkaânõâch Table 1: Results of measurements for the points pronasale, subnasale, and A in soft tissues Tabulka 2: VyÂsledky meïrïenõâ pro body labrale superior, labrale inferior a B na meï kkyâch tkaânõâch Table 2: Results of measurements for the points labrale superior, labrale inferior, and B in soft tissues 41

7 Tabulka 3: VyÂsledky meïrïenõâ pro bod pogonion Table 3: Results of measurements for the point pogonion vsï ech ostatnõâch bodech ( pronasale, subnasale, A, labrale inf., B, Po). U pacientuê kterïõâ podstoupili jesï teï genioplastiku (bud' s operacõâ na hornõâ cï elisti nebo prïi bimaxilaâ rnõâm vyâkonu) vychaâ zelalepsï õâprïedpoveï d'bodu pogonion u bimaxilaâ r- nõâch vyâkonuê. Diskuse Hodnocenõ pocï õâta cï ovyâ ch modelacõâ vytvorïenyâ ch v ruê znyâ ch programech bylo provedeno v neï kolikastudiõâch abyly hodnoceny i pocï õâta cï oveâ programy mezi sebou. Princip tvorby modelu je v pocïõâtacï ovyâch programech stejnyâ ajednotliveâ programy se lisï õâ pouzï ityâ m algoritmem amnozï stvõâm boduê pouzï ityâch prïi digitalizaci. NavõÂc se pocï õâta cï oveâ programy neustaâ le vyvõâjõâ afirmy pracujõâ na vylepsï enõâch tak jak se vyvõâjõâ poznatky o posunech meï kkyâ ch tkaâ nõâ v zaâ vislosti naposunu kostõâ. Tyto vztahy jsou ovlivnï ovaâ ny rasou, veï kem, elasticitou meï kkyâch tkaâ nõâ ajejich funkcï nõâmi vztahy, daâ le tlousït'kou kuêzïe apodkozïnõâch vrstev. Proto nemuêzï eme braâ t zcela stoprocentneï vyâ sledky studiõâ provedenyâ ch na pocï õâtacï ovyâch programech prïed 10 lety, protozïe v soucï asneâ dobeï je aktuaâ lnõâ zcelajinaâ verze programu, kde mohou byât neï ktereâ parametry zmeï neï neâ nebo upraveneâ. V roce 1997 provedli Upton, Sadowsky a Sarver [12] studii hodnotõâcõâ prïesnost modelacõâ v programu Quick Ceph Image. Ve studii bylo zarïazeno 40 pacientuê, kterïõâ podstoupili bimaxilaâ rnõâ chirurgickyâ vyâ kon. Modelace bylaprovedenanazaâ kladeï odecï tenõâ prïesnyâ ch posunuê kostõâ po prïekrytõâ kefalometrickeâ ho snõâmku prïed apo operaci. Vy sledky ukaâ zaly na statisticky signifikantnõâ rozdõâly v prïedpoveï di polohy dolnõâho rtu adaâ le v bodech subnasale, sulku a deâ lce hornõâho rtu. V na sï õâ studii naâ m u bimaxilaâ rnõâch vyâ konuê vysï ly nejprïesneïjsïõâvyâsledky. Statisticky vyâznamneâ rozdõâly jsme zjistili pouze u bodu labrale superior - takzï e v neprïesneâ poloze hornõâho rtu se s citovanou studiõâ shodujeme. DalsÏ õâ provedenaâ studie se tyâ kala vyâ konuê nadolnõâ cï elisti, bylaprovedenasinclairem [9] v roce 1995 apouzï ityâ software byl Vistadent. Do studie bylo zarïa- In bimaxillary surgery the statistically significant difference was recorded only in labrale superior. Agreement was proved in all the other points (pronasale, subnasale, A, labrale inf., B, Po). In patients with genioplastics (with the surgery of maxilla or bimaxillary surgery) the prediction of pogonion was more reliable in case of bimaxillary surgery. Discussion Several studies have evaluated computer simulations performed by means of different softwares; individual software programmes have been compared. The principle of simulation is the same, the individual softwares use different algorithms and different number of points in digitalization. The programmes have been still developing and the producers improve the algorithms according the new knowledge in the field. The relationships are influenced by the race, age, elasticity of soft tissues and their functional relations, thickness of epidermis and subcutaneous layers. Therefore, the results of studies performed with softwares available ten years ago cannot be 100% reliable, as today we work with new software versions with altered or modified parameters. In 1977 Upton, Sadowsky and Sarver [12] evaluated the accuracy of simulations in the Quick Ceph Image programme. The study included 40 patients with bimaxillary surgery. The simulation was performed on the basis of deduction of accurate bone movements after superimposition of a cephalogram before and after the surgery. The results proved statistically significant differences in the prediction of the position of the lower lip and in points subnasale, sulcus, as well as in the length of the upper lip. Our study showed the most accurate results in case of bimaxillary surgery. Statistically significant differences were found only in labrale superior, i.e. the inaccurate position of the upper lip is in agreement with the above mentioned study. 42

8 rocïnõâk17 zeno celkem 56 pacientuê. Modelace byla provedena stejnyâm zpuê sobem jako v prïedesïleâ i nasï õâ studii. VyÂsledky byly hodnoceny pouze subjektivneï, kdy ortodontistaachirurg porovnaâ vali visuaâ lneï provedenou modelaci s vyâ sledkem leâ cï by. NapeÏ tistupnï oveâ sï kaâ le bylo % prïedpoveï dõâ hodnocenyâ ch jako dobreâ azï vyâ borneâ. NeprÏesna bylaprïedpoveï d' dolnõâho rtu, mentolabiaâ lnõâho sulku abrady. Dolnõ ret byl retruzneï jsï õâ atencï õâ nezï vyâ sledek. V na sï õâ studii naâ m u vyâ konuê nadolnõâ cï elisti vysï la shodamezi modelacõâ avyâ sledkem ve 4 bodech ze 7. Statisticky signifikantnõâ rozdõâly byly v bodech subnasale, labrale inferior a pogonion. Da serïõâci, zïeprïedpo- veï d' dolnõâho rtu je meâneïprïesnaâ. Studie hodnotõâcõâ prïesnost modelacõâ u pacientuê, kterïõâ podstoupili osteotomii Le Fort I, bylaprovedena v roce 2001 Jacobsenem a Sarverem [13]. Pro modelaci byl pouzï it program Dentofacial Planner. Ve studii bylo zarïazeno celkem 46 pacientuê.vyâ sledky ukaâ zaly, zï e u 80 % pacientuê je mozïneâ zhotovit model ± 2mm shodnyâ s vyâ sledkem au 43 % pacientuê v rozmezõâ ± 1mmodvyÂsledku. V na sï õâ studii se ukaâ zala prïedpoveï d' posunu hornõâ cï elisti jako nejmeâ neï prïesnaâ. Zjistili jsme statisticky vyâznamneâ rozdõâly ve vsï ech meï rïenyâ ch bodech kromeï bodu B apogonion nameï kkyâch tkaâ nõâch. MozÏne chyby prïi provedenõâ modelace leâcï ebnyâch zmeï n mohou byât zpuê sobeny: 1. zhotovenõâm fotografie v nestandardnõâch podmõânkaâ ch (ruê znaâ vzdaâ lenost, prïõâtomnost stõânu prïed profilem, nevhodneâ pozadõâ) 2. malyâ m pocï tem digitalizovanyâ ch boduê, ktereâ pouzï ijeme prïi kefalometrickeâ analyâ ze (zaâ visõâ na typu analyâzy) 3. nezkusï enostõâ leâkarïe, kteryâ modelaci provaâdõâ V soucï asneâ dobeï jsou jizï natrhu programy, ktereâ naâ m umozïnï ujõâ provaâ deï t plaâ novaâ nõâ trojrozmeï rneï. K tomu je zapotrïebõâ speciaâ lnõâ CT scan a seâ rie fotografiõâ zachycujõâcõâ pacienta v jeden okamzïik z neï kolikauâ hluê (stereo fotografie). Ve 3D plaâ novaâ nõâ vidõâme budoucnost modelacõâ leâcï ebnyâ ch zmeï n. ZaÂveÏr Na29 pacientech, kterïõâ podstoupili kombinovanou ortodonticko chirurgickou leâcï bu jsme provedli modelaci leâcï ebnyâch zmeï n v programu Dolphin Imaging verze Na sledneï jsme provedenou modelaci porovnali s vyâsledkem leâcï by. Zjistili jsme, zï e nejmeâ neï prïesnaâ je prïedpoveï d' posunuê hornõâ cï elisti, kde vysï lashodapouze v bodech B apogonion nameï kkyâch tkaâ nõâch. Tedy ve 2 bodech ze 7. The study by Sinclair [9] in 1995 dealt with the treatment of the mandible and worked with the Vistadent software. The sample included 56 patients. The simulation was the same as in the study by Upton et al., and in our work. The evaluation of the results was subjective, i.e. an orthodontist and a surgeon compared visualized models with the treatment outcomes. On the five-grade scale, 60-83% of predictions were evaluated as good up to excellent. The prediction for the lower lip, mentolabial sulcus, and chin was not reliable. The lower lip was more retrusive and thinner in the modelation. In our study, the agreement between the simulation and the real outcome was found in 4 points out of 7. Statistically significant differences were found in subnasale, labrare inferior, and pogonion points. This suggests that the prediction for the lower lip is less reliable. In 2001, Jacobsen and Sarver [13] evaluated the accuracy of simulation in patients with osteotomy Le Fort I. The Dentofacial Planner software was used. The sample included 46 patients. The results showed that in 80% of patients the simulation agreed ± 2 mm with the outcome, and in 43% of patients the model agreed ± 1 mm with the outcome. In our study, the prediction of the maxilla movement was the least reliable. We found statistically significant differences in all the points measured except B and pogonion in soft tissues. The errors in simulation of the changes may be due to the following reasons: 1. photograph taken in non-standard conditions (different distance, shade in front of the profile, inappropriate background, etc.) 2. small number of digitalized points used in cephalometric analysis (depends on the type of the analysis performed) 3. less experienced physicians performing the simulation Nowadays, there are software programmes which make the three-dimensional planning possible. The special CT scan and series of photographs imaging the patient from many angles at the same time (stereo photography) are required. We believe that 3D planning is the future of the simulation of therapeutic changes. Conclusion We simulated therapeutic changes of 29 patients with the combined orthodontic-surgical treatment using the Dolphin Imaging 10.0 software. The models were then compared with the actual outcomes. The prediction of the maxilla movements was the least reliable - only B and pogonion points in soft tissues corresponded (only 2 points out of 7). 43

9 PrÏesneÏ jsï õâ bylaprïedpoveï d' posunuê dolnõâ cï elisti kde jsme zjistili shodu ve 4 bodech ze 7. Statisticky signifikantnõâ rozdõâly byly v bodech subnasale, labrale inferior apogonion. NejprÏesneÏ jsïõâ prïedpoveï d' bylau pacientuê, kterïõâ podstoupili bimaxilaâ rnõâ vyâkon. Zde jsme se shodovali v 6 bodech ze 7. The prediction of the mandible movements was more accurate. The agreement was recorded in 4 points out of 7. Statistically significant differences were found in subnasale, labrale inferior and pogonion points. The prediction in patients with bimaxillary surgery was the most reliable (6 points out of 7). Literatura/References: 1. Nanda, R.: Biomechanics and esthetic strategies in clinical orthodontics. Philadelphia: Elsevier, Arnett, G. W.; McLaughlin,R. P.: Facial and dental planning for orthodontist and oral surgeons. St. Louis: Mosby, Grubb, J. E.; Smith,T.; Sinclair, P.: Clinical and scientific applications/ advances in video imaging. Angle Orthodont. 1996, 66, s Phillips,C.; Hill, B. J.; Canna,Ch.: The influence of video imaging on patient's perceptions and expectations. Angle Orthodont. 1995, 65, s Sarver, D. M.: Video cephalometric diagnosis (VCD): A new concept in treatment planning. Amer. J. Orthodont. dentofacial Orthop. 1996, 110, s Smith, J. D.; Thomas, P. M.; Proffit, W. R.: A comparison of current prediction imaging programs. Amer. J. Orthodont. dentofacial Orthop. 2004, 125, s Sarver, D. M.: Video imaging - a computer facilitated approach to communication and planning in orthognatic surgery. Brit. J. Orthodont. 1993, 20, s Sarver, D. M.: Videoimaging: the pros and cons. Angle Orthodont. 1993, 63, s Sinclair, P. M.; Kilpelainen, P.; Phillips, C.; White, R. P.; Rogers, L.; Sarver, D. M.: The accuracy of video imaging in orthognatic surgery. Amer. J. Orthodont. dentofacial Orthop. 1995, 107, s Gossett, Ch. B.; Preston, B.; Dunford, R.; Lampasso, J.: Prediction accuracy of computer assisted surgical visual treatment objectives as compared with conventional visual treatment objectives, J. Oral Maxillofac. Surg. 2005, 63, s Konstiantos, K. A.; O`Reilly, M. T.; Close, J.: The validity of the prediction of soft tissue profile changes after LeFort I osteotomy using the Dentofacial planner. Amer. J. Orthodont. dentofacial Orthop. 1994, 105, s Cit in: Smith, J. D.; Thomas, P. M.; Proffit, W. R.: A comparison of current prediction imaging programs. Amer. J. Orthodont. dentofacial Orthop. 2004, 125, s Upton, P. M.; Sadowsky, P. L.; Sarver, D. M.; Heaven, T. J.: Evaluation of video imaging prediction in combined maxillary and mandibular orthognathic surgery. Amer. J. Orthodont. dentofacial Orthop. 1997, 112, s Jacobson, R.; Sarver, D. M.: The predictability of maxillary repositioning in LeFort I orthognatic surgery. Amer. J. Orthodont. dentofacial Orthop. 2002, 122, s MUDr.Sylvie Saifrtova Stomatologicka klinika 1.LF UK KaterÏinska 32, Praha 2 8. rocïnõâk JihocÏeskyÂch ortodontickyâch dnuê ¹SpolupraÂce para, orto, deïtske⪠se bude konat ve dnech 18. a v CÏeskyÂch BudeÏjovicõÂch v hotelu Maly pivovar. Ve spolupraâci s firmou ROD, p. PodlahovaÂ. Kontaktnõ adresa: MUDr. Milada Ha lkovaâ,vaâ clavskaâ 282, Strakonice, tel.: , halek@iol.cz 44