Quantitative changes over time in the three-dimensional assessment of facial swelling following mandibular third molar surgery: A follow-up study of 5 consecutive days

doi:10.21203/rs.3.rs-2592773/v1

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Quantitative changes over time in the three-dimensional assessment of facial swelling following mandibular third molar surgery: A follow-up study of 5 consecutive days

https://doi.org/10.21203/rs.3.rs-2592773/v1

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Objectives. The study aimed to analyze and quantify three-dimensional consecutive changes in facial swelling following impacted mandibular third molar (IM3M) surgery, and verify the repeatability and accuracy of three-dimensional(3D) photogrammetry.

Materials and methods. A total of 46 patients was scheduled to undergo IM3M surgery. 3D facial scanning images were obtained before surgery, and the first consecutive 5 days postoperatively. 3D software was used to assess and quantify volumetric changes between serial 3D images. Swelling of the face was measured in relation to the change in volume and thickness. Additionally, repeatability measurements for 3D images were performed on non-surgical side to gain access to the reliability and validity of this measurement.

Results. The maximum evident volumetric swelling was 23.64±11.15cm³, occurred on the second post-operative day, and the maximum thickness swelling was 6.08±2.25mm, occurred on the first post-operative day. The repeatability test showed no significant difference in pairs comparisons for the five non-surgical datasets.

Conclusions. Facial swelling after IM3M surgery reached its maximum volume on the 2nd postoperative day and its maximum thickness on the 1st postoperative day, and the 3D photogrammetry system is a reliable tool for measuring and monitoring changes in the swelling of the face.

Clinical Relevance. Quantity the consecutive changes over time in postoperative facial swelling following IMTM surgery，and verify the 3D photogrammetry is a reliable tool to monitor changes in facial swelling.

3D photogrammetry

facial swelling

third molar surgery

volumetric analysis

IM3M extraction is one of the most frequent procedures in oral and maxillofacial surgery and may lead to postoperative complaints, such as swelling, postoperative pain, and restricted mouth opening due to hard and soft tissue traumas^[1,2,3]. Facial swelling is one of the most unpleasant symptoms in the first days after surgery and can persist for several days, leading to significant psychological discomfort and functional deficiencies. The degree of post-operative swelling could objectively reflect surgical trauma after extractions. Many studies have investigated the postoperative swelling, and determined that the facial swelling reaches a characteristic maximum within 48-72 hours after the surgery procedure and begins to subside on the third or fourth day postoperatively^[4,5]. However, the tendency for swelling in the preceding observations was determined by experience, subjective or two-dimensional (2D) evaluation, and the primary limiting factor came from imprecise 2D measurements that were unable to capture the complete size range and discontinuous measurement time point^[6,7,8]. Additionally, there has not yet been a study that details the quantitative and sequential changes in facial swelling after IM3M surgery, and no substantial evidence to support the time estimate of swelling changes. Therefore, the purpose of this study was to utilize 3D stereo photogrammetry to measure consecutive changes of swelling over time via soft tissue volumetric and thickness changes in patients who underwent IM3M surgery, analyze and quantify the continuous changes of facial swelling, and verify the accuracy and reliability of the measurement method for the mid-lower facial region by the 3dMD system.

Eligible patients

From January 1 to April 1, 2019, patients who required to have their impacted third molars extracted at the Peking University School of Stomatology's Department of Oral and Maxillofacial Surgery were recruited for this study. The Human Ethics Committee at our hospital granted ethical approval for this study, which was carried out in accordance with the Helsinki Declaration (No. PKUSSIRB-201415068), and it was recorded in the Chinese Clinical Trial Registry (ChiCTR2000040767).

The following inclusion criteria were applied: (1) Between the ages of 18 and 40. (2) Good general and local health. (3) Radiographic evidence of an impacted third molar in the jaw. The exclusion criteria were as follows: (1) The presence of periodontitis, odontogenic cysts or tumors, trauma, or any signs of infection around the IM3M. (2) Postoperative cases with suppurative infections. (3) Not all follow-up was completed.

Study design

It was a self-control study. 46 volunteers were enrolled in total; 16 individuals were excluded from the trial due to loss of follow-up or suppurative infections. These 30 participants' bilateral sides were split into two groups: the surgery sides group and the non-surgical sides group. The non-surgical sides group was utilized to confirm the accuracy and repeatability of the 3dMD imaging method, while the surgical sides group was used to access the consecutive trend of face swelling following surgery.

Operation

Before surgery, informed consent was signed by each participant patient. The same surgeons carried out each procedure. Under local anesthetic, the third molar on the mandible was surgically removed. The procedure involved raising a full-thickness, three-cornered mucoperiosteal flap and performing bone removal and tooth sectioning. The surgical incision was stitched shut with a 4-0 silk suture after the mucoperiosteal flap was repositioned.

Scanning procedure

In this investigation, photographs of the samples were taken using the 3dMDface system (3dMD Ltd, Atlanta, Ga), a structured light system based on stereo photogrammetry and the structured light technique, with a natural head position, a relaxed facial expression, and eyes directed straight ahead. With three cameras on each side, the 3dMD system uses synchronized digital multicamera technology to produce photos of photorealistic quality. The device can take a 180-degree image of a person's entire face, including the area under the chin, in approximately 1.5 milliseconds at high resolution, with a theoretical accuracy of 0.2 millimeters. The follow-up is extended by 5 to 10 minutes with the 3dMD system^[9,10].

A 3D facial image was taken six times of each patient. A preoperative 3dMD image was taken right before surgery (T0) for comparison with the postoperative image in order to assess the con changes. At five different times after surgery—24 hours (T1), 48 hours (T2), 72 hours (T3), the fourth day (T4), and the fifth day (T5)—3dMD pictures were taken.

Data processing and measurement method

The same researcher used the same tool to capture each 3dMD image. All images were saved as. TSB files and edited with 3D software (3dMD patients Version 4.0). The 3D models of each patient were imported into the software to calculate the changes in shape brought on by the swelling. The forehead and bridge of the nose were used to align and record the two related 3D models (the model before and one day after surgery), as those regions did not differ regardless of the level of swelling (Figure.1A). After completing the superimpositions of two models, we applied the root mean square (RMS) value until it reached the smallest value. The RMS value, which is specified in the software manually and determines how consistent the registration process is, was recorded for individual, and the superimpositions with the RMS value below 1 were re-evaluated.

Four linear references on the facial images have been selected to help reduce error: line A, the first cervical stripe line, line B, the ala-tragus line, from the tragus to the base of the nasal wing, line C, the facial midline, and line D, the contour of the auricle to the hairline (Figure 1B-E). Following that, we deleted the excess data，and the region of interest (ROI) was chosen for the calculation. After we aligned the two 3D models(before and one day after surgery) and delineated the ROI，the thickness of swelling（TOS） and volume of swelling（VOS）were calculated by subtracting the two models (Figure 1F). The volume in milliliters and the thickness in millimeters of the swelling were measured.

Statistical analysis

The statistical analysis was conducted using the IBM SPSS statistics 22.0 program. The Shapiro-Wilcoxon test was used to determine whether the data were consistent with a normal distribution. To assess swelling changes between all-time points within patients, descriptive statistics and repeated measures analysis of variance were computed for TOS and VOS in the two groups, and the Bonferroni test was utilized for the post hoc analyses. P < 0.05 was considered statistically significant.

A total of 46 volunteers were enrolled into our study, and 16 volunteers were excluded due to loss of follow-up or suppurative infections. The mean age of the patients was 25.15 years (4.53±7.10).

Results of the volumetric analysis

Comparison of the volume and thickness swelling at different time intervals in the surgical side was done. Table1 displayed the modifications. From the first to the fifth postoperative day, the VOS was 20.70±9.13cm³, 23.64±11.15cm³, 22.72±11.80cm³, 18.11±8.85cm³, and 14.56±7.79cm³, and the TOS was 6.08±2.25mm, 4.80±0.85mm, 4.43±1.80mm, 3.71±1.15mm, and 3.09±1.22mm. At various postoperative times, there were significant differences in terms of VOS (Repeated measure ANOVA, F=11.556; P<0.001) and TOS (Repeated measure ANOVA, F=12.211; P<0.001). On the second postoperative day, there was the most evident volumetric swelling, and on the first postoperative day, there was the greatest thickness (Figure 2).

Repeatability test. The non-surgical side group's swelling data was collected for repeatability analysis. The measured mean values and multiple comparisons are displayed in Table 1. The outcomes for the five sets of data indicated no statistically significant differences (P>0.05). In light of this, we deduced that the experimental correctness and dependability of the 3dMD imaging approach was reliable.

Surgery to remove IM3M is frequently accompanied with excruciating postoperative discomforts such pain, swelling, and trismus. Up to a point, swelling is a problem brought on by soft tissue injuries. It is caused by the extravasation of fluid from the injured tissues as a result of the destruction or obstruction of the lymphatic vessels, which stops the lymph from draining and builds up in the tissues. Clinically, the edema is characterized by smooth, pale, and taut skin. When swelling is due to inflammation, the skin presents with redness, because of the local hyperemia⁵. Depending on the amount of tissue injure in the area, the edema ranges from small to moderate and, rarely, severe.

In the present study, we focused on the 3D volumetric soft tissue changes after 3rd molar surgery. Both clinicians and patients are very interested in how the soft tissues of the face change after third molar surgery. Digital technological advancements are changing the way images evaluated from 2D to 3D. In recent years, procedures such the visual analogue swelling scale, direct anthropometry, computed tomography, 3D optical assessment, and others have become widely employed for assessing postoperative swelling following third molar surgery^[6,8,11]. In our investigation, we used 3dMD imaging techniques, a 3D optical measurement technique that has been proven to evaluate the face edema in other studies, to quantify the degree of swelling^[9,10].

In our study, the key findings were that the most prominent TOS was on the 1st postoperative day, and VOS on the 2nd postoperative day. Previous studies that analyzed postoperative swelling concluded that it reaches its peak between 48 and 72 hours after surgery and starts to reduce on the third or fourth day afterward^[12,13,14]. However, the previous observations' swelling trend was determined by experiencing, subjective, or 2D judgment, and this time estimate is not supported by any convincing evidence. Our study, which was conducted in order to evaluate the swelling following third molar surgery, is the first to measure the swelling over a period of consecutive days in order to determine the pattern of change in postoperative swelling. As a result, it corrected the shortcomings of earlier empirical findings. Through the results and 3D images of measurement in 5 continuous days, we may infer the postoperative swelling change pattern from the findings and 3D images of measurements taken over a period of five days: 1. The TOS reaches the severe value and the swelling mainly affects a small region. 2. On the second postoperative day, the swelling volume reaches an extreme value and spreads to the tissue around the center. 3. The swelling starts to disappear, moving from the edges to the center on the third day (Figure 3).

Additionally, the non-surgical sides are measured in our study for repeatability analysis, which enables us to confirm the accuracy of this approach. In our study, there were no discernible variations in the outcomes between the non-surgical sides group in pairwise comparisons. We consider that this method's assessment produces a reliable outcome. Julielvnn et al used this method to evaluate facial anthropometric linear distances against direct anthropometry and reported that the 3dMD analysis provided more valid and reliable outcomes^[15]. Van der Vlis quantified the volume, duration, and reduction rate of postoperative swelling in orthognathic surgery patients using serial 3D images taken^[16]. In these reports, 3D stereo photogrammetry is a reliable, accurate, and noninvasive tool for measuring changes in soft tissue volume over time. The accuracy and reliability of the 3dMD face system have been proved with a relative accuracy less than 0.5mm and it can be a widespread facility for diagnosis and research in clinic^[17,18,19]. Our study's findings are consistent with those researches that have examined the reliability of the 3dMD system. Furthermore, the 3dMD image system's noninvasive, quick, and simple features are superior to other approaches since they allow for a quick, accurate, and reliable assessment of soft tissue without exposing patients to risks like radiation exposure, physical touch, or excessive prices ^[9,10,20]. Therefore, as a quick way for determining the extent of face swelling, this method might satisfy the needs of clinical diagnosis and analysis.

To our knowledge, this is the first study to employ the 3dMDface telephotographic system to objectively assess the successive changes in facial swelling following IM3M surgery. Within the constraints of this study, our findings indicate that the facial swelling after IM3M surgery reached its maximum volume on the second postoperative day and its maximum thickness on the first postoperative day, and that the 3D photogrammetry system is a reliable tool to monitor changes in facial swelling.

Author contributions

Fei Wang performed the performed the experiment; data analyses and wrote the manuscript;

Wei Cui helped perform the analysis with constructive discussions, data extraction, and writing original draft.

Yang-Yang Zhao contributed significantly to analysis and manuscript preparation.

Yu Liu, corresponding author, contributed project administration, validation, data curation, and review.

Fei Wang and Wei Cui are the co-first authors.

Funding

None

Competing interests

The authors declare no competing interests.

Disclosure

Fei Wang and Wei Cui are the co-first authors.

Ethical approval

Ethical approval was obtained from the Biomedical Ethics Committee of Peking University School of Stomatology (PKUSSIRB-201415068). The research protocol was pre-registered in the Chinese Clinical Trial Registry

(ChiCTR2000040767).

Patient consent

All patients provided written informed consent to participate in this study.

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Table 1. The volume and thickness of swelling variables at different time intervals for the surgical side and non-surgical side group.

		Mean±SD					P Value
		T1	T2	T3	T4	T5
Surgical side	VOS (cm3)	20.70±9.13	23.64±11.15	22.72±11.80	18.11±8.85	14.56±7.79	＜0.05

	TOS (mm)	6.08±2.25	4.8±0.85	4.43±1.80	3.71±1.15	3.09±1.22	＜0.05

Non-surgical side	VOS (cm3)	1.09±1.35	2.04±1.78	1.97±0.67	1.79±2.37	1.15±1.34	0.541

	TOS (mm)	0.24±0.23	0.13±0.54	0.14±0.67	0.12±0.33	0.21±0.48	0.673

VOS, the volume of swelling; TOS, the thickness of swelling.

No competing interests reported.

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Quantitative changes over time in the three-dimensional assessment of facial swelling following mandibular third molar surgery: A follow-up study of 5 consecutive days

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