9-24 Cran Anom I

CRANIOFACIAL ANOMALIES I: CEPHALOMETRICS AND ORTHOGNATHIC SURGERY
Arshad R Muzaffar MD and John Flood FRACS

INTRODUCTION The field of craniofacial surgery has grown dramatically over the past 25 years. Since the advent of combined intra- and extracranial movements of the face and skull, many abnormalities previously considered uncorrectable are now amenable to surgery. Together with advances in craniofacial surgery, there has been a need for more accurate preoperative diagnostics and more sophisticated methods to prognosticate surgical outcome. A basic understanding of the systematic approach to analysis of facial deformities, knowledge of the more popular techniques for osteotomy and tissue movement, and awareness of the long-term prognoses of such surgical manipulations will enable the craniofacial surgeon to make an appropriate treatment plan to deal with a patients deformity. Planning the skeletal, soft-tissue, and dental correction of craniofacial deformities requires careful collection of data from various sources, the patients description or perception of the problem, medical and dental history, clinical examination, medical photographs, cephalometric analysis, CT analysis, examination of radiographs, and evaluation of dental study models. For the surgery of craniofacial malformations to be considered successful and the results socially acceptable, the final dimensions and proportions obtained through surgical movements must closely approximate known normal values. The results of bony movements and their intimately related softtissue responses are discussed, along with a review of osteotomies of the midface and mandible. FACIAL PROPORTIONS General Esthetic Relationships Farkas1 compared the profile inclinations of randomly selected young adult Caucasians without occlusal problems to artworks of the past and present. Modern art representations were characterized by a stronger lower facial third and wider angles of inclination of the nasal bridge and chin than the older works. Similarly, the live subjects exhibited a receding lower face, less tilt to the forehead, and a less prominent upper lip and chin than was shown in classical art images. In a companion study, Farkas and associates2 analyzed the vertical and horizontal proportions of the Caucasian face. Their sampling included 153 young adults, 100 6-year-olds, 105 12-year-olds, and 103 18-year-olds. Analysis of their data led the authors to question the validity of nine classical Greek canons of facial proportion (Figs 1.11.7): Canon 1. The combined head-face height is divided into two equal parts.
Result (Fig 1.1). The vertex-endocanthion distance is greater than the endocanthion-gnathion distance in 80% of subjects.
Canon 2. The combined forehead-face height is divided into three equal parts.
Result (Fig 1.2). In 100% of subjects, the nasionsubnasale distance is less than the subnasalegnathion distance. In 95% the trichion-nasion distance is greater than the nasion-subnasale distance. The relationship between trichion-nasion and subnasale-gnathion varies.
SRPS Volume 9, Number 24
Canon 3. The combined head-face height is divided into four equal parts. Result (Fig 1.3). The glabella-subnasale distance is greater than the vertex-trichion distance in 87%, and the vertex-trichion distance is greater than the trichion-glabella distance in 52%. The subnasalegnathion distance is greater than the glabellasubnasale 68% of the time, greater than the trichion-glabella 100% of the time, and greater than the vertex-trichion 100% of the time.
Result (Fig 1.6). The interocular distance is greater than or equal to the fissure distance 85% of the time. Canon 7. The width of the mouth equals 1.5X the width of the nose.
Result (Fig 1.7). The width of the mouth is greater than 1.5X the width of the nose 60% of the time. Canon 8. The width of the nose equals one fourth the width of the face. Result. The width of the nose is either smaller or greater than one-fourth the width of the face 63% of the time. Canon 9. The inclination of the nasal bridge parallels the long medial axis of the ear. Result. The nasal bridge inclination exceeds the tilt of the medial axis of the ear in 91% of subjects.
Figs 1.1-1.7. Neoclassical canons of facial proportions compared with modern White faces. (Reprinted with permission from Farkas LG et al: Vertical and horizontal proportions of the face in young adult North American Caucasians: Revision of neoclassical canons. Plast Reconstr Surg 75:328, 1985.)
Canon 4. The length of the nose equals the length of the ear.
Result (Fig 1.4). Nose length is less than ear length in 95% of subjects. Canon 5. The interocular distance equals the width of the nose.
Result (Fig 1.5). The interocular distance is less than the nasal width in 38% of subjects, greater in 21.4%. Canon 6. The interocular distance equals the length of the fissure.
The most striking difference between the canon face and the average modern face occurs in the head, which is wider and longer in the canon because the calvarium and forehead are equally large. In contrast, the lower part of the modern face is elongated, with a much larger chin than the classical face. The differences between the neoclassical face as depicted by Renaissance artists and that of present-day North Americans can be seen in Figure 2. Farkas and Kolar3 analyzed ethnic variations in esthetic facial parameters among North American Caucasian women, and concluded that these variations are not of major concern when planning esthetic correction. Specific measurements for attractive and most attractive groups are given in the article, and deal with vertical, horizontal, and
given line at which the ratio of the smaller to the larger portion is exactly the same as that of the larger section to the original line. Ricketts4 claims the same proportions apply in the human face: a ratio of 1.0:1.618 is consistent with facial balance (Fig 3).
Fig 2. Proportions of A, the classical face versus B, the modern face in Whites. (Reprinted with permission from Farkas LG et al: Vertical and horizontal proportions of the face in young adult North American Caucasians: Revision of neoclassical canons. Plast Reconstr Surg 75:328, 1985.)
profile characteristics of the face. The authors note that a healthy face, which manifests esthetic indices within the normal range 2 (s), is not necessarily attractive. In the group selected for attractiveness, the proportion indices are in optimal relationship and statistically fall within the mean 1 (s). This range reflects the variability that is possible even among attractive faces. While an awareness of these ideal facial proportions undoubtedly sharpens our esthetic sense, strict adherence to predetermined values does not necessarily make for an attractive face in every case. In an effort to reduce the esthetics of the face to the language of mathematics, Ricketts4 proposed a relationship between facial form and the Golden Mean. The ancient Greeks deemed mathematical progression in nature as both pleasing and reproducible, while recognizing that absolute symmetry is monotonous and uninteresting. The Golden Mean, also called the Golden Section, Golden Ratio, or Divine Proportion, refers to the point on a
Fig 3. Golden sections in vertical and horizontal analysis of the face. (Reprinted with permission from Ricketts RM: Divine proportion in facial esthetics. Clin Plast Surg 9:401, 1982.)
FACIAL SUBUNITS A general impression of the configuration of the face can be obtained by observing the head. Heads are categorized as brachycephalic (short and wide), dolichocephalic (long and narrow), or mesocephalic (of medium length and width). The size, location, and angulation of the specific parts contribute to the overall impression and are important in facial harmony.5 Ethnic variations do not detract from the inherent balance between the facial subunits.3 Ears. The ear canal is located along a horizontal line halfway between the outer canthus of the eye and the alar-facial junction and between the back
of the skull and the frontofacial plane. The superior point of attachment of the ear to the head is just above the upper lid; the inferior point is in line with the alar-facial junction. The longitudinal axis of the ear is usually more vertical than the nasal dorsum by approximately 15. There is a great deal of variability in the exact inclination of the ear among subjects (9 to 29),2,6 but 20 off the vertical seems to be a pleasing angle.6 The ear protrudes from the skull posteriorly at an angle of 20.5 Forehead. Ousterhout7 discusses the occurrence and surgical correction of excessive glabellar prominence and supraorbital ridge projection, which he sees as characteristic of overly masculine features. The normal male skull has extensive supraorbital bossing above which there is a flat area comprising the vertical component of the forehead, which then gives way to a convex curvature in the upper forehead. In women the supraorbital bossing is considerably less pronounced and frequently nonexistent; above it there is usually less flatness and more of a continuous mild curvature to the upper forehead. The degree of deformity in forehead contour dictates the recommended treatment, as follows: Group I includes patients with normal or slightly anterior projection of the supraorbital rims, minimal to moderate bossing, thick skull bone over the frontal sinus, or absence of the frontal sinus. These deformities are corrected by bone reduction alone using a power burr. Group II includes individuals with relatively normal or slightly anterior placement of the supraorbital rims in whom the frontal bossing is combined with relatively thin bone over the frontal sinuses, which are of normal size. Correction requires completing as much contouring of the bone as possible without entering the sinus, and then augmenting the concavity above the frontal bossing with methyl methacrylate until the desired shape is achieved. Edgerton 8 believes sinus cranialization and secondary correction with methyl methacrylate is a reasonable alternative in these patients. Group III consists of patients whose supraorbital rims are so pronounced that adequate bone reduction is impossible without entering the frontal sinus. In this case the sinus is opened by an osteotomy and the entire anterior wall and associated supraorbital rim are set back and wired in position.
Eyes. The eyes are located at the junction of the upper and middle thirds of the face. They are separated by one eye-breadth, which equals the width of the root of the nose.5 The eyes are bounded by the bony orbital rims, which relate specifically to the cornea. In the Caucasian adult, the average vertical orbital height measured from the superior rim to the inferior rim is about 19 mm. The superior orbital rim protrudes beyond the inferior orbital rim some 11 to 14 mm. The anterior edge of the cornea lies approximately 2 to 3 mm anterior to the inferior orbital rim, 12 to 16 mm anterior to the lateral orbital rim, and 8 to 10 mm posterior to the superior orbital rim.9 The canthi distinguish the eyelids medially and laterally. The medial canthus is normally in line with or medial to a vertical plane taken from the lateral ala. The lateral canthus is 3 mm above the medial canthus,10 contributing to a fissure opening of approximately 30 mm. The intercanthal distance is approximately equal to the alar base width or onehalf the interpupillary distance.11 The upper lid is larger, more curved, and much more active and mobile than the lower lid. If the eye is divided into vertical thirds, the highest point of the upper lid is at the junction of the medial and central thirds while the lowest point of the lower lid corresponds with the border of the central and lateral thirds. Farkas and others12 compared anthropometric and cephalometric orbital measurements in White adult North Americans of both sexes representing 13 craniofacial syndromes involving hypertelorism. The abnormally wide surface (anthropometric) intercanthal distance had a 90% correlation with an abnormally wide bony (cephalometric) interorbital distance. The surface intercanthal width was larger than the bony interorbital distance in all patients. The differences were smaller in mild cases and larger in severe cases. The article offers useful tables of age-adjusted orbital measurements in the various syndromes compared with the normal population. Mouth and Lips. The distance from the base of the nose to the inferior border of the upper lip makes up one third of the lower third of the face. The lower two thirds extend from this point to the chin. The vermilion border of the lower lip is midway between the base of the nose and the chin.5
Ordinarily the corners of the mouth fall almost halfway between the outer limits of the alae and the pupils. (Pupil planes are established by drawing a line through the inner and outer canthi of each eye and dropping perpendiculars through the pupil.) A narrow mouth will approach the width of the nose, while a wide mouth may extend to just below the pupils.5 In profile and with the facial muscles relaxed, the lips should be very slightly parted and the lower lip should lie only just posterior to the upper lip. Bishara and coworkers13 sought to establish longitudinal standards for the following soft-tissue parameters of the facial profile:
facial convexity including the nose facial convexity excluding the nose Holdaway soft-tissue angle Merrifields Z angle Ricketts esthetic plane relative to the upper lip Ricketts esthetic plane relative to the lower lip
The upper lip should rest 4 mm posterior to a tangent drawn between the soft-tissue chin and the tip of the nose. Adult male upper lips are slightly more retracted than female upper lips, although male subjects aged 5 to 17 years consistently demonstrate a more protrusive upper lip than female subjects. This observation is important in treatment planning, arguing against applying adult standards to adolescents. The lower lip is ideally situated 2 mm posterior to the nose-chin plane in adult female subjects and slightly more posterior in male subjects. The lower lip becomes more retrusive with age in both sexes. Chin. The strength of a face is usually a function of the degree of prominence of the chin relative to the neck.5 Ricketts14 notes that the lips are contained within a line extending from the tip of the nose to the most prominent part of the chin (soft-tissue pogonion). A vertical line from the lowermost point of this line upwards should touch the vermilion of the upper lip (Fig 4). The skeletal position of the chin is illustrated in the section on cephalometrics and further defined in the section on genioplasty.
Fig 4. Nose-lip-chin relationships: Left, prognathic mandible; Center, orthognathic mandible; and Right, retrognathic mandible. (Reprinted with permission from Ricketts RM: Esthetics, environment, and the law of lip relation. Am J Orthod 54:272, 1968.)
Nose. The nose has been described as the focal point of the face.5 Together with the maxilla, the nose dominates the middle third of the face. The angle of projection of the nose from the face ranges from 30 to 36 (Fig 5), while the columella-lip angle varies from an average of 90 in men to 95 to 110 in women (Fig 6). In profile, a 2- to 3-mm-wide segment of columella should be seen below the rim of the ala. The nostrils are oval and their long axes should incline towards the tip.5 Additional details regarding the dimensions of the nose can be found in SRPS Volume 9, Number 18.15
Fig 5. Range of nasal dorsal angles. (Reprinted with permission from DOttaviano N and Baroudi R: Surgical and esthetic aspects of the facial profile. Int J Oral Surg 3:243, 1974.)
Fig 6. Range of columella-labial angles. (Reprinted with permission from DOttaviano N and Baroudi R: Surgical and esthetic aspects of the facial profile. Int J Oral Surg 3:243, 1974.)
PHOTOMETRICS Standardized photogrammometry complements direct clinical measurements and supplies clinical templates that are useful in formulating a treatment plan. Farkas3 states that photogrammometry, even under the most standardized conditions, offers only a limited number of reliable measurements because of distortion in the two-dimensional photographs. Others16-19 have found photometric analysis a useful adjunct in planning surgical skeletal changes of the face. The basis for standard positioning of the patient is the Frankfort horizontal line. This is a line passing through an imaginary plane touching four points: the two infraorbital rims and the two superior positions of the external auditory canals.20 A good studio chair is necessary for the subjects comfort and optimum positioning. The subject may be asked to apply light pressure to the lumbar region while in an upright sitting position. Unusual forward or backward bending will distort the image and produce a bad photograph. 21 One should also remember that as the subject gets closer to the lens, the amount of light reaching the film decreases. To obtain a good film frame and subject positioning, plastic surgeons can use the reproduction scale: eg, one-tenth life size on the film is equivalent to a 1:10 reproduction ratio. A viewfinder screen with a grid is helpful in obtaining a proper image, particularly when the tone is outside the standard view. Viewing 25 forward in a lighter view may highlight the opposite eyebrow, whereas 25 back may compress the eyebrow view. To obtain other views, the patient is rotated around the head central axis. In all right/left or superior/
inferior views, the patient should be rotated along the appropriate axis with an equal degree of change on either side. Perhaps most important, one must know exactly what anatomic part to stress. For instance, if the objective of the photograph is to evaluate the nose, the nasal tip should be centered in the field frame.22 The data gathered through photometric analysis can be both valuable and reliable provided the following criteria are met: a standard 90105-mm lens is used to minimize peripheral distortion a ruler is held in the field to guarantee accurate enlargement the head position is stabilized with a cephalostat or equivalent method the prescribed subject-to-camera distance is kept
critical soft-tissue landmarks are marked or otherwise identified only those landmarks that are exactly perpendicular or parallel to the lens are measured. This excludes distances involving depth-of-field, such as nasal length on AP view. Kinnebrew and colleagues16 offer the following simple guidelines for photometric analysis:
The pretreatment image is traced from a projected 35-mm slide which is sized to the cephalometric tracing to obtain a life-sized representation of the face. The image is then redrawn, adjusting the dysmorphic parts to the unchanged parts of the face to effect balance of the profile and restore normal contours. This recreated image is then used as an objective toward which treatment planning is directed... Kinnebrew (1983)
According to the authors, the resulting images faithfully duplicate 1:1 correspondence between the soft tissues and the bony skeleton. The authors16 discuss the anticipated soft-tissue response to the underlying skeletal change and plan the course of treatment based on the soft-tissue needs. Phillips and associates23 questioned the validity of this projectionsuperimposition technique on the basis of errors in enlargement factors between photographs and x-ray films discovered on grid analysis. Butow17 describes a lateral photometric analysis method founded on Leonardo da Vincis facial thirds that incorporates mathematically computed
triangles of the facial plane and nasal structures. Unfortunately, the esthetic norms were established from measurements of only one man and one woman considered to have normal features. Sen Savara and coworkers 24 advocate biostereometric photography for evaluating craniofacial malformations. The basic principle of stereophotogrammetry involves the juxtaposition of two stereophotographs so that the left eye sees the left photograph and the right eye sees the right photograph, both in proper relation. The result is the perception of depth as clearly as if the object were seen directly. The technique of stereophotography is adapted from methods used in topographic field mapping: An acrylic control frame is constructed to fit over and around the subjects head and targets are affixed to the control frame to establish interconnecting distances and arrive at X and Y coordinates geometrically. The X-Y-Z measurement thus obtained provides a contour map that is true to within 0.1 mm. The degree of accuracy possible with stereophotography, together with control of the magnification, allows exact correlation of soft-tissue values with those obtained by cephalometrograms and CT scans before surgery. Postoperative surface alterations in response to movement of the underlying bony structures can be precisely quantified. Preliminary studies indicate that the joined-coordinate systems is accurate to approximately 0.3 mm. COMPUTER IMAGING The Modern patient imaging involves the use of two-dimensional images captured and manipulated by readily available office-based computers. These systems have found extensive use in hair styling and makeup, landscaping, home remodeling, interior design, orthodontics and cosmetic dentistry,25 and plastic surgery. Computer imaging technology has evolved from an esthetic marketing tool to a realistic surgical communication device. Critics view computer imaging as sophisticated gadgetry designed to lure patients into surgery with the promise of tantalizing results. While imaging systems can undoubtedly be misused to deceive unsuspecting patients, this is a problem with the user rather than with the system. Those whose intentions are to sell their services based on surgical results they cannot deliver will find the means to do so, with or
without an imaging system. Computer-based analyses are used to predict surgical outcome by comparing scaled, undistorted images and the same images after modification by measured, scaled adjustments. Both the patients acceptance of a proposed surgical result and the surgeons ability to attain that result can be judged from a review of before and after images. Null25 reviews the essentials of computer imaging from a manufacturers viewpoint. All commonly available computer imaging systems have three basic components: (1) input or image acquisition; (2) image alteration or manipulation; and (3) image output. Input. The image may be acquired from slide or print scanners, moving video, or still video. Scanners offer the highest image resolution that is necessary for high-quality, high-resolution output. The process involves preliminary photography with production of a finished 35-mm slide or photographic print, and automatically means two patient visits, one for the photograph and another for the imaging. Moving video input can be achieved with standard video cameras and is the least expensive way of obtaining images. A software image-grabber captures the single frame that is to be manipulated. Problems with moving video input have to do with the wide-angle lenses common to video cameras, which can distort the image by a fishbowl effect. In addition, the distances and magnifications involved with video cameras must be standardized and rigidly maintained. Image resolution is the lowest of the three alternativesin the range of 200 300 lpiwhich translates into an adequate screen image but a blurred output. Still video works in much the same way as a 35mm single-lens-reflex camera. The input is captured on a small diskette within the camera, which is then imported to the computer. Resolution is approximately 400 lpi and output quality is intermediate between moving video and scanned image. The video sources have the advantage of one patient visit for consultation and imaging. Manipulation. After the image is imported into the computer, any of several software packages are available for image manipulation in either Mac or PC platform. A high-resolution color monitor with minimal pixel distortion is recommended for
viewing. Some custom-made programs include cephalometric scales that facilitate precise incremental changes. Output. The image may be sent to the output device in its original, imported form or after enhancement or reduction through the software program. The screen resolution is much less than acceptable for most output purposes, and is used only in the most inexpensive systems. The output results from direct electronic transport of the image to the output device. Image output is in the form of color or black-and-white prints or 35-mm slides. Slide-generating devices can be connected directly to the computer and will produce 35-mm slides of the preoperative and altered images. Alternatively, a color printer may be used to render an intermediate-resolution (300600 dpi) print of the altered image. The article by Papel26 describes a surgeons experience with imaging, and shows computer-generated surgical plans and postoperative analysis of his results. The ease and speed of diagnosis possible with office imaging and the usefulness of com-
municating with prospective patients in visible, graphic terms will undoubtedly lead to more extensive use of these systems. CEPHALOMETRICS Numerous methods have been devised to assess the spatial arrangement of the cranium, facial bones, and teeth relative to each other (Fig 7).27 Six major relationships have been described, as follows:28,29 maxilla to cranium
mandible to cranium maxilla to mandible maxillary teeth to maxilla mandibular teeth to mandible
maxillary teeth to mandibular teeth Traditional cephalometric analyses use the sella nasion or Frankfort horizontal (upper edge of acoustic meatus to inferior orbital rim) planes as reference lines.30 Other methods31 favor the natural head position over the Frankfort or sellanasion planes. Downs32 and Ricketts33 claim that the sella
Fig. 1. Schematic representation of an orthognathic face showing cranium (1), maxilla (2), maxillary denture (3), mandibular denture (4), and mandible (5).
Fig. 1
Fig. 3
Fig. 2. Schematic representation of a severe Class II, Division 1 malocclusion characterized by extreme overbite and overjet, caused by a retrusive mandible (5). Fig.3. Schematic representation of a severe Class II, Division 1 malocclusion characterized by extreme overbite and overjet, caused by a large and protrusive maxilla (2). Fig. 4. Schematic representation of a severe Class III malocclusion caused by an overdeveloped mandible (5) and an underdeveloped maxilla (2).
Fig. 2
Fig. 4
Fig 7. Cephalometric components of the face. (Reprinted with permission from Khouw FE, Proffit WR, White RP: Cephalometric evaluation of patients with dentofacial disharmonies requiring surgical correction. Oral Surg 29:789, 1970.)
is totally unrelated to the face. Ellis and McNamara34 also state that the sellas position varies with head posture, both anteroposteriorly and vertically. Nevertheless, from our review of cephalometric analyses we conclude that any of these methods can yield consistent and reproducible results as long as it is accurately applied. The cephalostat holds the head in a standard, fixed position. A pair of ear rods enter the external auditory meatus and minimize side-to-side changes in head position. The head is further stabilized with a rod resting passively on the soft-tissues over the inferior orbital rim or nasofrontal suture to prevent
head rotation along the sagittal plane. The x-ray cassette is held at a constant distance from the midline of the cephalostat and head. The radiograph is traced on a standard x-ray light or flat slide sorter using a fine-point (0.5 mm) lead pencil. A matte acetate sheet is attached to the radiograph, and both are affixed to the viewbox. Skeletal landmarks35 (Fig 8) must be identified to understand the bony morphology and plan the needed surgical correction.36 Cephalometric analysis can be staticcomparing the patient at any one point in time against stan-
1. MENTON (ME): The most inferior point on the symphyseal outline. 2. GNATHION (GN): The most anterior-inferior point on the contour of the bony chin symphysis. Determined by bisecting the angle formed by the mandibular plane and a line through Pogonion and Nasion. 3. POGONION (PG): The most anterior point on the contour of the bony chin. Determined by a tangent through Nasion. 4. B POINT (B): The point most posterior to a line from Infradentale to Pogonion on the anterior surface of the symphyseal
outline of the mandible. B Point should lie within the apical third of the incisor roots. When there is no curvature in this region and determination of B Point is not possible by the above method, it is chosen with the aid of preceding or succeeding films because erupting teeth obscure mandibular concavity on occasion. 5. INFRADENTALE (ID): The anterior superior point on the mandible at its labial contact with the mandibular central incisor. 6. LOWER INCISAL EDGE (LIE): The incisal tip of the mandibular central incisor. 7. UPPER INCISAL EDGE (UIE): The incisal tip of the maxillary central incisor. 8. SUPRADENTALE (SD): The most anterior inferior point on the maxilla at its labial contact with the maxillary central incisor. 9. A POINT (A): The most posterior point on the curve of the maxilla between the anterior nasal spine and supradentale. 10. ANTERIOR NASAL SPINE (ANS): The tip of the median, sharp bony process of the maxilla at the lower margin of the anterior nasal opening. 11. GONION (GO): The midpoint of the angle of the mandible. Found by bisecting the angle formed by the mandibular plane and a plane through Articulare, posterior and along the portion of the mandibular ramus inferior to it. 12. ARTICULARE (AR): The point of intersection of the inferior cranial base surface and the averaged posterior surfaces of the mandibular condyles. 13. SELLA TURCICA (S): The center of the pituitary fossa of the sphenoid bone. Determined by inspection. 14. NASION (N): The junction of the frontonasal suture at the most posterior point on the curve at the bridge of the nose. 15. ORBITALE (OR): The lowest point on the average of the right and left borders of the bony orbit. 16. PTERYGOMAXILLARY FISSURE (PTM): Appears as an inverted teardrop. Its anterior margin represents the posterior margin of the tuberosity of the maxilla. 17. PORION (PO): The midpoint of the line connecting the most superior point of the radiopacity generated by each of the two ear rods of the cephalostat.
Fig 8. Skeletal landmarks of the face. (Reprinted with permission from White GE: Basic cephalometrics. J Pedodont 2:322, Summer 1978.)
dards derived from other individuals, or dynamic comparing the patient against himself at various intervals. Regardless of the specific system one uses, the goal is the same: to obtain information about jaw-to-jaw and tooth-to-jaw relationships.36-40 For practical reasons the method should be clinically workable, diagnostically realistic, and simple rather than cumbersome. The analysis consists of four parts: 1) vertical midface measurements; 2) horizontal midface measurements; 3) horizontal lower face measurements; and 4) dental measurements. The segmental approach allows the clinician to view and evaluate each component alone and to relate the various components to one another and to the entire craniofacial complex.41 Normal Values Zide, Grayson, and McCarthy42,43 list the range of normal values for male and female subjects 16 years of age or older (Tables 1 and 2). Numerical values for earlier ages may be extrapolated from the growth charts published in An Atlas of Craniofacial Growth by Riolo and associates.44 Computerized data analyses45 show that female subjects generally complete 90% of their mandibular AP growth by age 9, 95% by age 13, and 98% by age 15. In contrast, male subjects attain 84% of mandibular AP growth by age 9 years, 90% by age 13, and 98% by age 19 years. The overall vector of facial bone growth is downward and forward, as illustrated by Enlow30 (Fig 9). Table 1 Vertical Midface Analysis
Fig 9. Diagrammatic representation of facial growth showing downward and forward expansion of the whole face relative to the cranial base. (Reprinted with permission from Enlow DH: The Human Face. New York, Harper & Row, 1968.)
Vertical Midface Analysis Zide, Grayson, and McCarthy36 recommend the following vertical measurements (Fig 10):
Table 2 Horizontal Midface Analysis
Fig 10. Vertical measurements for cephalometric analysis. (Reprinted with permission from Zide B, Grayson B, McCarthy JG: Cephalometric analysis: Part I. Plast Reconstr Surg 68:816, 1981.)
(From Zide B, Grayson B, McCarthy JG: Cephalometric analysis for upper and lower midface surgery: Part II. Plast Reconstr Surg 68:961, 1981.)
MeNanterior total face height (TFH), can be subdivided into NANSanterior upper face height (UFH) and ANSMeanterior lower face height (LFH), which is in turn subdivided into ANSSDincreased in vertical maxillary
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excesslong face syndrome. It is reduced in short face syndrome and following dental extraction and alveolar remodeling ANSUIEchanges with dental extraction and inclination of the incisors MeLIE MeIDis increased in mandibular deficiency syndrome and reduced following extractions and results in alveolar crest remodeling Interincisal ArGoposterior lower face height Horizontal Midface Analysis Measurements SN, SNO, ONA, and SNA are used to evaluate the midface in a horizontal plane (Fig 11).36
ONALinear measurement from orbitale along a line perpendicular to the NA; describes the position of the inferior orbital rim relative to the facial plane, NA. SNARepresents the internal angle between the lines connecting sella to nasion and nasion to A point; describes the position of the anterior limit of the maxillary apical base (A) in relation to the upper craniofacial complex. It is generally increased in maxillary hyperplasia and reduced in maxillary hypoplasia. Horizontal Lower Face Analysis Grayson41 recommends the following measurements (Fig 12): Ar-Pg, Ar-B, and Ar-LIEoblique mandibular measurements from the articulare at three levels. Go-Pg, Go-B, and Go-LIElinear measurements from the Go that describe mandibular body length at three levels. Ba-Pglinear measurement from the Ba to the most anterior point on the symphysis. When compared to the measurements of Ba-ANS and BaN, the relative AP position of these structures may be evaluated with respect to Ba. SNB (angular ratio of the point B to anterior cranial base)increased in mandibular protrusion and reduced in mandibular micrognathia. The SNPg (angular relationship of pogonion to anterior cranial base) is increased in macrogenia and reduced in microgenia. ANB (angular ratio between points A and B) increased in maxillary protrusion or mandibular retrusion and decreased in maxillary retrusion or mandibular protrusion. Angular Analysis SN/MPangular relationship between the inferior border of the mandible and the anterior cranial base (Fig 13). Measurements of the SNA, SNB, and ANB angles and of the lower facial height describe the downward and forward projection of the face and define one side of the dental quadrangle extending from ANSPNS plane to SNASNB plane to GOGN plane to GOPNS plane.35
Fig 11. Horizontal measurements for cephalometric analysis. (Reprinted with permission from Zide B, Grayson B, McCarthy JG: Cephalometric analysis: Part I. Plast Reconstr Surg 68:816, 1981.)
SNThe distance from the center of the sella turcica to the frontonasal suture, representing an approximation of the length of the anterior cranial base. This dimension is significantly reduced in the craniofacial synostosis syndrome. SNOThis measurement represents the internal angle between the lines connecting sella to nasion and nasion to orbitale. A reduced angular measurement may reflect retropositioning of the orbital rim, ie, deficiency of the upper midface. Old angular measurements relative to the cranial base are affected by abnormalities of the latter.
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Fig 12. Top, Horizontal midface measurements. Pt-M may be used when the posterior nasal spine (PNS) is missing or affected by the presence of a palatal cleft. Bottom, Horizontal lower face measurements. (From Grayson BH: Cephalometric analysis for the surgeon. Clin Plast Surg 16(4):633, 1989 (top); and Zide B, Grayson B, McCarthy JG: Cephalometric analysi: Part I. Plast Reconstr Surg 68:816, 1981 (center and bottom); with permission.)
Fig 13. Angular measurements for cephalometric analysis. (Reprinted with permission from Zide B, Grayson B, McCarthy JG: Cephalometric analysis: Part I. Plast Reconstr Surg 68:816, 1981.)
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Grayson41 details his system of cephalometric analysis for the plastic surgeon, including how to obtain tracings, various analyses and their meaning, treatment planning, and predicting surgical outcome. The author points out that because of image distortion in routine radiographs and errors in tracing measurements, the cephalometric drawing is, at best, only an approximation of the actual craniofacial structures under study. Given the variability in cephalometric values between and within populations, Grayson believes cephalometric analysis should be used only to suggest, not dictate, a surgical-orthodontic procedure. Basic Line According to Sassouni,39 five basic planes can be determined from the lateral cephalometrogram, namely 1) the orbital plane, drawn from the anterior clinoid process to a line tangential to the roof of the orbit
2) the parallel plane, which is simply a line parallel to the orbital plane through the base of the sella continued posteriorly 3) the palatal plane, drawn from anterior nasal spine to posterior nasal spine 4) the occlusal plane, representing the occlusal line of the patients teeth, and 5) the mandibular plane. In the perfect face, lines (2) through (5), if continued posteriorly, would pass through a common central point. This is rarely the case, however, and Phillips46 suggests using the center (O) of a circle 1 cm in diameter bound by the four lines (Fig 14). The Wits Appraisal The Wits appraisal is a simple and reliable method for relating the upper and lower jaws to each other. It consists of dropping perpendiculars from points A and B onto the occlusal plane (Fig 15).
Fig 15. The Wits appraisal for cephalometric analysis. (Reprinted with permission from Jacobson A: The proportionate template as a diagnostic aid. Am J Orthod 75:156, 1979.)
Fig 14. Cephalometric analysis using a center point of reference (O) around which four lines converge. (Reprinted with permission from Phillips JG: Photo-cephalometric analysis in treatment planning for surgical correction of facial disharmonies. J Maxillofac Surg 6:174, 1978.)
In Class I malocclusion, points AO and BO generally coincide. In Class II malocclusion, BO point is behind AO. In Class III malocclusion, BO point is ahead of AO.47 Patients with normal occlusions may exhibit jaws that are retrognathic, orthognathic, or prognathic (Fig 16).
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Fig 16. Relative position of the lower jaw in retrognathia and prognathism. (Reprinted with permission from Jacobson A: The proportionate template as a diagnostic aid. Am J Orthod 75:156, 1979.)
Applications Among the most useful relationships in cephalometrics is the anterior-posterior position of the jaws in reference to the cranium. Some common questions are: Is the midface prognathic, retrognathic, or orthognathic? Is the mandible prognathic, retrognathic, or orthognathic? Are the maxilla and mandible harmoniously related to each other or are they dysplastic? If dysplastic, is the condition mild, moderate, or severe? What is the location of the dysplasia? Are the lower facial structures of correct height and in proportion to each other? Obwegeser and Marentette48 use cephalometric measurements to determine the exact size, location, and relative position of the anterior cranial base, maxillary base, and mandibular base as the first step in facial analysis. They initially ignore the nose, lips, teeth, and chin, which, though influencing the profile line, are not crucial to a diagnosis. In the authors opinion the three bases of the facial skeleton define the profile type, and it is the profile type, not the occlusion, that directs the treatment plan. They identify three esthetically balanced profile types (Fig 17) and introduce terminology pertinent to the diagnosis and treatment of related facial abnormalities. CT ANALYSIS Improvements in medical imaging based on advanced computer technology have facilitated analysis of the facial skeleton. Axial computed
tomography and reformatted periaxial images of the skull produce plainer images that represent tissue slices of finite thickness. The anatomic detail on each individual sliced image can be exquisite. Computer graphics reformat the serial CT scans into a three-dimensional (3D) structure, but only an experienced operator can interpret the spatially integrated slices. Given the surgical ability to make large corrections of the jaws in three planes of space, treatment planning has become increasingly important. Predictive planning systems have evolved from simple cut and paste tracing methods to more elaborate computerized techniques based largely on the lateral cephalometric radiograph. More recently, video and 3D imaging techniques have become widely available. Herman49 presents a general overview of the usage and technical terminology of imaging. He discusses imaging on a CT or MRI scanner using software that runs on the scanners computer. The 3D98 software is designed for the GE CT/T 9800 scanner and is intended for 3D imaging of craniofacial cases. Marsh and colleagues50 review the applications of computer-assisted medical imaging in the management of craniofacial deformities. Improved diagnosis and treatment planning are the result, and quantitative recording of changes of surgery and growth is made possible through the use of CT imaging. Bite and coworkers51 favor 3D CT imaging for assessing orbital volume and predicting response after surgery for enophthalmos. Because the reference point of the lateral orbital rim is frequently displaced in posttraumatic deformities, they suggest a new fixed bony reference point for measuring degree of enophthalmos. Posnick and colleagues52 use CT scans to quantitatively evaluate the intracranial volume before and after surgical correction of craniosynostosis. The accuracy of the computer-generated analyses was validated by comparing direct measurements of intracranial volumes in dry skulls with indirect values calculated by means of 1.5- and 4-mm slice intervals from actual scans. The same indirect scan data were used preand postoperatively on patients operated on for craniosynostosis. Surgical findings confirmed that suture release and simultaneous resecting procedures did in fact increase the intracranial volumes.
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Fig 17. The three esthetically balanced face types. Left, straight anteface. Center, straight retroface. Right, average face. (Reprinted with permission from Obwegeser HL, Marentette LJ: Profile planning based on alterations in the positions of the bases of the facial thirds. J Oral Maxillofac Surg 44:302, 1986.)
Advances in CT imaging have led to integrated programs for computer-aided treatment planning and surgical simulation.53,54 An internal bony moulage is fabricated from the CT image and, aided by this moulage, computer-derived implants are designed to fit the bony contour precisely and to satisfy the soft-tissue needs. When asymmetries are involved, a mirror representation can be used. Cutting and associates54 describe a system that operates on a 3D database derived from combined PA and lateral cephalograms of the patient plus the Bolton normative standards. This system can be used to help plan craniofacial surgical procedures. A surgical simulation program based on the CT data can also be linked to the cephalometric-based program. After the clinician has selected the number and type of osteotomies to be performed, an automated optimization program computes the postoperative positions of the fragments that best fit the appropriate normal cephalometric form. The surgeon then interactively modifies the design to account for such variables as bone graft resorption, relapse tendency, occlusal disparities, and condition of the overlying soft-tissue matrix. Eales and colleagues55 evaluated the accuracy of computerized prediction of the soft-tissue profile after Le Fort I osteotomy. The computer package used was Dentofacial Planner 5.32 software (Dentofacial Software Inc, Toronto). The authors were surprised at how well the computer package was able to predict soft-tissue altlerations in relation to surgical movements of the maxilla, associated autorotation of the mandible, and after genio-
plasty (n=6). In 22 of 33 profile variables examined, no statistically significant differences were noted between the computer-predicted change and what actually occurred. The computer was less consistent when predicting changes about the nose and upper lip, where variability in the size, thickness, and morphology of the soft-tissues affected the calculations. The diminished accuracy in cleft lip/palate cases was attributed to the different movements that were required and to the scarred soft-tissues. The determining factor governing the response in CLP patients was the degree of inferior repositioning of the maxilla during surgery. The degree of movement that actually occurred was generally greater than predicted by the computer. The software translated the original shape of the upper lip to a new forward position, which changed lip shape and created problems in the prediction plot. Significant differences were found for vertical labrale superius, horizontal stomium superius, and lip thickness measurement between the predicted and the actual values. In the upper lip, the governing factor determining the relation of hard- to soft-tissue change is the initial lip thickness.56 Imai and Tajima57 evaluated the normal skull by CT scan and obtained reference data for the frontoorbital region. The authors used angles and measurements taken from the dorsum sellae to the frontoorbital region as a standard for advancing and reshaping forehead and orbital rims. With improved imaging technology and computer algorithms, there has been a proliferation of
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computer software programs to aid with the planning of orthognathic surgery.58-70 Like the imaging programs used in facial esthetic surgery, these programs can be used to visualize potential hard- and soft-tissue changes after one-jaw or two-jaw procedures. Most of these new imaging programs use three-dimensional CT scanning technology to facilitate or replace the traditional techniques of cephalometric tracings and model surgery, which can be time-consuming and complex. For instance, Okumura et al59 have used this technology to combine the cephalometric data and the dental study casts into a 3D virtual image for simultaneous evaluation of skeletal movements and occlusal relationships in orthognathic procedures (Fig 18). CLINICAL EXAMINATION Dryland Vig and Ellis71 discuss a systematic approach to the diagnosis and management of dentofacial deformities. The clinical examination is a very important component of the diagnostic workup of a surgical-orthodontic patient. Critical to the treatment plan are measurements of the face and intraoral structures including the occlusion and a functional analysis of the dynamic aspects of jaw movement. The facial proportions are evaluated with the patient facing the examiner and holding the lips and mandible at rest. Bilateral facial profile analysis is also indicated, especially if an asymmetry is present. Kent and Craig72 summarize the structural analyses recommended for patients with suspected craniofacial deformities (Table 3). In assessing vertical facial balance, the absolute numbers are not as important as the interrelationship of the upper to the middle to the lower facial thirds. Dentofacial deformities are most commonly expressed in the lower face, which is often subdivided into an upper one thirdextending between the subnasale and lip contact (stomion)and a lower two thirdsmeasured between the stomion and mentum. Vertical macrogenia will typically increase the distance between stomion and mentum, whereas vertical maxillary deficiency may decrease the distance between subnasale and stomion. Evaluation of transverse facial symmetry should pay particular attention to the cant of the maxillary occlusal plane, eyes, eyelid position, and interpupillary distance. The following instructions are excerpted from Dryland Vig and Ellis.
Fig 18. 3D virtual imaging of maxillofacial skeleton. Top, Preoperatively. Middle, After sagittal split ramus osteotomy. Bottom, Simulated occlusal relationship. (Reprinted with permission from Okumura H, Chen L-H, Tsutsumi S, et al: Threedimensional virtual imaging of facial skeleton and dental morphologic condition for treatment planning in orthognathic surgery. Am J Orthod Dentofacial Orthop 116:126, 1999.)
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Table 3 Frontal Soft- and Hard-Tissue Assessment
(From Kent JN, Craig MA: Secondary autogenous and alloplastic reshaping procedures for facial asymmetry. In: Atlas of the Oral and Maxillofacial Surgery Clinics of North America, Vol 4, No 1, March 1996.)
The nose should be assessed for any asymmetries regarding the dorsum, tip, or alar base. The width of the alar base should be measured, especially if maxillary surgery is anticipated. For the mouth, the amount of maxillary incisors showing at rest should be recorded, as should any gingival display. This measurement is repeated during function, especially smiling, when excessive gingival display may be one of the patients concerns. Normal maxillary incisor show at rest is 23 mm; during smiling, all crowns should be visible. While this is considered the esthetic norm, the actual tooth display will be related to the length of the upper lip. The length of the upper lip from the subnasale to the mucocutaneous junction (15 mm female; 17 mm male) and from the subnasale to stomion (20 mm female; 22 mm male) should be recorded. This will assist in identifying those individuals whose upper lip is short, as it may be unwise to attempt a normal tooth-to-lip relationship with vertical maxillary impaction. Decreasing the vertical dimension of the lower face to correct the amount of incisor display may result in loss of vertical facial balance if a short upper lip is present.
If the upper lip has a thin vermilion, maxillary surgery may further decrease the vermilion. At rest the upper and lower lips are usually in contact, but an interlabial gap may be present. An increase in lower facial height may result in lip incompetence. This is often characteristic of vertical maxillary excess, where the mandible is rotated downward and backward with apparent retrusion of the mandible. The effort to maintain lip contact results in a lip apart posture at rest and this resting lip posture is often confused with mouth breathing. The chin: the relationship of the chin to the facial midline and lower dental midline helps determine whether there is a skeletal or dental asymmetry of the mandible. A vertically long chin is characteristic of patients with anterior open bite. Excessive stippling of the soft tissue chin indicates activity in the mentalis muscle, which contracts to elevate the lower lip and produces lip contact when lip apart posture exists. It is important when assessing the patients profile that the patient is looking straight ahead in relaxed posture. If a patient with a normally positioned mandible looks slightly downward, the chin will appear retruded. Conversely, a patient
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SRPS Volume 9, Number 24 with mandibular retrusion can appear more balanced with the head tilted upwards. Specifically, one should assess the forehead to supraorbital rims; globes, orbital rims and nose; nasolabial angle. It is important to realize that a combination of dental position and nasal tip projection will contribute to an acute or obtuse nasolabial angle. [Full] sagittal protrusion of the maxillary incisors will reduce this angle and an upturned nasal tip will increase the angle. . . . The anteroposterior and vertical position of the chin, in relation to the face, should be in sagittal balance with the forehead and nose. The form of the submental area is included in the lower facial third. The intraoral evaluation [assesses the dentition, presence or absence of periodontal disease, and the occlusal relationship.] The occlusal relationship is evaluated after an assessment of each dental arch for crowding or spacing of the dentition. The horizontal incisor overjet and vertical overbite should be noted, and if an open bite is present, whether it is located anteriorly or involves the posterior teeth. To provide three-dimensional evaluation of dentition, any transverse discrepancy, usually identified as a crossbite, should be noted. . . . [Finally, signs of dysfunction should be investigated and temporomandibular joint (TMJ) disorders excluded.] Dryland Vig and Ellis (1989)
ORTHOGNATHIC SURGERY
Rosen73 states it should be evident that if the magnitude of facial skeletal imbalance increases, the extent of change required to correct it increases, and therefore the need for an osteotomy increases. What is perhaps not so evident is that an estimated 5% of White adults in the United States have a developmental imbalance of the facial skeleton.74 Typically this manifests as malocclusion during adolescence. Many of these youths will be treated orthodontically and as a result will have normal occlusion with residual skeletal disproportion. It is these same people who, once they become adults, will seek plastic surgery to improve their facial appearance. Osteotomy is most frequently indicated in these patients, because the extent of change required is greater than what could be reliably obtained by surface contouring. In addition, the vector of change is frequently in the vertical dimension and the location of the osteotomy required is usually in the maxilla or chin, where the morbidity is acceptably low. Facial osteotomies are designed to permit movement of the whole or part or the facial complex. The displaced segment may be advanced superiorly, anteriorly, or inferiorlyor set back posteriorly. The movement may incorporate rotation as well as any desired alteration in transverse dimension. A three-dimensional concept, therefore, is fundamental to the plan of any osteotomy. The soft-tissue attachments are important to the design of osteotomies, as they are the source of blood supply to the mobilized part. These same attachments are likely the main restriction to movement of the part, and can contribute to relapse. Sagittal osteotomies stabilize the osteotomy site in a transverse plane while allowing anterior-posterior, superior-inferior, and rotational movement. Step osteotomies allow AP movement and a change in the transverse dimension but provide vertical stability. A wedge ostectomy or wedge bone grafts added to the osteotomy stabilize it against rotation. Krekmanov75 reviews orthognathic maxillary and mandibular procedures, including their evolution to current standards of rigid fixation. The bibliographic references are extensive and a good source of information on any specific topic.
PRESURGICAL ORTHODONTICS Patients whose malocclusion reflects as severe skeletal discrepancy require combined evaluation by both a surgeon and an orthodontist. The dentoalveolar component of the malocclusion is to be treated by conventional orthodontic appliances to position the teeth in the correct relationship to the upper and lower jaws. Such orthodontic treatment is not intended to correct any occlusal malrelationship between the opposing dental arches. Rather, it should be considered a temporary or intermediate malocclusion by decompensating the dental camouflage, for the skeletal discrepancy makes the original malocclusion worse. This presurgical phase of orthodontic treatment facilitates surgical correction of the skeletal discrepancy and is followed by a short phase of postsurgical orthodontic treatment to refine the occlusion. This combination of orthodontics and surgery yields the best possible dentofacial esthetics and function.
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In cases requiring large movements of the maxilla or mandible, the technique of distraction osteogenesis may be useful. This technique stretches the soft-tissue attachments that otherwise would restrict the skeletal movement and cause relapse. Cope et al76 review the basic science of distraction osteogenesis, its history, evolution in mandibular surgery, and methods of distraction in current use. Table 4 compares the protocols used by different authors for mandibular lengthening and widening as well as their problems and complications. This article provides a useful overview of the subject and is worth reviewing.
Distraction osteogenesis has been used primarily in patients with congenital anomalies such as hemifacial microsomia, cleft-related maxillary hypoplasia, micrognathia (eg, Pierre Robin sequence), or midfacial hypoplasia (eg, Aperts or Crouzons syndromes).77-82 There may be a role for distraction osteogenesis in carefully selected patients undergoing orthognathic surgery to correct more common developmental imbalances of the facial skeleton. Van Sickels83 points out some of the advantages and disadvantages of distraction versus traditional orthognathic surgery. He notes that distraction
Table 4 Reported Osteodistraction Parameters for Mandibular Lengthening and Widening
(Modified from Cope JB, Samchukov ML, Cherkashin AM: Mandibular distraction osteogenesis: a historic perspective and future directions. Am J Orthod Dentofacial Orthop 115:448, 1999.)
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may be useful when large advancements of the maxilla or mandible are required. However, traditional orthognathic surgery is more versatile for moving the maxilla or mandible in several dimensions in space, such as with multi-piece maxillary osteotomies, and the final occlusion after orthognathic surgery is more precise than with distraction. Whats more, patient compliance and cooperation are much more important to the success of distraction procedures than of traditional orthognathic surgery. MANDIBULAR OSTEOTOMIES The issue of orthognathic surgery during facial growth is an important one to consider. While surgery is best postponed until growth is complete, in some cases delaying treatment is not the best option due to problems related to pain, speech, airway, anatomy, occlusion, esthetics, masticatory function, and psychosocial factors.84 Wolford et al84 review the more common mandibular deformities and the techniques that can be predictably and safely used in the growing patient. The TMJs and the tongue are important factors to consider when contemplating surgery, as pathologic conditions such as condylar hyper- or hypoplasia or macroglossia influence the growth of the mandible. Wolford et al84 discuss mandibular hypoplasia, hyperplasia, anterior dentoalveolar deformities, mandibular body deformities, and chin deformities. The surgical options for treatment in cases with deficient growth rates, normal growth rates, and accelerated growth rates are also described. This important article should be read by all surgeons who are considering doing orthognathic surgery in growing patients. Class III Prognathism Rakosi and Schilli85 discuss the pathogenesis of Class III malocclusion and its presentation during the deciduous, mixed, and permanent dentition phases. The authors distinguish between dentoalveolar Class III malocclusions, characterized by a normal mandibular base, lingually tipped maxillary incisors, and labially positioned mandibular incisors, and Class III malocclusions having a large mandibular base. The former can usually be managed successfully by orthodontics, while the latter almost
always require surgical treatment because of the large articular and gonial angles. The presence of maxillary hypoplasia as the causative factor in a Class III relationship must be excluded, for these cases necessitate maxillary as well as mandibular procedures. Lines and Steinhauser86 offer additional insight into the treatment of Class III malocclusions. They note that, in most instances of combined maxillary retrusion and mandibular protrusion, the mandibular defect is more responsible for the malocclusion than the maxilla. The exception to this is the maxillary hypoplasia and pseudoprognathism seen in cleft palate patients. The amount of chin prominence often determines the extent of surgical retrusion that is indicated, that is, whether the body of the mandible should be set back or just the anterior dentoalveolar complex. When the chin is prominent, the vertical dimension is high, or there is posterior crossbite, the entire body of the mandible is usually set back. Takahashi and Tsuruki87 advocate a surgical approach that is based on the type and severity of the mandibular prognathism. The authors reserve retropositioning of the lower anterior dentoalveolar segment for cases of mild mandibular prognathism without open bite. If there is open bite, they prefer posterior upward movement of the lower anterior alveolar segment and interpositional bone grafting using a piece of osteotomized chin. For moderate mandibular prognathism, with or without open bite, sagittal splitting of the Obwegeser type I or Obwegeser-Dal Pont is recommended. Severe cases with open bite are best treated by an Obwegeser II sagittal split osteotomy with partial resection of the mandibular angle.88 Our recommendations for the surgical management of mandibular prognathism are illustrated in Figure 19. Parker and colleagues89 review proposed techniques for the correction of mandibular prognathism. Various methods involve external vertical subcondylar osteotomy (EVSO), intraoral vertical subcondylar osteotomy (IVSO), and sagittal split osteotomy. The authors note that intraoral VSO is the preferred procedure for correction of uncomplicated mandibular prognathism. External subcondylar osteotomy is useful when more than 10 mm of setback is anticipated. Vertical and horizontal correction usually demands sagittal split osteotomy. A saggital split osteotomy is also pre-
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ferred in the event both the mandible and maxillary must be corrected or rigid fixation is desired.
ramus osteotomy for mandibular setback in minipigs. Such techniques may ultimately find a place in clinical orthognathic surgery. Minimal Prognathism Minimal prognathism without open bite can be treated by subapical osteotomy. If there is a small anterior open bite, subapical osteotomy complemented by a graft from the chin effectively elevates the segment while reducing chin projection. Some patients cannot tolerate orthodontic treatment of long duration, and in these cases Satoh and associates91 often do an anterior mandibular segmental osteotomy to correct minor degrees of prognathism. Their technique is called the Klle procedure,92 and is safe when performed below the apices of the teeth and above the mental foramina. Although the prognathic facial skeleton and malocclusion can be corrected by segmental osteotomy alone, a prognathic contour remains in the lower part of the mandible. The authors report on 11 patients with minor degrees of prognathism in whom they performed segmental osteotomy for correction of occlusal problems, double horizontal osteotomy for reduction and recession genioplasty, and decortication of the intact middle portion of the osteotomies, in the symphysis and laterally beyond the mental foramen. The maximum amount of setback possible with this technique is 4 to 5 mm. Moderate Prognathism Moderate prognathism with enlargement of the mandibular base deserves a vertical ramus osteotomy. This is a simple procedure less risky to the inferior alveolar nerve than the traditional sagittal split osteotomy, but is not indicated when vertical rotatory movements are necessary because it produces displacement and poor bony contact along the osteotomy margins. Moderate prognathism associated with open bite is corrected by a sagittal split osteotomy designed through the ramus.
Fig 19. Management options in mandibular prognathism.
Severe Prognathism Neither a sagittal split nor a vertical osteotomy is sufficient for correction of severe prognathism due to extreme telescoping of the segments and little
Minimally invasive techniques to treat prognathism are being developed. Troulis et al90 have demonstrated the feasibility of endoscopic vertical
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or no bony interface at the osteotomy site. In this case most authors prefer the Obwegeser II modification, which involves lateral sagittal ostectomy with removal of a segment commensurate with the amount of setback, and simultaneous ostectomy of the medial segment through the angle while preserving the inferior alveolar nerve. Mandibular body ostectomies are possible, but generally require dental extractions. Bell and Jacobs93 focus on the three-dimensional aspect of mandibular prognathism and analyze the rotational effect of the mandible at the temporomandibular joint when the maxillary height is altered. Resection of vertical maxillary excess causes the chin to rotate anteriorly and cephalad, increasing mandibular protrusion. Conversely, moving the maxilla inferiorly opens the mandibular angle, lengthening the face but decreasing prominence of the pogonion. Recent evidence suggests that chronic mouthbreathing during growth contributes to the longface syndrome and may be a factor in relapse after orthognathic surgery. When reconstructive surgery is contemplated for this deformity, preliminary steps should be taken to enhance nasal respiration. Posnick and colleagues94 note that the potential late complications of sagittal split or chin osteotomies include relapse, residual malocclusion, less than ideal facial esthetics, temporomandibular joint disorders, and residual damage of the inferior alveolar-mental nerve. During the sagittal split procedure, while completing the cortical cuts or during the actual splitting of the mandible into proximal and distal segments, laceration of the inferior alveolar nerve (partial or complete) may occur. Traction injury to the nerve (especially when the neurovascular bundle remains attached to the proximal segment after the split) and nerve compression during fixation of the segments represent additional risks to the nerve. In their study the authors sought to document sensory alterations of the chin, lower lip, and gingiva after sagittal split and chin osteotomies in adolescents. Three experimental groups were evaluated 1 year after orthognathic surgery: Group II consisted of patients who had had bilateral sagittal split osteotomies of the mandible (n=14 nerves); Group III had undergone an osteoplastic genioplasty (n=40 nerves); and Group IV had combination bilateral sagittal split
osteotomy and osteoplastic genioplasty ( n=42 nerves). Compared with controls (Group I, normal unoperated adolescents, n=134 nerves), subjective residual numbness was recorded in 2/7 patients in Group II, 2/20 patients in Group III, and 14/21 patients in Group IV. Jaaskelainen et al95 monitored inferior alveolar nerve function continuously while doing bilateral sagittal split osteotomies in 13 patients. Adverse effects on the sensory nerve action potentials were detected that prompted the authors to change their surgical technique, to use finer instruments and to limit the duration of medial opening to less than 10 minutes. The authors conclude that intraoperative monitoring of the nerve prevented nerve injury during splitting and fixation. If the improved outcome is confirmed by randomized clinical studies, nerve monitoring may indeed prove valuable in orthognathic surgery with sagittal split osteotomy. Timing The timing of surgery for mandibular prognathism is based on the severity of the malocclusion,96 but the patients age influences the treatment plan. In cases of severe disharmony, early surgery may be indicated in hopes of stimulating normal growth through physiological factors, but in most patients corrective surgery can be delayed until after the pubertal growth spurt. In cases of mild deformity, surgery can be further deferred until the late teens. Freihofer97 reviewed the surgical outcome in 12 adolescents who had backward displacement of the mandibular anterior segment. By the end of their growth period, 33% of patients showed marked occlusive relapse of the retropositioned segment. In contrast, the rate of relapse after segmental osteotomy in fully grown patients has been variously reported as 0 to 9%.98 Similarly, 15 of 31 adolescent patients exhibited considerable occlusal relapse after retropositioning of the mandible, prompting reoperation in 8 of them.97 Comparable rates in adults range between 5% and 15%. In Cook and Hinrichsens series,99 all patients who had significant relapse were under 19 years of age. Most authors currently recommend delaying correction of prognathism until after growth has stopped.
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Class II Mandibular Retrognathia Class II mandibular retrognathia is much more common than Class III prognathia.54 The cause of the retrognathia may be congenital, developmental, or acquired; examples of congenital occurrences are in the Treacher Collins and Pierre Robin syndromes and in Rombergs disease. Developmental causes are more frequent, however, such as birth trauma, TMJ injury, infection, muscle imbalance and improper nutrition. Acquired mandibular deficiency is also seen after resection for carcinoma or after facial trauma such as an automobile accident or gunshot wound. Mandibular retrognathia has also been implicated in the etiology of obstructive sleep apnea. Zucconi and coworkers100 studied 100 consecutive habitual snorers; of these, 55 had an apneahypapnea index (AHI) greater than 10, which qualified them as severe. Cephalometric and otolaryngologic variables were compared between these subjects and the 45 persons whose AHI indexes were less than 10. The two groups were found to be significantly different in measures of mandibular plane-to-hyoid bone distance, SNB angle, SNA angle, posterior airway space, tongue size, and body mass. Nevertheless, these variables together explained only 33% of the variance of the AHI in the total sample. The authors concluded that the lack of association between cephalometric variables and mild sleep apnea suggests that the difference in these variables may be the consequence, rather than the cause, of habitual snoring and the obstructive sleep apnea syndrome. Riley and colleagues101 reviewed the outcome of 306 patients consecutively treated for obstructive sleep apnea. All were evaluated by physical examination, cephalometric analysis, fiberoptic examination, and polysomnography before and after treatment. A two-phase surgical protocol was used for reconstruction of the upper airway: Phase 1 consisted of uvulopalatopharyngoplasty (UPPP) for palatal obstruction and genioglossus advancement with hyoid myotomy-suspension for base-oftongue obstruction. Patients who failed phase 1 were offered phase 2 reconstruction, which consisted of maxillary-mandibular advancement osteotomy. The overall success rate was 76.5%, and patients who underwent phase 2 (n=91) had a success rate of 97%. The authors conclude that a comprehensive presurgical evaluation is necessary
to plan a logical approach to reconstruction of the upper airway, and patients who complete the surgical protocol have a greater than 95% chance of long-term relief of their symptoms. Fox and Tilson102 reviewed the literature of mandibular advancement. Early techniques mainly involved step osteotomies of the mandibular body; these were followed by horizontal and oblique osteotomies of the ramus. Today, inverted-L and C osteotomies of the ramus and sagittal split osteotomy dominate the field. Figure 20 illustrates popular surgical options in the correction of mandibular deficiency.
Fig 20. Management options in Class II mandibular retrognathia.
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Hull and Smith103 prefer the C osteotomy over the sagittal split technique because the former is associated with fewer complications. Farrell and Kent,104 on the other hand, reserve the C osteotomy for cases in which the only requirement is for mandibular advancement. If an increase in posterior facial height is needed, they recommend an inverted-L osteotomy. Analysis of their results reveals variable degrees of relapse after mandibular advancement: 5% decrease in posterior facial height and 31% anterior collapse with the inverted-L osteotomy and 23% relapse with the C osteotomy (straight advancement). Most of the relapse occurred in the first 6 months postoperatively and was more significant in the younger age groups (under 20 years). While the design of the inverted-L and C osteotomies eliminates the effect of the masticatory muscle pull, the sphenomandibular ligament antagonizes advancement and restricts any increase in posterior facial height. The suprahyoid muscle group is placed under tension during correction of open bite and mandibular retrognathia, and this is thought to contribute to skeletal relapse. 105 Wessberg, Schendel, and Epker,105 however, compared the results of mandibular advancement with and without suprahyoid myotomy, and showed no significant difference in long-term relapse between the two groups. Lines and Steinhauser86 prefer the Dal Pont modification of the Obwegeser sagittal split technique for full mandibular advancement. Patients who appear chinless and have steep mandibular plane angles (>40) are ideal candidates for this procedure. Anticipating 20% to 25% relapse, the authors recommend overcorrection and possible anterior alveolar advancement in patients with prominent chins and relatively normal mandibular bases, because of the tendency for relapse seen with full advancement. They admit to a frequent need for bone grafting, extensive orthodontia, or fixed bridgework with anterior alveolar advancements. Rosen106 points out that, in patients with severe mandibular micrognathia, the rami are usually deficient vertically and the mandibular bodies are also deficient. Thus there is a deficient posterior facial height, an obtuse gonial angle, overly steep occlusal and mandibular plane, and a compensatory increase in anterior facial height with clockwise rotation of the entire maxillary-mandibular complex. Failure to correct the rotational deformity results in inad-
equate projection of the lower face, further reducing the posterior facial height, and no change in the steep occlusal mandibular planes. Rosen106 reports his results in 11 patients with extreme mandibular micrognathia who had correction of the occlusal plane. The technique involved rotation of the occlusal plane to its normal level relative to the Frankfort horizontal. A Le Fort I osteotomy is performed to shorten the anterior maxilla and a sagittal split ramus osteotomy is performed to advance and rotate the mandibular body counterclockwise. Together, they close the open bite created or worsened by Le Fort I osteotomy. Rosen found that mandibular rotation yielded a mean 17 mm of sagittal displacement at the B point, compared to just 10 mm at the first molar. Adequate projection of the lower face was achieved when the osteotomy was accompanied by a modest sliding genioplasty (mean 7 mm). A mean of 25 mm of total advancement was achieved at the pogonion. The posterior facial height was preserved and the mandibular and occlusal planes were normalized to mean angles of 27 and 10 respectively (Fig 21).
Fig 21. Preoperative (solid line) and immediately postoperative (dashed line) cephalometric tracings demonstrate leveling of occlusal plane by anterior maxillary intrusion, making the open bite worse, and counterclockwise rotation and advancement of mandibular body. Sliding genioplasty has advanced the pogonion 31 mm. (From Rosen HM: Occlusal plane rotation: aesthetic enhancement in mandibular micrognathia. Plast Reconstr Surg 91:1231, 1993; with permission.)
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A follow-up of 40 months showed a mean sagittal relapse at the B point of only 2 mm. The author notes superior esthetic results but cautions that longer followup is needed to confirm the stability. He concludes that in cases of mandibular underdevelopment, a small subset of patients with vertical deficiency of the mandibuar ramus and deficient posterior facial height will remain undercorrected by traditional orthognathic procedures simple mandibular advancementunless the occlusal plane deformity has been normalized. Timing The appropriate timing of surgical advancement is arguable. Nanda and colleagues107 studied facial growth subsequent to Le Fort I osteotomies in adolescent monkeys. Two groups of animals were studied: Group I had a Le Fort I advancement of 4 mm, while Group II had a 5-mm advancement and a 2.5mm impaction. The findings indicated that growth changes in the maxilla and mandible were related to the extent of injury caused by the maxillary surgery. The largest increments in rates of growth were observed in the control subjects, Group I, and Group II, in that order. The most interesting finding was that mandibular growth pattern followed maxillary growth pattern in both the experimental groups. Schendel and colleagues108 reviewed 12 children aged 8 to 16 who had a mean mandibular advancement of 5 mm and recommended early surgery in the growing child to promote harmonious mandibular growth and stability of the correction. Huang and Ross109 disagree, reporting severe growth disturbance and no subsequent gain in mandibular length following advancements of >10 mm and <9 mm. While these alarming results were associated with rather large advancements, caution is warranted when contemplating surgery on the growing child. Ellis and associates110,111 note that the muscle and connective tissue within the suprahyoid complex lengthen with mandibular advancement surgery. Posteriorly directed forces created by lengthening of these tissues have been implicated in postsurgical relapse. A possible consequence of rigid fixation for central ramus advancement osteotomy is that forces generated within the stretched perimandibular connective tissues must be countered by the temporomandibular joint (TMJ). If the
TMJ cannot counter this force, the condyle may move posteriorly within the fossa. Rotskoff112 has documented resorption along the anterior surface of the postglenoid spine and resorption of the posterior condylar cartilage after the condyle is placed posteriorly in the fossa during central ramus advancement osteotomies. Ellis and Sinn113 review 63 patients who had sagittal ramus advancement osteotomies to correct class II dental relationships. The results of this study indicated that orthopedic forces are generated by the perimandibular connective tissues following advancement by the mandible. These posteriorly directed forces are exerted on the advanced distal segment. The same forces are thought to be important in causing postsurgical relapse following mandibular advancement and dental fixation. Mandibular distraction osteogenesis has been used successfully in infants with severe retrognathia who are tracheostomy-dependent or who have obstructive sleep apnea.114,115 McCarthy et al77 reported successful decannulation in 4 of 4 patients treated with distraction osteogenesis. Cohen et al114 reported successful decannulation in 7 of 8 patients and improvement in the signs and symptoms of obstructive sleep apnea in 7 of 8 patients who had been tracheostomy candidates. Judge et al116 reported distraction of the mandible in a neonate with Pierre Robin sequence and Klippel-Feil syndrome who had acute airway obstruction at birth. In addition, distraction osteogenesis has been used for correction of mandibular hypoplasia and asymmetry in patients with hemifacial microsomia.77,80 CHIN Anterior horizontal osteotomy of the mandible is currently the procedure of choice for correcting skeletal chin deformity. The sectioned anterior mandible can be advanced either on a wide pedicle while maintaining soft-tissue attachments117 or as a free segment by completely detaching the softtissues from the graft.118 The soft-tissue attachments help to stabilize the skeletal alteration, make for a more predictable soft-tissue change, and minimize postoperative osseous resorption.119 It was Ellis120 who reported that pedicled grafts underwent less resorption than nonpedicled grafts in the monkey. This was more recently investigated in humans and confirmed by Vedtofte and colleagues121 (Table 5).
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Table 5 Relapse Following Genioplasty by Anterior Horizontal Osteotomy
(From Hoffman GR, Moloney FB: The stability of facial osteotomies. 3. Chin advancement. Aust Dent J 40(5):289, 1995; with permission.)
Lateral cephalometric evaluations are used to determine the desired horizontal and vertical dimensions of the chin. Wolford and Bates122 use relationships between the N-B line, A-Po line, subnasale vertical, and Burstones angle of facial convexity to predict the chins position in all three dimensions postoperatively. McCarthy123 proposes a system based on angles and distances measured from lines drawn through reproducible cephalometric landmarks. These lines include those described by Gonzales Ulloa and Stevens, Ricketts, Burstone, Steiner, and Holdaway. Hoffman and Moloney119 note that irrespective of the analytic criteria used, it is important to realize that significant differences can occur between clinical evaluation of the patients appearance and the numerical values obtained from cephalometric assessment. They write: It has been stated that when such a disparity does occur between subjective clinical assessment and objective cephalometric analysis, experienced surgeons will usually rely on the former, using the latter as a guideline rather than as a yardstick in the diagnostic phase of treatment. Hinds and Kent124 discuss the soft-tissue relationships of the chin to the lip and nose and suggest cephalometric analysis of the chin using a combination of Downs, Steiners, and Tweeds projections. The authors124 credit Hofer, Obwegeser, and Converse with most advances in the field of genioplasty and review the versatile horizontal osteotomy (Fig 22), as follows:
a) The sliding oblique horizontal osteotomy is used to correct excessive chin height as well as chin retrusion. May also be used to increase the vertical dimension of the chin in microgenia. b) The step horizontal osteotomy advances the chin without altering its vertical dimension. c) The horizontal osteotomy for asymmetry allows lateral shifting of the segment for contour alignment. d) The sandwich osteotomy makes use of an interposition graft to increase the height of the chin. e ) The horizontal osteotomy with ostectomy reduces chin height. Spear, Mausner, and Kawamoto125 report a twocenter experience with the sliding genioplasty as an outpatient procedure. The authors conclude that this is a simple bony advancement operation that can be safely performed under local anesthesia with good results. In his discussion of this paper, however, Wolfe126 cautions about the risk of aspiration from pooling of blood and secretions in the mouth, and states his preference for intubation. And despite deep sedation, 20% of patients from UCLA complained of discomfort during the procedure, which further argues for general anesthesia when performing a sliding genioplasty. Wolfe127 reviews the literature of horizontal osteotomy and discusses its applications for shortening and lengthening the chin. The author recommends a combination of clinical and cephalom-
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Fig 22. Horizontal osteotomy techniques. (A) Sliding oblique horizontal osteotomy. (B) Step horizontal osteotomy. (C) Horizontal osteotomy for asymmetry. (D) Sandwich horizontal osteotomy. (E) Horizontal osteotomy with ostectomy. (F) Correction of macrogenia by horizontal osteotomy. (Reprinted with permission from Hinds E, Kent JN: Genioplasty: The versatility of horizontal osteotomy. J Oral Surg 27:690, 1969.)
etric analyses to determine the vertical position of the chin, but does not give specific criteria for the various modifications based on results of the analyses. Wolfe notes that shortening the chin necessitates bone removal in a strip ostectomy rather than from the lower border of the symphysis. The lower segment is reattached to the remaining upper mandibular segment, preserving the muscle attachments to the inferior border of the chin for improved esthetics. When the chin is lengthened, interposition bone grafts are required, for which he favors cranial bone because of the relatively high incidence of sequestration and infection when iliac bone is used. Rosen128 reports the outcome of eight patients who had vertical augmentation genioplasty by transverse symphyseal osteotomy and interpositional implantation of porous, block hydroxyapatite. Seven patients in this series also had Class II occlusion and underwent simultaneous sagittal advancement of the chin. Preoperatively all patients had measured decreases in lower facial height. The mean vertical lengthening of the chin was 5.3 mm. Follow-up at a mean of 11 months revealed complete stability of the vertically repositioned symphyseal segments. The mean ratio of vertical soft- to hard-tissue augmentation was 0.89:1.
Rosen129 has carried the concept of vertical elongation of the chin to mask apparent deformities of the lower face. He notes that sliding genioplasty can be used to effectively camouflage the visual perception of a weak chin in most patients with Class II skeletal pattern; it cannot, however, correct the retrusive lower lip. An unnatural, overcorrected appearance can be avoided only by recognizing this limitation and restricting forward movement of the chin, so as not to advance it beyond the lower lip. Rosen states: One must be willing to accept residual facial disproportion in the sagittal plane, since the chin will remain weak relative to the upper lip and midface. Visual compensation for this [anterior-posterior disproportion] can be achieved by creating vertical disproportion . . . Excessive height of the lower face can be esthetically pleasing in the presence of a well-defined labiomental fold unaccompanied by lip strain. Rosen129 astutely notes that a significant number of patients requesting chin enlargement have lower face dysmorphology consisting of four components: a recessive chin; a recessive procumbent lower lip; an exaggerated labiomental fold; and a diminished to normal lower facial height. From a biomechanical perspective, as the chin is advanced the labiomental fold deepens, whereas vertical elon-
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gation of the chin tends to soften the fold. Esthetic refinements in genioplasty and the role of the labiomental fold are discussed by Rosen elsewhere.130 Precious and Delaire131 describe a functional genioplasty for the correction of anterior vertical mandibular excess. The indications for the procedure include patients with:
lip incompetence with a normal maxillary incisor to lip relationship. (These patients generally have an open-mouth posture and require excessive elevation of mental soft-tissue in order to obtain lip closure.) thinning of the anterior mandibular alveolus
flattening of the contour of the chin residual or associated cleft lip and cleft palate
pathology a requirement to adjust lower facial height after maxillary and mandibular osteotomies The treatment plan is to correct the lower anterior facial height to 55% of the total anterior facial height. The soft-tissue response to genioplasty procedures has been reviewed by Krekmanov and Kahnberg.132 They studied 65 patients who were assigned to one of four groups depending on the direction of the genioplasty. The soft-tissue response was equal to bone movement in anterior repositioning but less predictable in the posterior direction or when combined with vertical reduction. The authors note that, in many cases of long face syndrome or severe chin deficiency, it was extremely difficult to perform cephalometric analysis of the soft-tissues because the spastic condition of the mental muscle could disturb both the preoperative position of Pogs and the volume of soft tissue in front of the bone. This phenomenon, in combination with soft-tissue tension, makes it difficult to accurately predict soft-tissue movement in cases where an additional genioplasty is needed, especially in the vertical dimension. Occasionally it is necessary to modify the transverse dimension of the chin because it is excessively narrow. Raffaini and Sesenna133 proposed a hemi-genioplasty technique that allows use of the properly shaped hemichin as a reference point and that achieves symmetry in the correct transverse dimension by simple osteotomy of the distorted
hemichin. The method is applicable mainly in cases of asymmetry in the transverse plane, even if it allows the simultaneous correction of small sagittal discrepancies (maximum 2 to 3 mm). Osseous genioplasty to correct chin asymmetry in combination with orthognathic procedures requires careful and precise preoperative planning. Stefanova and Stella134 review the geometric considerations when planning correction of chin asymmetry and discuss their protocol of data collection, model surgery, diagnosis, and treatment planning. This is a useful article and should be reviewed by anyone contemplating chin realignment. One of the drawbacks of genioplasty is the potential for injury to the mental branch of the inferior alveolar nerve, which results in chin, lip, and tooth numbness or dysesthesia. Clinically recognized injury to the inferior alveolar nerve (reported frequently as up to 6%) may detract from this procedure.125,128 Ritter and colleagues135 used high-resolution radiographs to determine the anterior course of the inferior alveolar nerve in 52 hemimandibles. The neurovascular canal was found to be highly variable in its course, particularly with respect to its distance from the inferior border of the mandible (Fig 23). The authors conclude that if the osteotomies for sliding genioplasty were performed at least 6 mm below the inferior border of the mental foramen, injury to the mental nerve would be reduced. The reader is encouraged to study this article. Precious, Armstrong, and Morais136 review the anatomic placement of fixation devices in genioplasty and conclude that fixation devices should be placed in areas of future bone deposition. Their review before, immediately after, and 1 year following genioplasty showed a consistent pattern of bone apposition and resorption after advancement genioplasty. A consistent but inverse appositionresorption pattern was observed after reduction genioplasty (Fig 24). DeFreitas and colleagues137 evaluated skeletal stability and the remodeling process of the advanced genial segment when a single bone plate is used to stabilize the segment after osteotomy of the inferior border of the mandible. The results in 39 patients were analyzed with cephalometrics and clinical examination. Stability of the procedure was noted to be excellent; the pogonion maintained its immediate postsurgical horizontal position at longest follow-up. Despite the fact that the bone plate
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Fig 23. Measurements correlating the course of the inferior alveolar neurovascular canal with external landmarks show wide variability of the canal in relation to the caudal border of the mandible. (From Ritter EF, Moelleken BRW, Mathes SJ, Ousterhout DK: The course of the inferior alveolar neurovascular canal in relation to sliding genioplasty. J Craniofac Surg 3:20, 1992; with permission.)
Fig 24. Pattern of bone resorption (stippled area) and apposition (solid area) observed in all cases of A, advancement genioplasty with or without vertical reduction and B, posterior repositioning of the chin. (Reprinted with permission from Precious DS, Armstrong JE, Morais D: Anatomic placement of fixation devices in genioplasty. Oral Surg 73:2, 1992.)
covered the areas where most remodeling occurs, the remodeling pattern was similar to that seen with other forms of fixation. The plate is much simpler to place than non-rigid means of fixation such as wires. One can readily select the plate corresponding to the amount of advancement desired and be sure that this is what will be produced in the patient. Half the plate is attached to the advanced genial segment while the pull of the soft tissues holds the segment in position against the mandible. The amount of advancement is thus assessed before the remaining screws are secured to the superior flange of the bone plate. If the posterior extensions of the advanced genial segment are not equally advanced, the entire segment can be readily twisted to one side or the other, straightening the chin. If one wishes to increase the vertical dimension of the chin during the advancement procedure, a longer plate can be selected and unbent to provide the desired movement. According to Collins and Epker,138 when considering augmentation genioplasty the surgeon should
also evaluate the submental region for the presence of excessive fat or an obtuse cervicomental (neck-chin) angle without lipohyperplasia. (The normal angle is 100-140.) When a very obtuse neck-chin angle exists concomitant with a moderately retruded chin, and in the absence of lipohyperplasia, attention must be given to the relation of the hyoid bone and suprahyoid musculature. The relationship of the hyoid bone to the 3rd cervical vertebra and mandibular symphysis is reproducible and relatively constant. The normal hyoid bone is approximately 32 mm anterior to the body of C3, 37 mm posterior to the symphysis, and 5 mm below a line drawn from C3 to the mandibular symphysis.139 If the hyoid bone is low or lying forward, the results of augmentation genioplasty alone may be compromised. In these cases, posterior-superior repositioning of the geniohyoid and anterior digastric muscles may be indicated to improve the neck-chin angle. A common complication of advancement genioplasty is the hourglass deformity, which consists of notching along the inferior border of the
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mandible at the osteotomy site. Hobar and Byrd140 correct this iatrogenic indentation by means of hydroxyapatite granules mixed into a paste and used as a spackling compound to even out the lateral mandibular contour. Wider, Spiro, and Wolfe141 describe their experience in 50 patients with simultaneous osseous genioplasty and meloplasty with associated posterior plication of the platysma. Complications were minimal and easily corrected, and the postoperative contour was excellent. Alloplastic chin implants are a popular technique for augmentation genioplasty. They are appropriate in cases of mild retrogenia without vertical or horizontal disproportions.126,127 The procedures simplicity and low morbidity are the main reasons for its popularity. However, because of reports of foreign body reaction and infection associated with implants, some surgeons still prefer the use of sliding genioplasty. Loss of an implant due to infection, extrusion, or displacement is a concern. If an implant is removed due to displacement or size discrepancy, generally it is simultaneously and successfully replaced with a new implant. When an implant is removed due to extrusion or infection, however, an interval of 3 to 6 months is allowed to elapse before a new implant is inserted. A failed implant results in additional surgical procedure(s); more important, secondary chin disfigurements can occur after implant removal due to capsular contracture and abnormal redraping of the mentalis muscle.142,143 Silicone, MedPor, and GoreTex have all been used as implant materials. In cases of implant infection or extrusion, Li and Cheney144 use a sliding genioplasty immediately after removing the implant. The rationale for this protocol is that as long as its periosteum is preserved, the genial segment is well vascularized by the genioglossus, geniohyoid, and anterior digastric muscles at its inferior and lingual borders, and therefore it is resistant to infection. Secondary chin ptosis, soft-tissue bunching and dimpling, and altered lip motion can be extremely difficult to correct after failed chin implant removal, but these problems can be avoided by doing an immediate sliding genioplasty. A surgical strategy reduces the waiting period, cost, and morbidity associated with alternative treatment methods. The concept of immediate genioplasty following removal of an alloplastic chin implant has also
been championed by Cohen and others.142 The authors reviewed the clinical records of 10 patients whose alloplastic chin implants had been removed and in whom secondary chin deformities subsequently developed. Initial augmentation was performed 2 to 20 years before the patients sought advice regarding chin ptosis, soft-tissue pogonial bunching and dimpling, or asymmetrical lower lip motion. Four patients underwent advancement genioplasty with resuspension of their mentalis muscle, but the deformities proved refractory to delayed surgical treatment. According to the authors,142 Zide and McCarthy143 proposed three pathologic mechanisms leading to disturbance of mentalis function: (1) displacement of [the muscles] origin; (2) elongation and redraping; and (3) deficits of muscular bulk. . . . Zide and McCarthy approached the problem of ptosis by resuspension of the mentalis origin through transalveolar drill holes. Matarasso and coworkers145 studied six patients who had esthetically positioned and appropriately sized Silastic chin implants. All patients exhibited labial incompetence. The authors noted a correlation between preoperative baseline labial incompetence and mentalis muscle hyperactivity and progressive bony erosion. Although theirs is a small series, they conclude that bone erosion occurs in many patients who have undergone silicone rubber chin implantation. . . . It appears that the unrelenting forces exerted by mentalis muscle contraction on a compressible implant material are predominant factors in the predisposition for continued erosion. Guyuron and Raszewski146 retrospectively studied the objective and subjective outcomes of osteoplastic (n=34) and alloplastic (n=42) genioplasties in 76 patients. Their analysis showed that although both groups were highly satisfied with their surgical result, those who had osteotomy had a slightly higher satisfaction rate. Morbidity was the same for either procedure. Soft-tissue response was more predictable after osteoplastic genioplasty than when implants were used. Similarly, the cervicomental angle was more improved after osteoplastic genioplasty than after alloplastic genioplasty. Guyuron and Kadi147 reviewed the problems following genioplasty and treatment of the various
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complications that might ensue from alloplastic genioplasty and osteotomies.
MAXILLARY OSTEOTOMIES
Surgical correction of a maxillary deformity may involve movement in an anterior-posterior, inferior-superior, or transverse direction, and the Le Fort I osteotomy is the basis for all of these (Fig 25).
and unattractive nasolabial angle with intrusion of the maxilla. Posnick et al150-152 discuss modifications of the Le Fort I osteotomy in unilateral and bilateral cleft lip and palate deformities. The technique safely and reliably corrects the maxillary hypoplasia, closes residual oronasal fistulas, fills bone defects, and controls the cleft dental gap. The authors stress two points: 1) the need to preserve attached gingiva at the cleft site and 2) to produce a positive overjet and overbite. Prosthetics are used to complete the dental rehabilitation, and are particularly necessary in bilateral cleft deformities. Wolford and associates,153 in part 2 of their discussion of orthognathic surgery during growth, review the growth considerations affecting the maxilla. They then discuss maxillary hypoplasia, maxillary protrusion, vertical maxillary hyperplasia, and double-jaw surgery. The LeFort I osteotomy is the primary procedure for treatment of the maxilla in all these situations. The authors emphasize certain key points regarding the surgical correction of maxillary dentofacial deformities in the growing patient, as follows:
1. Early surgical correction may be beneficial in some patients for functional, esthetic, and psychosocial reasons. 2. The TMJs must be functionally healthy and stable for predictable surgical results. 3. The LeFort I osteotomy eliminates further AP growth of the maxilla. 4. Surgical correction of vertical maxillary hyperplasia with normal mandibular growth can be predictably performed during growth. Postsurgically, the vector of facial growth will be in a downward and backward direction. 5. Double-jaw surgery may be predictably performed in selected instances for specific jaw deformities. Wolford et al (2001)
Fig 25. Le Fort I osteotomy. (Reprinted with permission from Jackson IT, Munro IR, Salyer KE, Whitaker LA: Atlas of Craniomaxillofacial Surgery. St Louis, CV Mosby, 1982.)
Bell and McBride148 give step-by-step instructions on how to do a Le Fort I osteotomy. They stress the importance of the down fracture to facilitate visualization of the superior surface of the maxilla and to gain access to the crucial area between the perpendicular process of the palatine bone, maxillary tuberosity, and pterygoid plate. Special mention is made of techniques for widening and narrowing the maxilla, setback, and advancement. Kawamoto149 describes in detail and illustrates the surgical technique of Le Fort I osteotomy (Fig 26). Kawamoto149 stresses the importance of preoperative assessment, especially noting the lip-tooth ratio and gauging the effect of maxillary movement on alar base width. Management of the anterior nasal spine is also discussed. In cases of vertical maxillary excess, the spine should be left attached to the nasal septum to avoid creating a more acute
Vertical maxillary hyperplasia excluded, more predictable results can be obtained when surgery is performed close to or after completion of maxillary growth (approximately age 15 in girls; age 17 or 18 in boys). The horseshoe osteotomy preserves the attachment of the nasal septum to the hard palate, thus allowing some continued AP growth while mobilizing only the dentoalveolar structures (Fig 27).
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Fig 26. Technique of Le Fort I osteotomy. See text for details. (Modified from Kawamoto HJ Jr: Simplification of the Le Fort I osteotomy. Clin Plast Surg 16(4):777, 1989.)
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VERTICAL DEFICIENCY SHORT FACE SYNDROME Bell155 describes the short face syndrome and its surgical correction. On frontal projection, the typical patient shows an edentulous-appearing, short, square face. With the jaw at rest or when the patient is speaking or smiling, the maxillary incisors are hidden behind the upper lip. The upper lip curves downward and the corners of the mouth are below the midline. The upper third of the face is within normal limits. The middle third is characterized by a nose with broad alar bases and large nostrils. There is decreased facial height localized to the lower third. The posterior part of the face appears wide because of prominent mandibular angles. Cephalometric examination reveals decreased vertical maxillary height, a large freeway space, and a low mandibular plane angle, which are pathognomonic of vertical maxillary deficiency. There is often a Class I or II malocclusion with a deep overbite. Vertical maxillary deficiency may be associated with anterior-posterior maxillary deficiency in patients with mandibular prognathism or cleft lip and palate. Orthodontia is sometimes effective in the young and growing child; in adults, surgery is indicated. Clinical assessment should determine the amount of inferior maxillary displacement that is needed for 3 mm of maxillary incisor exposure with the upper lip at rest. The surgical goal is to attain acceptable facial proportions, with the lower face assuming approximately 55% of the total facial height. Cortical-cancellous bone grafts from the iliac crest, sculptured as dumbbells to the preoperative planned dimensions, are inserted in the gap created in the maxillary defect.155 Bell and Scheideman156 report the long-term occlusal and soft-tissue changes following surgical treatment of the short face. Relapse averaging 30% of the correction (approximately 2 mm) was repeatedly seen in the first 23 months postoperatively. Some lengthening of the upper lip was noted, but not to a consistent degree. To accommodate this upper lip lengthening, the preoperative plan should incorporate inferior maxillary repositioning in excess of that considered necessary to achieve a normal incisor-to-lip relationship, that is, aiming for 34 mm of incisor show. Hedemark and Freihofer157 noted 50% to 100% relapse in patients treated with vertical downward
Fig 27. Horseshoe osteotomy maintains attachment of horizontal palate to vomer and lateral nasal walls. Only the dentoalveolus is mobilized. (Reprinted with permission from Wolford LM, Karras SC, Mehra P: Considerations for orthognathic surgery during growth, Part 2: maxillary deformities. Am J Orthod Dentofac Orthop 119:102, 2001.)
MAXILLARY HYPOPLASIA Jackson154 emphasizes that a hypoplastic maxilla can be present in association with normal occlusion as well as with malocclusion of the Class III type. Patients who have maxillary hypoplasia with normal occlusion often go unrecognized because their deformity may be rather mild; they are often seen in consultation when they request a rhinoplasty. The nose may be large or small, but the significant feature is paranasal hypoplasia, frequently localized to the alar base region and to the superior upper lip; in other words, these patients have a weak midface. Intraoral examination confirms normal occlusion, but the upper part of the alveolus shelves backwards instead of vertically, particularly in the area between the canines. With age, these patients tend to develop deep nasolabial fold and often have a sad or angry look. Augmentation of the anterior maxilla is an essential element in the treatment of these patients, often complementing rhinoplasty or a facelift procedure.154 Examples of the management of maxillary hypoplasia in the face of normal occlusion are given.154 Jackson154 further discusses maxillary retrusion in conjunction with maxillary hypoplasia. He points out that the retruded maxilla may be either hypoplastic or normal, and the diagnosis plays significantly in the decision tree for adequate treatment.
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tilting of the maxilla and conventional wire fixation. They concluded that the surgical plan should allow for this relapse by initial overcorrection, and suggested plate osteosynthesis as the method of fixation. Rosen158 reports his experience with definitive surgical correction of vertical maxillary deficiency. Rosen158 describes the perioperative course of nine patients who underwent inferior maxillary repositioning resulting in no residual bone contact between the down-fractured maxilla and the superior midface. The mean distance of inferior maxillary displacement was 6.2 mm. Osteotomy gaps were implanted with porous block hydroxyapatite (Interpore 200), and the maxillae were rigidly fixed in position with miniplates. No postoperative maxillary-mandibular fixation was used and no complications were associated with the procedure. Follow-up reported was from 11 to 28 months. During this time there was a mean vertical relapse of 4.3%, which is significantly better than for other series. Postoperatively the upper lip was lengthened 20% to 50% of the magnitude of skeletal repositioning, especially if the upper lip had been compressed by the lower lip from an overrotated mandible. The authors experience supports the use of rigid miniplate fixation in facial osteotomies and is testimony to the value of hydroxyapatite as a bone graft substitute.158 VERTICAL EXCESS LONG FACE SYNDROME The following are typical features of vertical maxillary excess:159,160 >3.5 mm exposure of the upper anterior teeth with the lips at rest lip incompetence with an interlabial gap of >3.5 mm a convex nasal dorsum
narrow alar bases in proportion to the remainder of the face a nasolabial angle within the limits of normal
a recessed chin increased facial height primarily in the lower

one-third Clinical evaluation of the lip-tooth relationship forms the basis for projecting the extent of superior repositioning that will be needed to effect cor-
rectionthat is, how far the incisors must be raised. The acceptable amount of upper incisor exposure with the lip at rest is approximately 2.5 mm. Because the upper lip will shorten approximately 20% of the distance the upper teeth and maxilla are moved, compensatory overcorrection of 20% is indicated.148,160-162 Other goals of treatment are to establish a proper relationship with the chin and to achieve good overall lower facial height. To this end, autorotation of the mandible may be necessary. Rotation about the condyle frequently dictates resection of various amounts of bone from the anterior maxilla compared with the posterior segments. Occlusal analysis of patients with long face syndrome often reveals a Class II malocclusion with or without anterior open bite. The exact occlusal relationships should be determined preoperatively by means of dental models and confirmed by cephalometry and sketches. With this information, the degree of correction necessary to obtain the desired esthetic result and profile changes can be accurately planned.161 To avoid septal buckling or deviation and interference with superior advancement, a segment of nasal septum equal to the desired maxillary displacement must be resected. Because superior maxillary repositioning of more than 4 or 5 mm will compromise the nasal airway, the nasal septum is not reduced in height, but rather a horseshoeshaped osteotomy of the nasal floor is performed to separate the palatal and dentoalveolar portions of the maxilla. The midpalatal segment is held passively at the presurgical level by the nasal septum while the anterior and posterior dentoalveolar segments are superiorly repositioned around them.148 With movements of more than 5 mm, burring of the margins of the piriform aperture is often necessary to avoid undesirable elevation of the alar bases. Kawamoto149 warns of consequences of intrusion of the anterior nasal spine with maxillary impaction. A silver blade is used to make a Vshaped cut below the anterior nasal spine in order to leave this structure attached to the nasal septum. This avoids an unpleasant uptilt to the nasal tip. The transverse dimension of the maxilla is altered by means of the horseshoe palatal osteotomy or parasagittal osteotomies. If narrowing is desired, parasagittal ostectomies may be added. These segmental osteotomies can be executed under direct
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vision by using the down fracture method. Rosen163 notes that sagittal maxillary deficiency and vertical maxillary excess are frequently accompanied by transverse maxillary deficiency. At the time the maxilla is advanced or impacted, it should be properly segmented to expand it transversely and establish normal buccal-lingual-dental relationships. In Rosens estimation, parasagittal osteotomies can reliably widen the posterior maxilla 68 mm. When significant expansion is required in the canine region, he prefers a four-piece Le Fort I osteotomy. Although the most common type of vertical maxillary excess is represented by the classic long face syndrome, Schendel and Carlotti164 identify six dysmorphic subgroups according to variable degrees of vertical maxillary excess. In fact, 22% of patients with long face syndrome in their study did not have vertical maxillary excess, but instead had short upper lips with normal maxillae and long faces secondary to excessive chin height. The chin excess is independent of maxillary excess and as such not entirely secondary to posterior-inferior rotation of the mandible. Proper distinction between these subgroups has obvious implications to the treatment plan. Washburn, Schendel, and Epker165 analyzed the results of superior maxillary repositioning in 16 children aged 10 to 16 years. The authors recommend a maxillary alveolar osteotomy, avoiding transection of the nasal septum. Stable occlusion and an esthetically satisfactory outcome were noted in all. The stability can be predicted from the available human growth studies, which show that maxillary growth is virtually complete by 10 to 13 years of age. There is also no evidence to suggest that disproportionate maxillary growth continues beyond the normal growth period in individuals with vertical maxillary excess.165 In a study of 61 patients treated with surgical superior repositioning of the maxilla and wire fixation, Proffit and colleagues166 report vertical stability in 80% during the first postsurgical year, while 20% had 2 mm or more postsurgical movement of skeletal landmarks. Bailey and colleagues167 assessed changes in dental and skeletal relationships of 49 patients whose maxillae had been superiorly repositioned by Le Fort I osteotomy 5 years earlier. Most patients who had changes during the first 6 weeks postoperatively showed further superior movement of
the maxilla, but this was offset by inferior movement from the time of fixation release to the 1-year reporting interval.166 In the short term, therefore, superior repositioning of the maxilla can be considered stable, perhaps the most stable orthognathic surgical procedure, even without rigid fixation. The authors note that
From 1 to 5 years postsurgery, minimal changes occurred in skeletal and dental landmarks in the majority of patients, but approximately 25% of the patients showed 2 mm or more of downward movement of the maxilla and/or eruption of maxillary teeth, leading to downward-backward rotation of the mandible. . . . An increase in overbite, resulting from incisor eruption, was noted in 14%, and an increase in overjet occurred in 12% as the mandible rotated. It appears that modest long term skeletal and dental changes occur in some surgically treated long face patients. Only one patient had more than 1 mm of open bite on long-term follow-up. The likelihood of long-term change was not related to the age of the patient, stability during the first postsurgical year, or segmentation of the maxilla at surgery. Bailey et al (1994)
Zarrinkelk and coworkers168 remark that superior repositioning of the maxilla also produces a forward rotation of the mandible that may reduce an apparent mandibular deficiency. Patients with either VME or retrognathia have reduced maximum bite forces and slightly reduced maximum range of motion before treatment.169 Their study compared morphology and function of patients with combined vertical maxillary excess and mandibular retrognathia with other controls. The authors also looked at how these parameters changed after combined maxillary intrusion and mandibular advancement surgery. Fifteen female patients with VME and straight retrognathia were compared with 26 female controls before and up to 3 years after orthognathic surgery. Facial skeletal morphology, mandibular range of motion, maximum isometric bite force, and EMG activity of selected muscles of mastication were measured. At surgery the maxilla was elevated an average of 2.8 mm and the mandible was lengthened by an average of 7.1 mm. The authors report that
All of the postoperative morphologic measurements were closer to normal values. The patients masseter mechanical advantage was significantly lower than that of controls both before and after
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SRPS Volume 9, Number 24 surgery. Surgically induced changes in mechanical advantages were very small. The patients maximum range of motion and excursion during mastication were all lower than those of controls before surgery. All measurements of mobility decreased immediately after surgery, with a gradual return to preoperative values. However, even 3 years after surgery, all of the motion measurements remained smaller than those of the controls. Before surgery, the patients had maximum isometric bite forces significantly lower than those of controls. Bite forces increased significantly after surgery, approaching normal values within 2 years. The activity levels in the muscles of mastication during isometric bites were not significantly altered by surgery. Zarrinkelk et al (1996)
tured to accommodate the desired positional change. Wolfe, Lin, and Berkowitz171 state that
Maxillary protrusion may exist by itself or along with mandibular protrusion in the condition of bimaxillary protrusion. Surgical approaches to the maxilla, depending on arch form and other orthodontic considerations, may involve the following: 1. Tooth extractions (usually of premolars) and premaxillary setback (Wassmund/Wunderer); the same result can often be obtained by dental extractions and orthodontic therapy alone, although they require a much longer treatment time. 2. Posterior movement of the entire maxilla after Le Fort I mobilization, by removing bone in the maxillary tuberosity and third molar area. 3. Combination of 1 and 2 for more pronounced cases: Le Fort I osteotomy, posterior movement of the entire maxilla, maxillary tooth extractions, and segmentation of the maxilla with premaxillary setback. Wolfe, Lin, and Berkowitz (1997)
An earlier study by Upton and associates170 examined the premise that malocclusion and unbalanced skeletal relationships of the facial structures contribute to orofacial dysfunction syndromes. RETROGNATHIA Deformities of vertical maxillary deficiency may also include some posterior displacement of the maxilla as part of the syndrome. Treatment usually involves maxillary advancement of <67 mm,148 and bone grafts in the pterygomaxillary osteotomy are generally not required. Bell and McBride148 offer clinical details of wiring and fixation techniques for the mobilized segment. A frequent indication for maxillary advancement is the mandibular pseudoprognathism seen in association with cleft palate. Maxillary advancements in excess of 1 cm may be needed, and in these cases bone grafts in the pterygomaxillary osteotomy are recommended.148 Lines and Steinhauser86 also recommend overcorrection by at least 25% because of a tendency to relapse. PROGNATHISM Posterior repositioning of the maxilla may be indicated as part of the treatment for vertical maxillary excess. The maxilla can be set back 45 mm by reducing the posterior aspects of the maxillary tuberosities.148 When the planned posterior movement exceeds the amount of available bone in the tuberosity, the pterygoid plate is sectioned and frac-
Krekmanov and colleagues172 published what is to date the largest surgical series of posterior repositioning of the entire maxilla. Of the 30 patients in the study, 29 had associated vertical maxillary hyperplasia. Bone was removed from the maxillary tuberosity area and the maxilla was trimmed to good contact along the osteotomy line. On cephalometric analysis the mean distance of posterior repositioning was -2.0 2.1 mm, with a range of 0.02 to -8.5 mm. In cases of additional superior repositioning, the maxilla was telescoped in the lateral and posterior regions. The authors do not mention removing either of the third molar teeth. Kawamoto 173 states that maxillary retropositioning procedures are infrequently used because they tend to give the face an aged appearance. Once the upper lip is robbed of the support of the underlying anterior teeth, whether by an orthodontic plan of bicuspid extraction or by surgical setback, unpleasant soft-tissue changes can occur. The upper lip moves back and thins. Fullness of the upper lip vermilion . . decreases. . . . The upper lip also descends, which can produce an unflattering lesser show of teeth. In patients with a component of maxillary anterior protrusion, the nasal alar bases are buried into the face and the nasolabial folds deepen.
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The classic paper by Freihofer174 on latitude and limitation of midface movements should be required reading for anyone contemplating doing a Le Fort I osteotomy. SIMULTANEOUS MAXILLARY AND MANDIBULAR OSTEOTOMIES Epker and associates175 review selected dentofacial deformities that call for simultaneous mobilization of the maxilla and mandible in Class III, Class II, and Class I relationships. In general, combined upper and lower jaw surgery should be considered when occlusal relationships dictate skeletal movement of >1012 mm. Combined surgery is also indicated to maintain the appropriate relationship between the tip of the nose, upper and lower lip, and chin, which is frequently impossible when surgery is limited to a single jaw. Lindorf and Steinhauser176 discuss the planning and execution of simultaneous mandibular and maxillary surgery. Plate and screw fixation of the mobilized parts provides the necessary rigidity for simultaneous movements, while an intermediate splint enables proper orientation of the mobilized mandible with regard to the still intact maxilla. Once the mandibular segments have been stabilized with rigid fixation, the maxilla can be mobilized. Guyuron177 discusses combined maxillary and mandibular osteotomies and points to problems that can arise from previous orthodontic treatment, including missing teeth, alteration of arch form, tooth root resorption, and temporomandibular joint dysfunction. The need for accurate evaluation of the patients smile is emphasized. Specifically there should be minimal or no gum show, and the distance between the oral commissure and the pupil should be equal on both sides. Guyuron177 details the technique of double jaw surgery and postoperative care of the patient and summarizes the preparation and use of interocclusal splints in the surgical sequence. Most studies of stability after two-jaw surgery show the maxilla to be relatively more stable than the mandible.178-182 A major problem that may develop from simultaneous mobilization of the maxilla and mandible is facial asymmetry. Possible causes of facial asymmetry after two-jaw surgery are torquing of the maxilla or mandible and canting of the occlusal plane,183 mandibular proximal segment rotation, or
malposition of the inferior fragment of the genioplasty. Schendel184 notes that asymmetry in the vertical plane is evidenced by a difference in the vertical position of the maxillary molars from one side to the other. This cant of the maxillary occlusal plane will produce a similar cant of the mandibular occlusal plane. Orthodontics may be able to correct a mild cant of the occlusal plane. Reoperation is necessary if a significant facial asymmetry is present due to occlusal plane cant. CLEFT ORTHOGNATHIC SURGERY Primary repair of cleft lip and palate during infancy and early childhood often leads to maxillary growth restriction, secondary deformities of the jaw, and malocclusion. Orthognathic surgery is performed when adolescent patients have a residually clefted and perforated maxilla. Readers are urged to examine the comprehensive reviews by Marsh and Galic185 and ORyan186 on maxillofacial osteotomies for patients with cleft lip and palate and complications of orthognathic surgery, respectively. Posnick and Tompson187 reviewed the complications and long-term results of jaw surgery in a series of 116 adolescents who had probably different palate repairs in infancy or childhood. In all cases the basic orthognathic procedure included Le Fort I osteotomy. In addition, 87 patients had osteoplastic genioplasty and 32 had simultaneous sagittal split osteotomies of the mandible. Autogenous cortical-cancellous iliac bone grafts were used in all but six patients. Lateral cephalometric radiographs obtained 1 year postoperatively showed that a positive overjet was maintained in 97% of patients and a positive overbite in 89%. Overall, 89% of residual oronasal fistulas were successfully closed. Schendel and Mason184 reviewed 6 years of orthognathic surgery at Stanford University during which 315 patients underwent 474 osteotomies. Fourteen patients later required surgical revision. The authors give an excellent overview of the adverse outcomes of orthognathic surgery in the management of residual problems. Attention is directed toward problems of healing, especially bone; occlusal relapse; temporomandibular joint dysfunction; and other functional problems such as nasal airway obstruction. The adverse esthetic outcomes relate mainly to the nose, lips, and cheeks.
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Likewise a review on mandibular surgery assesses problems of healing, occlusal relapse, TMJ dysfunction, and nerve injury. PLATE FIXATION Miniplates have lately become the standard of care in the stabilization of facial osteotomies and fractures. Beals and Munro188 described an experience with miniplates in fixation of the skull, maxilla, and mandible in 74 patients. Little if any maxillomandibular wiring was used. No infections were reported, fixation was stable in all, and only 1% of plates became exposed and had to be removed. Technical points emphasized are passive fitting of the plates and precise drilling so as to avoid distraction of the mobilized fragments. Luyk and Ward-Booth189 analyzed their results in 11 Le Fort I osteotomies using Champy miniplates without bone grafts. Stability appeared to be good, with patients showing no relapse at 10 months postoperatively and an average horizontal maxillary advancement of 3.7 mm. Taylor190 reviewed complications of osteotomies with rigid fixation and concluded that most complications could be traced to technical errors. Anatomic variation in the position of the inferior alveolar nerve and poor quality or quantity of bone were complicating factors. Posnick and Dagys191 reviewed the long-term skeletal stability and relapse patterns of 35 patients with unilateral cleft lip and palate, maxillary hypoplasia, and class III malocclusion who underwent Le Fort I maxillary osteotomy. The advanced maxilla was fixed with miniplates. Clinical follow-up ranged from 1.5 to 4.5 years with a mean of 1.5 years. The authors found no significant difference in horizontal or vertical surgical change or relapse between patients who had maxillary surgery alone (n=24) and those who had surgery on both jaws (n=11). One year after surgery all patients showed a positive overjet and 86% had a positive overbite. There was no significant correlation between the amount of advancement or displacement and degree of relapse, but surgical overcorrection and perioperative orthodontics had been performed in anticipation of relapse. Posnick and Dagys speculate that the cause of relapse may be multifactorial and may not be explained by cleft palate scar tissue alone. They conclude that miniplate-and-screw
internal fixation is useful, but it does not eliminate relapse in patients with unilateral cleft lip and palate who undergo Le Fort I osteotomy. Costa and coworkers192 review the literature regarding stability of the LeFort I osteotomy in maxillary inferior repositioning, which is known to have a high relapse rate. The authors conclude that inferior repositioning stabilized with rigid fixation and bone grafting is a predictable procedure with an acceptable rate of relapse (35% posteriorly and 15% anteriorly). This is the technique of choice based upon their review of the literature. Berger and associates193 compared two groups of patients undergoing bilateral sagittal split osteotomy (BSSO). One group was treated with transosseous wiring (n=26) and the other with rigid fixation (n=28). Despite minimal statistical differences in relapse between the groups, the authors state that the potential was greater for relapse in patients stabilized with transosseous wiring. In a 3-year follow-up analysis of 80 consecutive mandibular prognathism patients treated with bilateral sagittal split osteotomy and rigid fixation, Mobarak and others194 found BSSO to be a fairly stable clinical procedure. The mean relapse rate at pogonion was 26%, and most of the relapse (72%) occurred during the first 6 months after surgery. A study by Talebzadeh and Pogrel 195 of 20 patients treated with osseous genioplasty with rigid fixation documented relapse rates of 0.38 mm at pogonion, 1.2 mm at soft-tissue pogonion, and 1.5 mm at soft-tissue B point. Relapse was not related to the amount of advancement. The authors found essentially no significant relapse 12 months after genioplasty stabilized with rigid fixation. Nemeth and colleagues196 evaluated the risk of increased TMJ disorders after rigid fixation of BSSO. The prospective study comprised 127 patients randomized to either rigid or wire fixation. At 2 years follow-up, no statistically significant difference was detected between the groups regarding temporomandibular joint dysfunction. Shand and Heggie197 report preliminary results in 31 patients who underwent maxillary, mandibular, or bimaxillary orthognathic procedures stabilized with resorbable plates and screws. The follow-up interval ranged from 2 to 8 months. Six patients had mild mobility of the maxilla in the early postoperative period, but stability was within
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normal limits at 6 weeks postoperatively. The authors conclude that resorbable plates represent a good fixation method for orthognathic procedures. Although this report is encouraging, the data are quite preliminary and must be independently confirmed with longer follow-up. The technique is not currently the standard of care in orthognathic surgery. MIDFACIAL AND CRANIOFACIAL OSTEOTOMIES Converse and Wood-Smith198 give detailed descriptions of the techniques for orbital, paranasal, and maxillary osteotomies and discuss modifications of the low maxillary osteotomyLe Fort I, pyramidal nasomaxillary or nasoorbitomaxillary osteotomyLe Fort II, and high maxillary osteotomyLe Fort III (Figs 28-30).199
Fig 29. Le Fort II osteotomy. (Reprinted with permission from Jackson IT, Munro IR, Salyer KE, Whitaker LA: Atlas of Craniomaxillofacial Surgery. St Louis, CV Mosby, 1982.)
Fig 28. Le Fort I osteotomy, showing the burr used to make a U-shaped osteotomy around the palatal vault. (Reprinted with permission from Jackson IT, Munro IR, Salyer KE, Whitaker LA: Atlas of Craniomaxillofacial Surgery. St Louis, CV Mosby, 1982.)
The following general observations can be made regarding the effect of these osteotomies on the facial skeleton: The Le Fort I osteotomy affects the upper lip and the lower fourth of the nose. It may alter nasal tip projection, alar base width, and the nasolabial angle. It has no effect on nasal length, projection of the cheeks, or orbital volume. The Le Fort II osteotomy allows nasal lengthening and alteration of the dorsal nasal angle and affects the projection of the upper lip through the attached maxilla. It allows correction of
Fig 30. Le Fort III osteotomy. (Reprinted with permission from Jackson IT, Munro IR, Salyer KE, Whitaker LA: Atlas of Craniomaxillofacial Surgery. St Louis, CV Mosby, 1982.)
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telecanthus with modifications in the nasoorbitoethmoidal area. The cheeks and orbital volume are not affected. The Le Fort III osteotomy alters the orbital volume and the projection of the cheeks, lengthens the nose and changes its dorsal angle, and modifies upper lip projection through its attached maxillary component. When performing a Le Fort I osteotomy on a cleft patient, Converse and Wood-Smith198 recommend a transverse cut across the posterior portion of the hard palate so as to leave the posterior border of the hard palate and the attachments of the soft palate undisturbed. This averts the possibility of shortening the soft palate with resultant velopharyngeal incompetence. Converse and Wood-Smith 198 also describe modifications of paranasal osteotomies to lengthen the foreshortened nose and trace improvements in the design of the Le Fort III osteotomy through Tessiers work. Special reference is made to the inferior and medial orbital cuts that do not disturb the lacrimal apparatus so that it can move forward with the midface. The authors stress the advantage of splitting the zygoma and stepping the cut through the zygomatic body to increase lateral stability. A study of the stability of Le Fort III advancements in children with Crouzons, Aperts, and Pfeiffers syndromes by Bachmayer and Ross200 concluded that relapse was neither occlusiondependent nor related to the amount of forward maxillary advancement, but instead was inversely proportional to the degree of stability of the midfacial segment, and to this end recommend rigid fixation. The authors note that overcorrection in children is necessary to compensate for the lack of maxillary growth after Le Fort III osteotomy in the presence of a normally growing mandible. Posnick and associates201 discuss a modified occlusal splint that avoids tracheostomy in total midface osteotomies. The authors discuss various methods for circumventing the restrictions of either oral or nasotracheal intubation, including guiding the orotracheal tube behind the maxillary tuberosity, exiting the orotracheal tube out the oral cavity through an incision in the floor of the mouth and submental skin, intraoperative oral-to-nasal tube switch, and finally the suggested dental splint, which allows both orotracheal intubation and exacting
occlusal relationships without the need for direct contact of the teeth. SOFT-TISSUE RESPONSE The correction of dentofacial and craniofacial abnormalities is not complete without consideration of the soft-tissue response to bony manipulation. The degree of correlation that exists between changes in the soft-tissues of the face and their underlying skeleton determines which adjustments need to be made in the preoperative tracings to bring about the desired result. Table 6 summarizes the currently available data on soft-tissue response to bony movement.86,156,202-205 Table 6 Soft-Tissue Response to Facial Skeletal Changes
Willmot202 stresses that, in planning the profile response to mandibular surgery, one cannot rely on the soft-tissues of the lips and chin following the mandible posteriorly in a uniform 1:1 relationship. For this reason, the technique of cutting up photographs of the patient to trace the existing profile in
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a position equivalent to the bony change is inaccurate. Analyzing lip changes following mandibular retropositioning, the author202 concluded that the soft-tissue pogonion became less prominent in relation to the inferior labial sulcus, and deepening of the inferior labial sulcus was mainly due to forward movement of the labrale inferius, rather than actual deepening of the sulcus itself. Changes in total height of the lower lip from soft-tissue pogonion to labrale inferius were insignificant, but the distance between the inferior labial sulcus and the labrale inferius decreased a mean 1.8 mm. Hayes and associates206 quantified the changes seen in the cervicomental angle and the lip-chinthroat angles in response to mandibular advancement. The authors concluded that following mandibular advancement (1) the soft-tissue cervicomental angle and lip-chin-throat angle decreased; (2) a significant positive correlation exists between the changes in the soft-tissue cervicomental angle and the soft-tissue lip-chin-throat angle after mandibular advancement; (3) for each degree of reduction in the lip-chin-throat angle, the cervicomental angle decreases by 0.77; (4) a decrease of approximately 1.5 in the cervicomental angle can be expected for each 1 mm of mandibular advancement. Shelly and associates207 evaluated the changes in profile with mandibular advancement in 34 patients. Pre- and post-treatment cephalograms were used to generate silhouette images which were then graded by lay persons and orthodontic residents. All observers agreed on a consistent improvement in profile esthetics for patients with an initial ANB angle of 6 or greater. Improved profile esthetics were recorded only 50% of the time when the initial ANB angle was less than 6; the other 50% of patients were thought to be worse after surgery. The authors recommend that only patients with an initial ANB angle of at lest 6 be considered for mandibular advancement surgery. Hayes and colleagues206 also monitored hyoid bone positional changes in the study. Twenty-five years earlier, Schendel, Wolford, and Epker108 had noted that on surgical advancement of the mandible, the hyoid bone responded with a forward movement, but with time tended to return toward its preoperative position. Hayes et al206 confirmed that the hyoid bone moves toward the sella, nasion, and posterior nasal spine after mandibular advance-
ment surgery; the overall movement can be described as superior with a slight anterior component. Following an adaptive process that occurs at the bone-tendon interface,208 the hyoid tends to reside in a position close to its preoperative location. Marino and associates209 reported that the overall success of double-chin correction through softtissue surgery depends on the position of the hyoid bone. A hyoid bone that is located inferior to the 4th cervical vertebra tends to predispose the person to a less-than-ideal treatment result. Krekmanov and Kahnberg210 reviewed the softtissue response to genioplasty in 65 patients. Subjects were grouped according to the direction of chin movement: straight anterior (n=17); posterior (n=12); vertical reduction (n=19); or superioranterior (n=17) repositioning. The authors concluded that soft-tissue response was equal to bone movement during anterior repositioning but less predictable in the posterior direction or when combined with vertical reduction. However, patients who had vertical reduction of the mandible also showed soft-tissue movement equal to the amount of reduction, so that the horizontal relation between the soft-tissue and the skeletal pogonion did not change. Ewing and Ross 211 compared the soft-tissue response of mandibular advancement alone and combined with genioplasty. When mandibular advancement alone was performed, they found a consistent 1:1 ratio of soft- to hard-tissue advancement at the pogonion, and predictions could be accurate in both anterior-posterior and vertical directions. When a genioplasty was added to the advancement, however, the results were much less consistent: the mean ratio of soft-tissue to skeletal movement was .9:1 at the pogonion, but the average difference in movement between the soft tissues and the skeleton was approximately 3 mm. Thus when mandibular advancement is combined with genioplasty, it is impossible to predict the anterior-posterior soft-tissue changes that will follow with any degree of accuracy. Changes in vertical dimensions were also more marked when genioplasty was performed. The lower lip showed a variable response to surgery particularly in the genioplasty group, which had a mean 0.5:1 ratio of soft-tissue to skeletal change with a range of 4 mm in either direction. After genioplasty the soft tissue
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pogonion moved inferiorly relative to the underlying pogonion. The behavior of the lower lip was significantly different in the nongenioplasty and genioplasty cases. The lip thinned by 1.4 mm and 3.1 mm respectively, but there was wide variability in both groups.212 Van Sickels and colleagues213 studied the interplay between vertical and horizontal movement of the bony chin. The authors noted that the farther the chin was advanced, the less the soft-tissue followed the advancement. In addition, vertical movement of the chin greatly influenced the overall result. The more the bony chin is shortened, the thicker the soft-tissue chin becomes, and the reverse is true when the chin is lengthened. Finally, horizontal resorption/stability appears to be influenced by the amount of dissection, rather than the amount of advancement. Freihofer214 compared the soft-tissue response to Le Fort I osteotomy in cleft and noncleft patients and found no significant difference in the ratio of response between the two groups. Considerable individual variation was noted, however, and patients with thick fleshy lips seemed to have a less favorable soft-tissue response than those with thin lips. Because the soft-tissue response was about 50% that of the bony movement, it was frequently necessary to place the maxilla at an Angle Class II relationship to obtain the desired improvement in the profile. The author stresses the importance of preserving the nasal spine to gain the needed projection of the subnasale. Hack and others181 reviewed the long-term predictability of soft-tissue changes after Le Fort I surgery. The objectives of their study were to determine the stability of soft-tissue changes 5 years after Le Fort I osteotomy; to find reliable correlations, if any, of soft-tissue changes to bone movements; and to ascertain the predictability of softtissue change as an aid to orthodontic treatment planning. Analysis of the stability data revealed that most horizontal and vertical soft-tissue changes after Le Fort I surgery occurred in the first year after surgery. Significant (>10%) change continued to occur over the subsequent 4 years for subnasale, labrale inferius, upper lip protrusion, lower lip protrusion, and soft-tissue convexity. Reliable correlations of skeletal change at surgery to 5-year softtissue change could be made for 10 variables. The
authors felt that, given the relatively low reliability of long term correlations, it is possible that softtissue movements may become progressively independent of bony manipulations over time. Detailed and comprehensive tabulations of measurements for hard- and soft-tissue landmarks at three chronological points in the study are included in the article. Betts and associates215 looked specifically at changes in the nasal and labial soft-tissues in response to surgical repositioning of the maxilla. The authors emphasized alterations in this zone because accurate prediction of postoperative function and esthetics of the nose and upper lip requires an understanding of the relation between maxillary surgical movement and soft-tissue change. Multiple stepwise regression analyses were done on the data for 32 patients who were evaluated preoperatively and 1 year postoperatively. The variables examined were age, sex, and whether alar cinch suture, V-Y closure, or contouring of the anterior nasal spine had been performed. The authors concluded that accurate predictions could be made if the patients were grouped by vectorspecific maxillary movements. In general, the base of the nose widened in all patients regardless of the vector of surgical maxillary movement. Narrow noses widened more than did broad noses, and alar cinch suture widened the alar base even more. There was an associated shortening of the nose. The nasolabial angle decreased or remained constant in most patients, whereas the upper lip widened and lengthened at the philtral columns. The results indicate that soft-tissue changes associated with maxillary surgery may be affected more by the position of the soft-tissue incision and by the methods used in closure than by the surgically induced skeletal change. McCance and colleagues216 reviewed the softand hard-tissue changes after bimaxillary orthognathic surgery in 16 patients with skeletal Class III occlusion. Follow-up was at 1 year postoperatively. After a Le Fort I osteotomy there was commonly a 1:1 ratio of soft-tissue to bone movement in the midline, which increased to 1.25:1 at the alar bases and over the canine regions bilaterally. There was also a 1.25:1 or greater ratio over the chin and mentalis regions following mandibular setback.
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DENTAL EXTRACTION AND FACIAL FORM The possible effect of dental extractions on the development of the maxilla and mandible has been debated for years, particularly in the orthodontic literature. A team of investigators from Ann Arbor217 compared long-term outcomes of orthodontic treatment of Class II patients whose premolars had or had not been extracted. Patients were judged on six measures of protrusion and crowding of teeth and assigned to three prognostic groups: clear-cut extraction, clear-cut nonextraction, and an intermediate, borderline category. Some 15 years after treatment, 62 clear-cut patients (33 extraction and 29 nonextraction) were recalled and examined. They found that both groups underwent essentially the same change: decreased profile convexity and mandibular displacement mesially and anteroposteriorly. The authors offer a good discussion of the arguments pro and con dental extraction therapy, and based their study on the premise that, on the face of it, a reduction in the rate of premolar extraction would seem desirable. Detailed analysis of multiple cephalometric variables, however, led them to conclude that their findings failed to support the common belief that premolar extraction causes dished-in profiles, distalized mandibles, and craniomandibular dysfunction. Douglass and coauthors218 looked at cephalometric changes occurring in patients after 20 years of wearing complete dentures. They found a loss of vertical dimension on profile; the mandible was rotated in a counterclockwise fashion that resulted in increased prognathism; the maxillary alveolus was stable; the mandibular alveolus resorbed; and the dentures rotated counterclockwise and shifted forward slightly. From these observations, the reader may conclude that the effect of teeth on the function and anatomy of the maxillary and mandibular skeleton cannot be overlooked. COMPLICATIONS El Deeb, Wolford, and Bevis219 offer a thoughtful review of the complications of orthognathic surgery. Complications can be broken down into presurgical, surgical, and postsurgical occurrences. Significant presurgical complications may include a failure to remove maxillary and mandibular third molars prior to orthognathic surgery. The authors suggest that the third molars should be removed at
least 912 months before surgery so as to avoid undesirable splits or fracturing of mobilized segments. In addition, the authors point to the value of thorough planning for interdental cuts. This involves orthodontic manipulation to divert the tooth roots in order to provide access for the bone cuts. Minimal orthodontics is advocated when the tooth roots are short due to underdevelopment. The primary orthodontic goal of positioning teeth over basal bone is emphasized. Surgical complications include obstruction of the airway, edema, hemorrhage, infection, segment mobility, hypesthesia and paresthesia, and relapse. The use of rigid fixation eliminates the need for maxillary-mandibular fixation and significantly lessens the risk of airway problems. In Le Fort I maxillary surgery the vessels most commonly involved in bleeding complications include the posterior superior alveolar artery, descending palatine artery, anterior and posterior palatine arteries and veins, the pterygoid plexus, and the maxillary artery or its branches. In mandibular surgery the most frequently injured vessels are the inferior alveolar artery and vein, the facial artery and vein, the masseteric artery, the retromandibular vein, and the maxillary artery or any of its branches. Eight infections were reported in 600 cases of sagittal split osteotomy, reaffirming the value of prophylactic antibiotics. The most important contributing factors to wound infection in orthognathic surgery are contamination during and immediately following surgery, age of the patient, length of the surgical procedure, and avascular necrosis of bone. CT scans and MRI were useful in detecting infection early in the postoperative period. Nerve injury was most common in the mandible. The subcondylar vertical osteotomy was associated with a significantly lower incidence of neurosensory deficit than the sagittal split osteotomy. An 85% incidence of paresthesia was noted immediately after sagittal split osteotomy, which diminished to 9% by 1 year postoperatively. Prolonged paresthesia was most common in patients older than 40. Most often injured during sagittal split osteotomy was the inferior alveolar nerve, and the injury occurred primarily during medial retraction of the nerve when performing the medial horizontal osteotomy cut or upon completion of the sagittal split, when the nerve adheres to the proximal segment and is stretched. A fine spatulate chisel facili-
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tates bone splitting and lessens the risk to the inferior alveolar nerve. The authors also noted a decrease in maxillarymandibular opening following orthognathic surgery. This decrease was dramatic in patients treated by sagittal split osteotomy. The authors advocate routine preoperative clinical assessment of mandibular function and a systematic postoperative regimen of muscular and occlusal rehabilitation to normalize muscle function, condylar movement, and range of mandibular motion. A major cause of relapse after orthognathic surgery is secondary to unstable orthodontic movement, which essentially means that the teeth have been moved off the basal bone. Takeuchi, Furusawa, and Hirose220 investigated the mechanism of paresthesia associated with sagittal split mandibular ramus osteotomy. Using threedimensional computed tomography, the authors determined that the inferior alveolar neurovascular bundles remained intact during the sagittal osteotomy in all cases. On the basis of their CT analysis they concluded that one of the likely causes of sensory loss to the mental nerve is compression of the nerve trunk by the mandibular foramen, and this in turn results from posterior movement of the mandibular ramus. These conclusions were based on bone resorption seen in front of the foramen mandibulae and the distance from the foramen mandibulae to the spina mentalis. Loss of segments, loss of tooth viability, overimpaction, and fistula formation are also discussed. This article is recommended to all clinicians contemplating orthognathic surgery, as it stresses the importance of thorough anatomical knowledge and careful planning in the safe execution of craniofacial osteotomies.
CONCLUSION A systematic approach to the analysis of facial deformities is essential to state-of-the-art surgical results. The best plan of treatment must take into consideration the origin of the deformity and factors peculiar to these cases. Preoperative evaluation should involve a clinical analysis that emphasizes the relationships among existing structures and how they compare to established acceptable norms. These proportions should then be correlated with the bony morphology as seen in cephalometric testing. Reference points must be carefully evaluated and, if involved in the deformity, their position must be corrected to enable proper evaluation of the remaining parts. These measurements must then be correlated with a careful assessment of dental occlusion. No single system of analysis is applicable to all patients. The face-bow articulator lets the dental casts be arranged in space to duplicate the occlusal relationships of the patient. Exact model surgery can be performed, and the three-dimensional alterations between the upper and lower jaw can be visualized and computed. At this point analysis yields the movements needed to achieve the desired bony and soft-tissue changes. (These measurements may differ, however, and the clinical impression must take precedence.) The expected result of surgery is arrived at by translating the measured distances into mock surgical tracings after correcting for the ratio of response between the soft and hard tissues. Osteotomies can then be planned following traditional lines or incorporating modifications designed for specific adjustments of the bony framework.
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RECOMMENDED READING
Zide B, Grayson B, McCarthy JG: Cephalometric analysis for upper and lower midface surgery: part II. Plast Reconstr Surg 68:961, 1981. Zide B, Grayson B, McCarthy JG: Cephalometric analysis for mandibular surgery: part III. Plast Reconstr Surg 69:155, 1982. Okumura H, Chen L-H, Tsutsumi S, et al: Three-dimensional virtual imaging of facial skeleton and dental morphologic condition for treatment planning in orthognathic surgery. Am J Orthod Dentofac Orthop 116:126, 1999. Csaszar GR, Bruker-Csaszar B, Niederdellmann H: Prediction of soft tissue profiles in orthodontic surgery with the Dentofacial Planner. Int J Adult Orthod Orthognath Surg 14:285, 1999. Curtis TJ, Casko JS, Jakobsen JR, Southard TE: Accuracy of a computerized method of predicting softtissue changes from orthognathic surgery. JCO 34:524, 2000. Molina F, Ortiz Monasterio F, Aguilar MP, Barrera J: Maxillary distraction: aesthetic and functional benefits in cleft lip-palate and prognathic patients during mixed dentition. Plast Reconstr Surg 101:951, 1998. Cope JB, Samchukov ML, Cherkashin AM: Mandibular distraction osteogenesis: a historic perspective and future directions. Am J Orthod Dentofac Orthop 115:448, 1999. Van Sickels JE: Distraction osteogenesis versus orthognathic surgery (commentary). Am J Orthod Dentofac Orthop 118:482, 2000. Wolford LM, Karras SC, Mehra P: Considerations for orthognathic surgery during growth, Part 1: mandibular deformities. Am J Orthod Dentofac Orthop 119:95, 2001. Wolford LM, Karras SC, Mehra P: Considerations for orthognathic surgery during growth, Part 2: maxillary deformities. Am J Orthod Dentofac Orthop 119:102, 2001. Dryland Vig K, Ellis E 3rd: Diagnosis and treatment planning for the surgical-orthodontic patient. Clin Plast Surg 16:645, 1989. Kawamoto HJ Jr: Simplification of the Le Fort I osteotomy. Clin Plast Surg 16:777, 1989. Posnick JC, Tompson B: Modification of the maxillary Le Fort I osteotomy in cleft-orthognathic surgery: the bilateral cleft lip and palate deformity. J Oral Maxillofac Surg 51:2, 1993. Rosen HM: Aesthetic guidelines in genioplasty: the role of facial disproportion. Plast Reconstr Surg 95:463, 1995. Wider TM, Spiro SA, Wolfe SA: Simultaneous osseous genioplasty and meloplasty. Plast Reconstr Surg 99:1273, 1997. Costa F, Robiony M, Politi M: Stability of Le Fort I osteotomy in maxillary inferior repositioning: review of the literature. Int J Adult Orthod Orthognath Surg 15:197, 2000. Berger JL, Pangrazio-Kulbersh V, Bacchus SN, Kaczynski R: Stability of bilateral sagittal split ramus osteotomy: rigid fixation versus transosseous wiring. Am J Orthod Dentofac Orthop 118:397, 2000. Posnick JC, Dagys AP: Skeletal stability and relapse patterns after Le Fort I maxillary osteotomy fixed with miniplates: the unilateral cleft lip and palate deformity. Plast Reconstr Surg 94:924, 1994. Posnick JC, Tompson: Cleft-orthognathic surgery: complications and long-term results. Plast Reconstr Surg 96:255, 1995.
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9-24 Cran Anom I

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CRANIOFACIAL ANOMALIES I: CEPHALOMETRICS AND ORTHOGNATHIC SURGERY

Arshad R Muzaffar MD and John Flood FRACS

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Table 2 Horizontal Midface Analysis

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Table 3 Frontal Soft- and Hard-Tissue Assessment

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Table 4 Reported Osteodistraction Parameters for Mandibular Lengthening and Widening

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Fig 19. Management options in mandibular prognathism.

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Fig 20. Management options in Class II mandibular retrognathia.

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Table 5 Relapse Following Genioplasty by Anterior Horizontal Osteotomy

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complications that might ensue from alloplastic genioplasty and osteotomies.

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a recessed chin increased facial height primarily in the lower

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13. 14. 15. 16.

17. 18. 19. 20. 21. 22. 23. 24. 25.

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70. 71. 72. 73. 74. 75.

77. 78. 79.

80. 81. 82. 83. 84. 85. 86. 87. 88.

65. 66. 67.

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95. 96. 97. 98. 99. 100. 101.

102. 103. 104. 105.

106. 107. 108.