CLINICIAN'S CORNER

Correction of facial asymmetry and maxillary

canting with corticotomy and 1-jaw orthognathic
surgery
Hyo-Won Ahn,a Dong Hwi Seo,b Seong-Hun Kim,c Baek-Soo Lee,d Kyu-Rhim Chung,e and Gerald Nelsonf
Seoul and Suwon, Korea, and San Francisco, Calif
Although 2-jaw orthognathic surgery is a typical recommendation for the treatment of facial asymmetry, another
good treatment alternative is maxillary corticotomy with temporary skeletal anchorage devices followed by
mandibular orthognathic surgery. The corticotomy procedure described here can achieve unilateral molar intrusion and occlusal plane canting correction with potentially fewer complications than 2-jaw orthognathic surgery.
The approach allows movement of dentoalveolar segments in less time than with conventional dental intrusion
using temporary skeletal anchorage devices. A 2-jaw asymmetry with occlusal plane canting might be corrected
using maxillary corticotomy and mandibular orthognathics rather than 2-jaw orthognathics. Two patients with
facial asymmetry are presented here. In each one, the maxillary cant was corrected over a period of 2 to 3 months
with 3.5 mm of intrusion of the unilateral buccal segment. After the preorthognathic cant correction, orthognathic
surgery was done to correct the mandibular asymmetry. (Am J Orthod Dentofacial Orthop 2014;146:795-805)

acial asymmetry is one reason that patients seek orthognathic surgery combined with orthodontic
treatment. Common features of facial asymmetry
include a mandibular deviation to the right or left that increases gradually from the upper to the lower face. This is
usually associated with a cant of the maxilla and the
maxillary occlusal plane.1 Severt and Proft2 reported
that the frequencies of facial asymmetry are 5%, 36%,
and 74% in the upper, middle, and lower thirds of the
face, respectively. In such cases, dramatic improvement

a
Assistant professor, Department of Orthodontics, College of Dentistry, Kyung
Hee University, Seoul, Korea.
b
Postgraduate student, Department of Orthodontics, College of Dentistry, Kyung
Hee University, Seoul, Korea.
c
Associate professor and chair, Department of Orthodontics, College of Dentistry,
Kyung Hee University, Seoul, Korea.
d
Professor, Department of Oral and Maxillofacial Surgery, College of Dentistry,
Kyung Hee University Medical Center, Seoul, Korea.
e
Professor and chair, Department of Orthodontics, School of Medicine, Ajou University, Suwon, Korea.
f
Clinical professor and interim chair, Division of Orthodontics, Department of Orofacial Science, University of California at San Francisco, San Francisco, Calif.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported.
Supported by the National Research Foundation of Korea funded by the Korea
government (MEST) (number 2012R1A5A2051388).
Address correspondence to: Seong-Hun Kim, Department of Orthodontics, College of Dentistry, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul
130-701, Republic of Korea; e-mail, bravortho@gmail.com.
Submitted, August 2013; revised and accepted, August 2014.
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.08.018

of facial balance comes with surgery to the mandible.

Correction of the maxillary cant is usually a prerequisite.
Consequently, correction typically includes a combination of LeFort I osteotomy and bilateral sagittal split
ramus osteotomy.3
Case reports have been published demonstrating
nonorthognathic correction of the maxillary cant
before orthognathic surgery.4,5 Posterior bite-blocks
or high-pull headgear has been used to intrude the molars conventionally. Both of these methods require signicant patient cooperation. With either method, it is
difcult to control the direction and quantity of tooth
movement.6,7 With the advent of temporary skeletal
anchorage devices (TSADs), orthodontic molar
intrusion and occlusal plane canting correction have
been
reported,
with
minimal
surgical
intervention.4,5,8,9 Kang et al4 introduced a rhythmic
arch system using TSADs and obtained a considerable
amount of canting correction. Jeon et al5 reported
correction of mandibular prognathism with mandibular
surgery only, correcting the maxillary asymmetry by
intrusion of the maxillary molars unilaterally using
TSADs. However, the treatment times were extended,
increasing the risk of side effects.10
Since K
ole11 suggested clinical applications of corticotomy in 1959, various technical advancements have been
reported.12-15 One is orthopedic force application against
intraosseous anchorage after corticotomy.14,15 A heavier
force is applied than the orthodontic force because the
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Fig 1. A and B, Palatal and C and D, buccal corticotomy with piezosurgery (SONIC SURGEON 300;
Dong Il Technology, Hwasung, Korea); E and F, application of miniplates for intrusion of the posterior
segment.

aim of this technique is not tooth movement through the

bone but rather bony block movement by compression
osteogenesis.12,16 If the cortical layer of the basal and
alveolar bone is removed, medullary bone can be bent
by traction force.14
We have called the combination of corticotomy
and orthopedic force application using TSADs speedy
surgical orthodontics (SSO).14,15 By using this
protocol, correction of a signicant facial asymmetry
can be achieved with single-jaw surgery. Omitting
the corticotomy element means slower correction
and lacks the correction of the supporting bone that
corticotomy allows. This report includes 2 patients
who demonstrate the clinical application of correcting
an occlusal plane cant with corticotomies and orthopedic force.
Overerupted maxillary molars and premolars are rst
passively splinted with a prefabricated bondable splint.
This splint consists of a 0.036-in stainless steel wire

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with a power arm extension, soldered to mesh-backed

pads. Bonding these splints to the buccal and palatal aspects of the teeth stabilizes the teeth as 1 unit. The corticotomy procedure can be done after the teeth are
stabilized.
The corticotomies were performed in 2 stages to
ensure a good blood supply. The rst was done on the
palatal side. The second was done 2 weeks later on the
buccal side (Fig 1).
For the palatal corticotomy, a ap was elevated in the
regions of the maxillary premolars and molars after a
sulcular incision. A vertical corticotomy using piezosurgery and a round bur with a slow-speed hand piece was
performed between the rst premolar and the second
premolar with care not to damage the root apices. A horizontal corticotomy was next, 3 mm above the root apex
from the premolars to the distal aspect of the
second molar. A second vertical corticotomy was performed distal to the second molar up to the alveolar crest

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Fig 2. Pretreatment extraoral and intraoral photographs of patient 1.

(Fig 1, A and B). The ap was closed, followed by a

2-week healing period.
The buccal corticotomy was combined with placement of the TSADs and extraction of the maxillary rst
premolar (part of the treatment plan to resolve crowding). The palatal corticotomy outline is similar to that
on the buccal aspect (Fig 1, C and D). On the midpalatal
area, a miniplate with 2 horizontal arms (Jin Biomed,
Bucheon, Korea) that were oriented toward the target
teeth was implanted on the midpalatal area for palatal
intrusion. Flap surgery was not necessary because the
soft tissues on the midpalatal area were thin (Fig 1, E).
On the buccal side between the rst and second molar
areas, we placed an I-shaped titanium C-tube plate,
with 2 anchoring holes and a 0.036-in diameter tubeshaped head, to serve as the point of orthodontic force
application (Fig 1, F). With elastic chain, 500 g of force
was applied to intrude the posterior segment immediately after the perisegmental corticotomy. At the same
time, the maxillary canine was retracted into the extraction site (Fig 1, F).

PATIENT 1

A 15-year-old girl came to the Kyung Hee dental hospital in Seoul, Korea, with the chief complaint of facial
asymmetry. She had a straight lateral prole, mesognathic facial type, eye-level canting (right side down),
lip-line canting (right side high), chin deviation to the
right, and an acceptable display of her maxillary anterior
teeth (Fig 2, A). The intraoral photographs showed an
Angle Class I malocclusion, severe anterior crowding,
an ectopically positioned maxillary left canine, a
mandibular dental midline discrepancy to the right,
and transverse compensation of the maxillary and
mandibular molars (Fig 2, B).
The cephalometric analysis indicated a hyperdivergent skeletal pattern (FMA, 32.8 ), normal relationships
of the maxilla (SNA, 80.7 ) and the mandible (SNB,
77.9 ), maxillary occlusal plane cant (left side down),
menton deviation to the right side (7.0 mm), and upright
maxillary and mandibular incisors (U1-FH, 108.2 ;
IMPA, 81.9 ) (Fig 3 and Table). Although her condyle
was thin and narrow, especially on right side, there

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Table. Cephalometric survey of patient 1

Measurement
Mean SD Pretreatment Posttreatment
Skeletal-horizontal
SNA ( )
81.6 3.2
80.7
80.7
SNB ( )
79.2 3.0
77.9
76.1
2.5 1.8
2.8
4.6
ANB ( )
Skeletal-vertical
PFH/AFH (%)
66.8 4.3
59.9
58.1
FMA ( )
25.4 4.6
32.8
36.4
17.9 3.8
21.2
24.6
SN-OP ( )
SN To PP ( )
10.2 3.2
9.8
10.0
Dental
FH-UI ( )
116.0 5.7
108.2
116.5
IMPA ( )
95.9 6.4
81.9
88.9
Interincisal angle ( ) 123.8 8.3
137.0
117.9
FMIA ( )
59.8 7.2
65.2
54.5
Soft tissue
Nasolabial angle ( )
93.2 8.0
97.2
96.1
UL-E plane (mm)
-0.9 2.2
-1.7
-0.2
LL-E plane (mm)
0.6 2.3
-0.7
0.7

Fig 3. Pretreatment posteroanterior cephalogram of

patient 1.

was no clinical symptom of temporomandibular disorder

or a centric occlusion-centric relation discrepancy. On
the axial cut of the cone-beam computed tomography
(CBCT) images (Alphard Vega; Asahi Roentgen, Kyoto,
Japan), the vertical height difference of the buccal
cusp tips between the maxillary left and right rst molars
was about 3.5 mm, and both buccal cusp tips had
abnormal torque because of the transverse compensation (Fig 4, A). The torque would be evaluated after
the cant correction. Accordingly, the diagnosis was a
Class I skeletal relationship, steep mandibular plane
angle, facial asymmetry, and severe crowding.
The treatment objectives were correction of the facial
asymmetry, elimination of crowding of the maxillary and
mandibular dentition, and establishment of a normal
occlusion. The canting extended to the orbit, correction
of which was not part of the treatment plan. We set a
goal to correct the facial asymmetry below the LeFort I
level and initially planned 2-jaw surgery. However, the
patient wanted to minimize the expense and scope of
the surgical intervention. Fortunately, she had a normally positioned maxilla anteroposteriorly and a dental
midline coincident with the facial midline. The alternative plan she selected was a bilateral sagittal split ramus
osteotomy after SSO maxillary cant correction with a
unilateral corticotomy. Because the maxillary incisors
were upright and the maxillary left canine was blocked,
the plan included unilateral extraction of the left rst
premolar. Corticotomies on both sides were performed

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as described, and an orthopedic intrusion force was

immediately applied.
In 3 months, intrusion of the maxillary left posterior
segment was complete. To prevent extrusion of the
opposing teeth, a resin bite-block was added on the
left mandibular molars. CBCT scans and superimposition
of the cephalograms conrmed 3.5 mm of intrusion of
the maxillary left molars (Fig 4, B). The buccal and
lingual bonded mesh appliances were removed, and
brackets (Quicklear; Forestadent, Pforzheim, Germany)
were placed on the maxillary teeth for further leveling
and alignment. Cross elastics were used between the
TSADs on the maxillary arch and the mandibular molars
for transverse decompensation.
After the preoperative orthodontic treatment, the
midline of the maxillary dentition coincided with the
facial midline, and the maxillary occlusal canting and
the transverse decompensation were corrected (Figs 5
and 6). An asymmetric mandibular setback was then
performed with bilateral sagittal split ramus osteotomy.
Orthodontic treatment was resumed 6 weeks postsurgery and was completed after 5 months. The total
active treatment period was 22 months. At debonding,
the extraoral photographs showed a distinct improvement of the facial symmetry and a beautiful smile
line (Fig 7, A). The single-jaw surgery alone achieved
good facial symmetry even in the middle face level. In
the maxilla, the facial gingival line showed mild asymmetry because of the gingival height of the maxillary
left canine. The maxillary left canine was positioned
higher before treatment and moved signicantly both
downward and in a distal direction after unilateral
extraction of the rst premolar; this might have been

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Fig 4. Comparison between A, pretreatment and B, after-intrusion axial images of the maxillary left
posterior segment of patient 1. In 3 months, 3.5 mm of intrusion of the maxillary left molars was
achieved, and the molar compensation was corrected.

Fig 5. Preorthognathic surgery extraoral and intraoral photographs of patient 1.

responsible for the difference in crown length. The

dental midlines of the maxilla and the mandible coincided with the facial midline. A Class I functional occlusion with ideal overjet and overbite was obtained (Fig 7,

B). No signicant root resorption was evident in the

panoramic radiograph. The posttreatment lateral cephalometric analysis and superimposition showed good
inclination of the maxillary and mandibular incisors

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800

Fig 6. Preorthognathic surgery posteroanterior cephalogram of patient 1.

(U1-FH, 116.5 ; IMPA, 88.9 ) and a favorable maxillomandibular relationship (Fig 8). The occlusal plane was
greater by 3 than before treatment (SN-OP, 21.2 to
24.6 ). The treatment results were well maintained at
8 months after debonding (Fig 9).
PATIENT 2

A 21-year-old man came with a chief complaint of

facial asymmetry. He had a normal skeletal relationship
of the maxilla anteroposteriorly. The occlusal planes
were canted down on the right side. Moderate anterior
crowding was observed, with a superiorly positioned
canine on the extruded side (Fig 10). Similar to the previous patient, a corticotomy of the maxillary right segment
and extraction of the right rst premolar were performed.
The right posterior segment was successfully intruded by
3.5 mm over 2 months (Figs 10, D-F, and 11). After
10 months, the transverse dental compensation was
resolved, and single-jaw surgery was done (Fig 12).
DISCUSSION

The 3-dimensional morphologic variety of facial

asymmetry characteristics generates many subtypes.17,18
Precise and accurate diagnosis and surgical treatment
planning are important to address the underlying
causes of a facial asymmetry. The clinician will
evaluate the asymmetry of the upper third of the face
(orbital dystopia) to determine whether it will be
included in treatment planning. In the mandible, one
can see various degrees of menton deviation, frontal

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ramal inclination, gonion canted toward the

midsagittal plane, and arch-form discrepancies.19 Skeletal asymmetry problems in the maxilla are much less
frequent or complex than in the mandible, where the degree of asymmetry tends to increase with greater distance from the cranium.19
Case selection is critical when considering a maxillary
corticotomy (SSO) combined with single-jaw surgery in
patients with facial asymmetry. The maxillary deformity
should be limited to canting. If sagittal, transverse, and
bilateral vertical maxillary skeletal corrections are necessary, then SSO would not be an option. After the corticotomy is completed, the outcome should be a normal
orientation of the occlusal plane and an acceptable
mandibular function.
The goals of the orthodontic-corticotomy phase
before orthognathic surgery are to correct the cant, eliminate the transverse dental compensation, and align the
teeth to their proper positions.20 For the cant correction,
the clinician will analyze the differential force applications between the buccal and palatal sides. With careful
planning, torque control can be achieved simultaneously
with intrusion. Without such precise treatment planning
of the SSO phase, the result can be an extended treatment time.
What are the benets of SSO when compared with 2jaw surgery? After 2-jaw orthognathic surgery, the patient may experience a longer and more uncomfortable
healing period, a change in the alar base, and a period
of restricted nasal breathing. The corticotomy procedure
presented here requires 2 in-ofce surgical approaches,
under local anesthesia, and takes about 30 minutes.
Postsurgical healing is less eventful. Corticotomy has
been used as an alternative method to orthognathic surgery or conventional orthodontics in borderline cases of
adults.11,14 By removing the cortical layer, tooth
movement is faster, and less root resorption is
expected compared with conventional orthodontic
intrusion.21 As Suya12 explained in corticotomy-facilitated orthodontics, the tooth has a role as a handle
when bands of medullary bone move as a block. Tooth
movement after corticotomy is primarily bony block
movement rather than individual tooth movement. Histologic study with dogs showed that the appearance of
necrotic tissue that was called hyalinization was
restricted to 1 week in the corticotomy group, instead
of lasting 4 weeks in the orthodontic movementonly
control group.22 This quick removal of hyalinization tissue can be explained by the regional acceleratory phenomenon.
Corticotomy is associated with a reduced chance of
root damage during surgery. Note that the amount of
canting correction is not limited to the width of

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Fig 7. Posttreatment extraoral and intraoral photographs of patient 1.

corticotomy. It is preferable to remove the cortical layer

as much as the planned intrusion to facilitate compressive osteogenesis. However, intrusion up to 6 mm has
proved to be clinically acceptable.14,16 Two-jaw surgery
achieves impaction without additional dental intrusion,
but there is a limit to how much impaction is possible.
With a corticotomy, not only does a wide path of cortical
plate removal provide bone block, but also the additional
dental intrusion allows for more cant correction than orthognathics could achieve. The TSAD anchors include a
C-tube in the buccal posterior maxilla or zygomatic
buttress and a miniplate in the midpalatal suture. These
devices work together to provide compression osteogenesis and intrude the posterior fragment.23 Orthopedic
intrusion with a corticotomy (SSO) permits rapid repositioning of the dental segments.24 The regional accelerated phenomenon during compression accelerates the
completion of the treatment.
Many studies of orthodontic intrusion with TSADs
have reported complications such as root resorption

or extended treatment time.21,22 Corticotomyinduced compression osteogenesis by orthopedic

traction produced faster tooth movement and consequently a reduced risk of root resorption.21,25 In the
patients presented here, 3.5 mm of intrusion was
achieved in 2 to 3 months. The root lengths of the
maxillary rst and second premolars and the rst
molar were evaluated between pretreament and
after-intrusion with CBCT (Invivo5 software;
Anatomage, San Jose, Calif). The palatal root of the
rst molar was shortened by 2.4 mm in patient 1. All
other root lengths were shortened less than 1 mm. A
signicant amount of intrusion was achieved during
a relatively short time without notable root resorption.
The miniplate is more suitable than the mini-implant
for SSO because of the heavier force requirements (250 g
per each side). For the palatal area, implantation of the
miniplate in the midpalatal area is recommended. The
thinner soft tissue layer and thicker cortical bone depth
provide better initial stability than would the palatal

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Fig 8. A, Posttreatment superimposition between the pretreatment and nal cephalometric tracings; B,
the posteroanterior cephalogram; and C, the panoramic radiograph of patient 1.

slope. No nerves or vessels pass through this area. On the

buccal side, the skeletal anchorage is positioned at
least 2 to 3 mm above the horizontal corticotomy line
to avoid the area of active bone remodeling and obstacles such as dilacerated roots, an expanded maxillary
sinus, or a severe alveolar ridge resorption.26 The miniplate can also be used for distalization of the whole
dentition or canine retraction, without the need of additional TSADs.
One important issue regarding occlusal canting
correction is stability. Proft et al27 demonstrated
that vertical asymmetry correction by surgery of the

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maxilla is quite stable. Others also reported that maxillary stability after LeFort I osteotomy for cant correction does not differ from that for maxillary
advancement.28 There have been no long-term studies
about the stability of orthodontic intrusion with TSADs
for the treatment of canted occlusal planes. There are
limited data on the correction of anterior open bite.
Lee and Park29 reported a 10.4% relapse rate for the
intruded maxillary molars and an 18.1% relapse rate
for overbites at 1 year posttreatment. Baek et al30
also reported a 22.9% relapse rate for intruded maxillary molars and a 17.0% relapse rate for overbites at

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Fig 9. Eight-month retention extraoral and intraoral photographs of patient 1.

Fig 10. Intraoral photographs of patient 2: A-C, on the day of corticotomy; D-F, after intrusion.

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Fig 11. Comparison between A, pretreatment and B, after-intrusion axial images of the maxillary right
posterior segment of patient 2. In 2 months, 3.5 mm of intrusion of the maxillary right molars was
achieved.

Fig 12. Posteroanterior cephalograms: A, pretreatment, B, after intrusion, and C, after 1-jaw orthognathic surgery of patient 2. The midsagittal reference line, maxillary occlusal plane, and menton deviation are shown.

3 years posttreatment. There are no long-term data on

the stability of maxillary posterior impaction with corticotomy. Corticotomy is expected to be more stable
than conventional orthodontic intrusion because it is
considered bony block movement rather than individual tooth movement only. Further studies will be useful
on the effects of various force intervals after corticotomy and its long-term stability.
CONCLUSIONS

Maxillary corticotomy combined with TSADs (SSO)

achieved unilateral molar intrusion and occlusal plane
canting correction. It is a potentially less expensive,
in-ofce alternative to cant correction with 2-jaw

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orthognathic surgery. In selected patients with facial

asymmetry, maxillary cant correction with maxillary corticotomy combined with TSADs can allow a 1-jaw surgery treatment plan that would otherwise require
2-jaw orthognathic surgery.
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American Journal of Orthodontics and Dentofacial Orthopedics

December 2014  Vol 146  Issue 6