Assessment of Patients for Orthognathic

Surgery
L' TanyaJ. Bailey, William R. Proffit, and Raymond White, Jr
Ra pi d a d v a n c e s i n o r t h o g n a t h i c s u r g e r y n o w a l l o w t h e cl i ni ci an t o t r e a t
s e v e r e d e n t o f a c i a l d e f o r mi t i e s t h a t w e r e onc e o n l y ma n a g e a b l e by o r t h o d o n -
t i c c a mo u f l a g e . T h e s e cases w e r e o f t e n c o mp r o mi s e d w i t h u n a c c e p t a b l e
f aci al e s t he t i c s a nd u n s t a b l e occl usal r esul t s. Ov e r t h e pa s t 25 year s, t h e r e
h a v e be e n n u me r o u s i mp r o v e me n t s i n t e c h n o l o g y a n d t h e sur gi cal ma n a g e -
m e n t of d e n t o f a c i a l d e f o r mi t i e s . T h e s e p r o g r e s s i o n s n o w a l l o w mo r e pr e di c t -
a b l e sur gi cal o u t c o me s , wh i c h e n s u r e p a t i e n t s a t i s f a c t i on. N o t al l p a t i e n t s
ar e c a n d i d a t e s f or sur gi cal t r e a t me n t ; t h e r e f o r e , p a t i e n t a s s e s s me n t and
s e l e c t i on r e ma i n s p a r a mo u n t i n t h e pr ocess of d i a g n o s i n g a nd t r e a t m e n t
p l a n n i n g f o r t hi s t y p e of i r r e v e r s i b l e t r e a t me n t . T h e i nc l us i on of p a t i e n t s i n
t h e d e c i s i o n - ma k i n g pr ocess i ncr eases t h e i r a wa r e n e s s a nd a c c e p t a n c e of
t h e f i nal r esul t . T h e pa s t t h r e e d e c a d e s i n d i c a t e an i nc r e a s e d u s a g e of
o r t h o d o n t i c t r e a t m e n t by b o t h c hi l dr e n a nd a dul t s . P a t i e n t d e mo g r a p h i c
pr of i l e s f o r s e v e r e occl usal a n d f aci al c ha r a c t e r i s t i c s ar e p r e s e n t e d i n an
e f f or t t o u n d e r s t a n d t h e e p i d e mi o l o g i c a l f a c t or s of ma l o c c l u s i o n a nd p r e d i c t
t h e p o p u l a t i o n ' s ne e d f o r t hi s ser vi ce. ( S e mi n O r t h o d 1999; 5: 209- 222. ) Copy-
right 1999 by W.B. Saunders Company
T
r e me ndous advances in t he ar ea of or t hog-
nat hi c s ur ger y have oc c ur r e d over t he past
25 years. Rapi d advances in surgical t echnol ogy
have ma de it possible to successfully t r eat pa-
tients f or whom or t hodont i c camouf l age was
once t he onl y me t h o d of t r eat i ng a dent of aci al
deformi t y, whi ch of t en r esul t ed in est het i cal l y
unaccept abl e and, qui t e of t en, unst abl e results.
Several fact ors may i ndi cat e t he ne e d f or or t hog-
nat hi c surgery. They of t en pr es ent as i mpai r ed
mast i cat i on and t e mpr oma ndi bul a r pai n and
dysfunct i on, as well as susceptibility to caries and
per i odont al disease ( because of t he difficulty
mai nt ai ni ng oral hygi ene when t eet h are severely
p r o t r u d e d and i r r egul ar ) . One of t he most
i mpor t a nt fact ors t hat is of t en over l ooked is t he
psychosoci al ef f ect f r om t he unes t bet i c appear -
From the Departments of Orthodontics and Oral and Maxillofa-
cial Surgery, University of North Carolina-Chapel Hill School of
Dentistry, Chapel Hill, NC.
Address carrespondence to L'ThnyaJ. Bailey, DDS, MS, Associate
Professor; UNC-Chapel Hill School of Dentistry, Department of
Orthodontics, Chapel Hill, NC 27599-7450.
Copyright 1999 by W.B. Saunders Company
1073-8746/99/0504-0002510. 00/0
ance of a severe mal occl usi on. Pr ope r pat i ent
sel ect i on r emai ns t he pr i mar y f act or r esul t i ng i n
successful t r eat ment out come.
It is ext r emel y i mpor t a nt t hat t he cl i ni ci an
does not over l ook t he i mpor t a nc e of i ncl udi ng
t he pa t i e nt a nd par ent s i n t he t r e a t me nt -
pl anni ng process. Acker man and Proffit I sug-
gest ed t he cl i ni ci an is gener al l y mor e i nf l uenced
by obj ect i ve fi ndi ngs (ie, t he pr obl e m list),
wher eas pat i ent s are mor e i nf l uenced by subjec-
tive fi ndi ngs (ie, t hei r per cept i on of t hei r needs
a nd values). Thi s di chot omy makes effective
c ommuni c a t i on an essent i al t ool when one is
f aced with t he deci si on bet ween or t hodont i c
camouf l age or sur gi cal - or t hodont i c cor r ect i on.
The mo d e r n c onc e pt of pat i ent a ut onomy versus
pat er nal i sm in or t hodont i c t r eat ment pl anni ng
shifts t he r ol e of t he doc t or f r om t he sole
deci si on ma ke r in t he t r eat ment - pl anni ng pro-
cess t oward i ncl usi on of t he pat i ent as co-deci si on
maker.
The pat i ent - par ent c onf e r e nc e shoul d i ncl ude
t he following t hree component s: (1) a descr i pt i on
of t he pr obl e m list by t he or t hodont i st . The
pat i ent shoul d have i nput on t he pr i or i t i zat i on
Seminars in Orthodontics, kb/5, No 4 (December), 1999: pp 209-222 209
210 Bai l ey, Pr of f i t , a n d W h i t e
of t he p r o b l e m list, (2) a revi ew of t he r i s k/
benef i t cons i der at i ons mus t be pr es ent ed. The
mer i t s of each t r e a t me nt al t er nat i ve s houl d be
given, i ncl udi ng t he cons i der at i on of no t reat -
me n t as an opt i on becaus e mos t or t hodont i c
t r e a t me nt is el ect i ve, a nd (3) cons i der at i on of
t he pat i ent ' s expect at i ons a nd val ues is of par a-
mo u n t i mpor t a nc e . I n f o r me d cons ent r equi r es
not onl y obt ai ni ng t he pat i ent ' s per mi s s i on to
t r eat af t er havi ng expl ai ned t he risks, but also a
di al ogue bet ween t he cl i ni ci an a nd pat i ent in
deci di ng on t he fi nal t r e a t me nt pl an. I t is i mpor -
t ant t hat t he pa t i e nt a nd doc t or c o n mmn i c a t e
openl y a bout t he deci s i on- maki ng pr ocess be-
cause t he pat i ent ' s pe r c e pt i on of t he p r o b l e m is
not always t he s ame as t he doc t or ' s under s t and-
i ng of t he issue. 2
Ac k e r ma n a nd Proffi t 3 f ur t he r r e c o mme n d
t hat t he cl i ni ci an does not i gnor e t he l i mi t at i ons
of t he soft tissues in gui di ng t he t r eat ment -
pl a nni ng process. They suggest t hese soft tissue
const r ai nt s involve several ar eas of concer n: (1)
t he pr essur es e xe r t e d on t he t eet h by t he lips,
cheeks, a nd t ongue ar e a p r i ma r y d e t e r mi n a n t
of stability, (2) t he pe r i odont a l a t t a c hme nt appa-
r at us is a f unda me nt a l cons i der at i on in oral
heal t h, (3) t he t e mp r o ma n d i b u l a r mus cul ar and
connect i ve tissue c o mp o n e n t s have a maj or r ol e
in f unct i on, a nd (4) t he soft tissue i n t e g u me n t of
t he ent i r e face de t e r mi ne s esthetics. Cephal omet -
ric val ues gui di ng t he posi t i on of t he i nci sors are
r est r i ct ed by racial, et hni c, a nd p r e t r e a t me n t
posi t i ons; t hus, or t hodont i c t r e a t me nt s houl d
r ef l ect t he a mo u n t of i nci sor c ha nge t hat woul d
occur rel at i ve to stability becaus e t he pr et r eat -
me n t posi t i on likely refl ect s t he soft tissue i nfl u-
ences. Thes e i nvest i gat ors also suggest t hat an-
t e r opos t e r i or expans i on of t he i nci sors by mo r e
t han 2 mm or t r ansver se expans i on by mo r e t han
4 or 5 mm will likely be unst abl e. I f macr ogl os s i a
exists, t her e is t he possi bi l i t y const r i ct i on of t he
l ower ar ch to close spaces woul d not be mai n-
t ai ned.
Pr evi ous gui del i nes have be e n publ i s hed out -
l i ni ng t he r el at i ons hi p bet ween t he pe r i odon-
t i um and or t hodont i c t r eat ment . 4,5 Gingival reces-
si on a nd dehi s cence of t he al veol ar b o n e may
occur wi t h or t hodont i c e xpa ns i on when t he
at t ached gi ngi va is t hi n, especi al l y whe n accom-
pa ni e d by pl aque a c c umul a t i on a nd i nf l amma-
t i on. I f t her e is i na de qua t e at t ached gingiva,
gi ngi val gr af t i ng of t he ar ea is r e c o mme n d e d to
avoi d recessi on.
Cont r over sy cont i nues r egar di ng t he exact
p l a c e me n t of t he condyl es wi t hi n t he fossae;
however, it is gener al l y a gr e e d t hat t r e a t me nt
t hat di spl aces t he condyl es mo r e t han a smal l
di st ance f r om t hei r mos t r el axed r e t r ude d posi-
t i on i ncr eases t he pot ent i al f or r el apse t owar d a
mo r e c omf or t a bl e l ocat i on. 6,7
The n u mb e r of pot ent i al sur gi cal - or t hodont i c
pat i ent s has be e n elusive. The f ocus of t he
r e ma i ni ng di scussi on pr ovi des gui del i nes to t he
l i mi t s of or t hodont i c t her apy and t he r e f or e t he
i ndi cat i ons f or or t hogna t hi c surgery, as pr eci sel y
as possi bl e, wi t h est i mat es on how ma n y pat i ent s
in t he US popul a t i on woul d r equi r e surgi cal
t r e a t me nt bas ed on t hese gui del i nes.
Indi cati ons for Surgical-Orthodontic
Treatment
I f t he pat i ent has a mal occl us i on wi t h a good
skel et al j aw r el at i onshi p, or t hodont i c t oot h move-
me n t al one is usual l y suffi ci ent to cor r ect a
cr owded and i r r egul ar dent i t i on. Ac ke r ma n a nd
Proffi t ~ cl earl y del i neat ed t he est het i c gui del i nes
t hat s houl d be us ed when eval uat i ng t he soft
tissue i nt egument . Thes e i nvest i gat ors suggest:
1. Pr ot r act i on of t he i nci sors woul d be pr ef er -
abl e in a pat i ent wi t h a l ar ge nos e or chi n,
pr ovi di ng t her e woul d not be excessi ve deep-
eni ng of t he ment ol abi al fol d.
2. Or t hodont i c s al one can r ar el y c or r e c t severe
mi df ace def i ci ency or ma ndi bul a r pr ogna-
t hi sm becaus e t hese two condi t i ons of t en ar e
a c c o mp a n i e d by unes t het i c lip posi t i on and
neck f or m.
3. Moder at e a mount s of ma ndi bul a r def i ci ency
ar e of t en accept abl e to pat i ent s, al t hough t he
or t hodont i s t mi ght pr e f e r mo r e p r o mi n e n c e
of t he l ower face.
4. Maxi l l ar y i nci sors s houl d never be r et r act ed
to t he poi nt t hat t he i ncl i nat i on of t he u p p e r
lip be c ome s negat i ve to a t r ue vert i cal line.
5. Pr ot r us i on of t he i nci sors is excessi ve and
unes t het i c i f t he pr ot r udi ng t eet h cause lip
s epar at i on gr e a t e r t han 4 mm at r est and lip
st rai n to gai n lip seal cr eat es an i l l -defi ned
ment ol abi al sulcus, a nd or t hodont i c ret rac-
t i on of t he pr ot r udi ng i nci sors is i ndi cat ed.
Assessment of Orthognathic Surgery Patients 211
6. Ove r r e t r a c t i on of t he maxi l l ar y i nci sors of t en
tilts t he oecl usal pl ane down ant eri orl y, creat -
i ng an excessi ve di spl ay of gingiva, whi ch is
cons i der ed unest het i c. Pat i ent s do not mi nd
i f onl y mo d e r a t e a mount s of gi ngi va show on
smile.
7. Whe n t he l ower lip is t r a ppe d u n d e r t he
maxi l l ar y i nci sors (as in cases of excessi ve
overj et ) or when t he ma ndi bul a r i nci sors have
b e e n excessively pr ocl i ned (as in camouf l age
of skel et al Class I I mal occl usi ons) , t he result-
i ng lip posi t i on is unaccept abl e.
8. Lack of a ver mi l i on b o r d e r (whi ch of t en
resul t s f r om a concave pr of i l e wi t h t hi nni ng
of t he u p p e r lip) is not desi r abl e. Toot h
mo v e me n t t hat pr ocl i nes t he i nci sor woul d
cr eat e an est het i cal l y f ul l er lip.
9. Ext r e me bi l abi al pr ot r us i on is gener al l y per-
cei ved as unaccept abl e, r egar dl ess of raci al or
et hni c gr oup.
Most cl i ni ci ans agr ee t he basi c i ndi cat i on f or
s ur gi cal - or t hodont i c t r e a t me nt is a skel et al pr ob-
l em of such severi t y t hat accept abl e c or r e c t i on is
not possi bl e wi t h or t hodont i cs al one. Mer el y
cor r ect i ng t he dent al mal occl us i on does not
adequat el y addr ess t he pr obl e m; t he goal s of
t r e a t me nt mus t i ncl ude good faci al est het i cs, as
well as stability i n t he ul t i mat e posi t i ons of t he
dent i t i on and jaws. Wi t h this i n mi nd, t he clini-
ci an' s r esponsi bi l i t y t o t he pot ent i al or t hog-
nat hi c pat i ent is to of f er a t r e a t me nt pl an t hat
will accompl i s h bot h desi r abl e est het i c a nd st abl e
results. Whe n a j aw di s cr epancy a c c ompa ni e s a
severe mal occl usi on, t her e ar e t hr ee br oa d possi-
bilities f or cor r ect i on: (1) gr owt h modi f i cat i on,
(2) camouf l age ( or t hodont i c pos i t i oni ng of t he
t eet h to c ompe ns a t e f or t he j aw di scr epancy) , or
(3) or t hogna t hi c s ur ger y in conj unct i on wi t h
or t hodont i cs to r epos i t i on t he j aws a n d / o r den-
t oal veol ar segment s.
Proffi t a nd Ac k e r ma n 8 i nt r oduc e d t he con-
cept of t he envel ope of di s cr epancy to gr aphi -
cally i l l ust rat e how mu c h c ha nge can be pr o-
duc e d by vari ous t ypes of t r e a t me nt (Fig 1). Thi s
di agr am hel ps si mpl i fy t he r el at i ons hi p of t he
t hr ee basi c t r e a t me nt possi bi l i t i es f or skel et al
di scr epanci es. The i nner circle, or envel ope,
r epr es ent s t he l i mi t at i ons of c a mouf l a ge t reat -
me n t i nvol vi ng onl y or t hodont i cs ; t he mi ddl e
envel ope i l l ust rat es t he l i mi t s of c o mb i n e d or t h-
odont i c t r e a t me nt a nd gr owt h modi f i cat i on; a nd
- i~\\
\ \ ~ \ \\
I
I B J
/ i /
F i g u r e 1. The envelopes of discrepancy, showing the
amount of change in the anteroposterior and vertical
planes of space that could be expected from ort hodon-
tic tooth movement alone (the inner envelope), orth-
odontic tooth movement combi ned with growth modi-
fication (the middle envelope), and orthognathic
surgery (the out er envelope). The possibilities of
t reat ment are not symmetric with regard to the three
planes of space. For example, t reat ment for growth
modification is more effective in mandibular defi-
ciency than in mandibular excess. (Reprinted with
permission from Proffit WR, Ackerman JL: Diagnosis
and t reat ment planning, in Graber TM, Swain BF
[eds]: Current Concepts and Techniques, chap 1,
Philadelphia, PA, CV Mosby, 1982.)
t he out e r envel ope shows t he l i mi t s of surgi cal
cor r ect i on.
Gr owt h modi f i cat i on, gener al l y r e f e r r e d to as
dent of aci al or t hopedi cs , is t he mos t desi r abl e
a p p r o a c h to a severe skel et al p r o b l e m when t he
2 1 2 Bailey, Projfit, a n d Whi t e
pot ent i al f or f ur t he r gr owt h exists. Al t hough t he
pa t t e r n of gr owt h can be f avor abl y modi f i e d f or
s ome pat i ent s, t he capaci t y f or ma j or i nc r e me nt s
in gr owt h is r a t he r l i mi t ed. The var i at i on in
r es pons e of i ndi vi dual pat i ent s, however, sug-
gests gr owt h modi f i cat i on s houl d be a t t e mpt e d
in pr e a dol e s c e nt pat i ent s, a nd par ent s s houl d be
wa r ne d t hat it mi ght not succeed.
Whe n a mo d e r a t e skel et al di s cr epancy exists
and t her e is no pot ent i al f or f ur t he r gr owt h ( or i f
mo r e c ha nge is r e qui r e d t han can be accom-
pl i shed t hr ough gr owt h modi f i cat i on al one) ,
or t hodont i c camouf l age s houl d be cons i der ed.
The t eet h ar e r epos i t i oned t o est abl i sh n o r ma l
over j et a nd over bi t e i n an ef f or t t o c ompe ns a t e
f or t he j aw di screpancy. I n a mo d e r a t e skel et al
Class I I mal occl us i on i nvol vi ng ma ndi bul a r defi-
ciency, t he maxi l l ar y i nci sors can be r et r act ed
a nd t he ma n d i b u l a r i nci sors pr ocl i ned t o est ab-
lish overj et . Ext r act i on of s ome t eet h will usual l y
be r equi r ed so t hat e n o u g h space in t he ar ch can
be cr eat ed t o al l ow si gni f i cant mo v e me n t of
ot he r t eet h. Such t r e a t me nt c a nnot be consi d-
e r e d successful i f it resul t s in a r eas onabl e dent al
occl usi on at t he e xpe ns e of faci al est het i cs. I n
addi t i on, t her e ar e limits to how f ar t he per i odon-
t i um will a c c o mmo d a t e t he di s pl a c e me nt of
t eet h f r om t hei r n o r ma l posi t i ons. Consi der -
at i on of camouf l age r equi r es car ef ul exami na-
t i on f or t he pat i ent ' s ul t i mat e faci al est het i cs a nd
occl usal stability.
The fi nal t r e a t me nt opt i on f or a severe skel-
et al di s cr epancy is or t hogna t hi c surgery. Onc e
gr owt h has ceased, s ur ger y be c ome s t he onl y
me a ns of cor r ect i ng a severe j aw di screpancy.
Al t hough s ur ger y may al l ow gr e a t e r changes,
t her e ar e still l i mi t at i ons to t he surgi cal opt i ons,
d e p e n d i n g on t he t ype of p r o b l e m a nd di r ect i on
of desi r ed j aw move me nt , a nd cer t ai n pr obl e ms
ar e mo r e r ecept i ve t o surgi cal cor r ect i on t han
ot her s. Wh e n dent al c ompe ns a t i on is pr es ent ,
ei t her nat ur al l y or pr evi ousl y p r o d u c e d by or t h-
odont i c t r eat ment , t hese dent al posi t i ons mus t
be r ever s ed be f or e surgi cal r epos i t i oni ng of t he
jaws. The gr eat er t he dent al c ompe ns a t i on, t he
smal l er t he ma gni t ude of j aw mo v e me n t t he
s ur ge on has t o c or r e c t t he skel et al di screpancy.
The t e r m r ever s e o r t h o d o n t i c s is of t en us ed i n
r e f e r e nc e to t he del i ber at e mo v e me n t of t eet h in
a di r ect i on t hat a ppe a r s to ma ke t he occl usi on
worse initially when pr e pa r i ng t he dent i t i on f or
or t hogna t hi c surgery. Whe n dent al compens a-
t i ons exist, t hey l i mi t t he di st ance t he j aws can be
r epos i t i oned to achi eve a desi r abl e est het i c re-
sult. Gr eat er c ha nge can be e xpe c t e d when
t r eat i ng a chi l d (who mos t likely has s ome
r e ma i ni ng pot ent i al f or gr owt h) wi t h or t hodon-
tic t oot h mo v e me n t pl us gr owt h modi f i cat i on
t han f or an adul t wi t h camouf l age or t hodont i cs
al one. Consequent l y, gi ven t he s ame severi t y of
skel et al def or mi t i es i n bot h a chi l d a nd an adul t ,
or t hodont i cs al one in t he chi l d may pr oduc e a
desi r abl e result, wher eas t he adul t woul d not be
ma na ge a bl e wi t hout a surgi cal opt i on. On e an-
swer to t he quest i on of " Wh e n is a p r o b l e m t oo
severe f or or t hodont i c t r e a t me nt onl y?" is " Whe n
t he c ombi na t i on of t oot h mo v e me n t a nd gr owt h
modi f i cat i on does not have t he pot ent i al to
br i ng t he pat i ent t o n o r ma l occl us i on. " I n a
gr owi ng chi l d, a mal occl us i on t hat c a nnot be
c or r e c t e d by or t hodont i cs in addi t i on t o gr owt h
modi f i cat i on is severe e nough t hat it mer i t s
cons i der at i on of a surgi cal pl an. I n t he nongr ow-
i ng pat i ent , i f t he mal occl us i on is t oo severe to
be t r eat ed wi t h c a mouf l a ge or t hodont i c t oot h
move me nt , t hen a surgi cal t r e a t me nt pl an s houl d
be i mp l e me n t e d to obt ai n a r eas onabl e result.
The envel ope of di s cr epancy is bas ed on occl usal
consi der at i ons, a nd est het i c l i mi t s apply. Mer el y
obt ai ni ng an i deal occl usi on at t he expens e of
c o mp r o mi s e d faci al est het i cs does not const i t ut e
a successful t r e a t me nt out c ome .
Proffi t et al 9 have pr ovi ded s ome gui del i nes
f or pr edi ct i ng successful o u t c o me when t he
choi ce bet ween surgi cal versus or t hodont i c cor-
r ect i on exists f or an adol es cent be yond t he
adol escent gr owt h s pur t ( and t her ef or e no l onger
a pr i me candi dat e f or gr owt h modi f i cat i on) .
The y c o mp a r e d 40 pat i ent s successful l y t r eat ed
wi t h or t hogna t hi c s ur ger y f or cor r ect i on of Class
I I mal occl us i on wi t h 40 pat i ent s successfully
t r eat ed wi t h or t hodont i cs al one. Th e r e wer e 21
pat i ent s whose or t hodont i c t r e a t me nt ha d be e n
d e t e r mi n e d to be unsuccessf ul i ncl uded as a
t hi r d gr oup in t he study. The successful t reat -
me n t in surgi cal pat i ent s r esul t ed f r om ma ndi bu-
l ar a d v a n c e me n t in two t hi r ds of t he gr oup; t he
ot he r one t hi r d ha d vert i cal r epos i t i oni ng of t he
maxi l l a, ei t her al one or in c ombi na t i on wi t h
ma ndi bul a r surgery. Ret r act i on of t he maxi l l ar y
i nci sors and pr ot r act i on of t he ma ndi bul a r inci-
sors achi eved t he successful o u t c o me in t he
or t hodont i c- onl y gr oup. Thi s gr oup of pat i ent s
also e xpe r i e nc e d a si gni fi cant a mo u n t of vert i cal
Assessment of Orthognathic Surgery Patients 213
gr owt h, wi t h 40% havi ng a nt e r opos t e r i or gr owt h
gr e a t e r t ha n 2 mm.
The i mpor t a nt clinical quest i on answer ed f r om
this st udy was t he di f f er ence be t we e n t he unsuc-
cessfully t r eat ed or t hodont i c gr oup a nd t he ot he r
two successful l y t r eat ed gr oups. Surpri si ngl y, t he
unsuccessf ul l y t r eat ed or t hodont i c g r o u p ha d
si mi l ar changes dur i ng t r e a t me nt to t he success-
ful gr oup. The ma j or di f f er ence was t hey ha d
gr e a t e r overj et , mo r e severe ma n d i b u l a r defi-
ciency, a nd gr e a t e r a nt e r i or face he i ght initially.
The concl us i on was a sat i sf act or y or t hodont i c
out come is unlikely, and t her ef or e surgery is likely
to be needed for Class II adolescents be yond t he
gr owt h s pur t when t her e is over j et gr e a t e r t han
10 mm. Successful or t hodont i c t r e a t me nt is less
likely when excessi ve over j et is a c c o mp a n i e d by
any of t hese fi ndi ngs: (1) t he p o g o n i o n t o
na s i on- pe r pe ndi c ul a r di st ance is gr e a t e r t han 18
mm, (2) ma n d i b u l a r body l engt h is less t han 70
mm, or (3) face he i ght is gr eat er t ha n 125 r am.
Tr e a t me n t Opt i ons and Ou t c o me s
The fol l owi ng case r e por t i l l ust rat es s ome of t he
t r e a t me nt opt i ons pr evi ousl y di scussed.
Case Report
Thi s 9-year, 1- mont h- ol d boy (Fig 2A-E) pr e-
s ent ed in t he mi xe d dent i t i on wi t h a chi ef
c ompl a i nt of " I have an over bi t e. " The pat i ent ' s
medi cal hi st or y i ndi cat ed he ha d b e e n hospi t al -
i zed as a t oddl e r to have t ubes pl aced f or re-
pe a t e d ear i nfect i ons. He ha d b e e n di agnos ed
wi t h at t ent i on defi ci t di s or der but was not pres-
ent i y t aki ng medi cat i on. The mot i vat i on f or
t r e a t me n t was pr i mar i l y ext er nal , f r o m t he
mot her . The pat i ent i ndi cat ed s ome a p p r e h e n -
si on, wi t h a l ack of desi r e f or wear i ng or t hodon-
tic appl i ances, but woul d do so i f it woul d give
hi m "st r ai ght t eet h. " No s e c onda r y sex char act er -
istics wer e evi dent . Pr evi ous dent al car e ha d
b e e n regul ar, and an or al e xa mi na t i on i ndi cat ed
fai r oral hygi ene, wi t h l ocal i zed gingivitis a nd
mi n i mu m pl aque accumul at i on.
The pat i ent ' s Class I I skel et al a nd dent al
mal occl us i on i nvol ved ma ndi bul a r defi ci ency.
The pat i ent ha d an over]et of 7 r am. Space
analysis i ndi cat ed an a de qua t e a mo u n t of space
to a c c o mmo d a t e all t he p e r ma n e n t t eet h. The
pa t i e nt was of f er ed a t wo- phase t r e a t me nt pl an,
wi t h phas e 1 i nvol vi ng gr owt h modi f i cat i on wi t h
a bi ona t or f unct i onal appl i ance. Compr e he ns i ve
or t hodont i cs wi t h f i xed appl i ances woul d fol l ow
this phas e of t r eat ment , wi t h t he t i mi ng de pe n-
de nt on t he e r upt i on pat t er n.
The pa t i e nt was not ver y compl i ant , a nd af t er
15 mont hs (Fig 3A-E), t he mol ar s ha d b e e n
c or r e c t e d t o a Class I r el at i onshi p, but t he
over j et was r e duc e d by onl y 1 mm. Th e r e had
b e e n s ome hor i zont al growt h; however, mos t of
t he gr owt h dur i ng this pe r i od was in a vert i cal
di r ect i on. I t was deci ded at this poi nt to di scon-
t i nue t he f unct i onal appl i ance a nd wai t f or t he
e r upt i on of mo r e t eet h bef or e i ni t i at i ng phas e 2
t r eat ment .
Twent y-t wo mont hs passed be f or e a s e c ond
phas e of t r e a t me nt was r e c o mme n d e d (Fig 4A-
E). At t hi s t i me, t he pat i ent was also pr es cr i bed a
hi ghpul l h e a d g e a r a nd a l ower l i ngual hol di ng
ar ch as mo r e p e r ma n e n t t eet h c ont i nue d t o
er upt . Compl e t e fi xed appl i ances wer e b o n d e d
11 mont hs later, a nd c ompr e he ns i ve t r e a t me nt
c ont i nue d f or an addi t i onal 14 mont hs bef or e it
was d e t e r mi n e d no addi t i onal gr owt h woul d
occur to assist in t he cor r ect i on of t he pat i ent ' s
ma n d i b u l a r defi ci ency.
An or t hogna t hi c surgi cal t r e a t me nt pl an in-
vol vi ng a bi l at er al sagittal spl i t os t e ot omy to
advance t he mandi bl e, wi t h a l ower b o r d e r
os t e ot omy f or i mpr ove d p o g o n i o n pr oj ect i on,
was r e c o mme n d e d . Ext r act i on of t he ma ndi bu-
l ar first bi cuspi ds was r e qui r e d t o r et r act t he
ma n d i b u l a r i nci sors and maxi mi ze t he a mo u n t
of surgi cal advancement . Twelve mont hs later,
t he pa t i e nt el ect ed t o accept this r e c o mme n d a -
t i on. Fi gur e 5A-E i ncl udes t he pr esur gi cal phot o-
gr a phs of this pat i ent . Six mont hs af t er t he
ma n d i b u l a r surgery, t he pa t i e nt was d e b a n d e d
(Fig 6A-E). Al t hough t he occl usi on was slightly
less t han i deal , t he deci si on to d e b a n d earl y was
ma d e becaus e of t he e x t e n d e d l engt h of t reat -
me n t t i me a nd f or medi cal reasons.
Phase 1 t r e a t me nt t i me was 15 mont hs , a nd
phas e 2 t r e a t me nt l ast ed 25 mont hs . Th e t ot al
t r e a t me nt t i me was e xt e nde d be yond t he aver age
becaus e t he dent al d e v e l o p me n t af t er phas e 1
t r e a t me n t r e qui r e d a t r ansi t i on bet ween t he
mi xe d dent i t i on a nd p e r ma n e n t dent i t i on be-
f or e t he p l a c e me n t o f f i xed appl i ances. The
c e pha l ome t r i c t raci ngs f r o m (1) initial to e nd of
phase 1 (Fig 7A), (2) end of phase 1 to pr esur ger y
(Fig 7B), (3) pr esur ger y to i mmedi at e pos t s ur ger y
(Fig 7C), a nd (4) pos t s ur ger y to fi nal (Fig 7D).
214 Bailey, Proffit, and White
Figure 2. Patient R.M., aged 9 years 1 mont h, before
treatment. His chief complaint was excess overjet (A, B).
Further growth was considered possible. Examination
of the profile shows obvious mandi bul ar deficiency.
Patient R.M., intraoral views. He has a Class lI, Division
1 malocclusion (C, D, E).
Assessment of Orthognathic Surgery Patients 215
Figure 3. Facial phot ographs of R.M. (aged 10 years 3
months) after 15 mont hs of functional appl i ance (bio-
nator) treatment. Mandi bul ar deficiency was not signifi-
cantly i mproved (A, B). Int raoral phot ographs of R.M.
after 15 mont hs of functional appliance t reat ment
showing i mpr ovement of t he mol ar rel at i onshi p
(C, D, E).
216 Bailey, Proffit, and White
Figure 4. Facial photographs of R.M. (aged 12 years 1
mont h) 22 months after cessation of the functional
appliance (A, B). At this time, the patient began
highpull headgear therapy with a lower lingual holding
arch for a period of 11 mont hs before it was det ermi ned
there was no fllrther growth potential. Tooth erupt i on
did not allow for pl acement of complete fixed appli-
ances until the age of 14.3 years, at which time he was
offered an orthognathic surgical treatment plan, which
he declined. Intraoral photographs of R.M. before
headgear therapy with a lower lingual arch. He was not
very compliant with headgear therapy (C, D, E).
Assessment of Orthognathic Surgery Patients 217
Figure S. Presurgical photos of R.M., aged 15 years 11
mont hs (A, B). After 12 months of complete fixed
orthodontic appliances, he elected to have a bilateral
sagittal split osteotomy to advance the mandible, with a
lower border osteotomy to improve chin projection.
Presurgical intraoral photographs of R.M (C, D, E).
Mandibular first bicuspids have been extracted to re-
tract the mandi bul ar incisors and maximize the amount
of advancement. This would also help prevent mucogin-
gival problems from developing because the patient
also had reduced attached gingiva around the lower
anterior teeth.
218 Bailey, Proffit, and White
Fi gure 6. Post t reat ment facial phot ographs of R.M.
with i mproved facial balance (A, B). Post t reat ment
occlusal relationships with ideal ovmjet and overbite
(C, D, E). Molar relationship is Class II1 because of
extraction of mandi bul ar first bicuspids.
Assessment of Orthognathic Surgery Patients 219
....... ~ .... ' . . . ~ ~ ""
i
~'. ,"
Figure 7. Superimposition tracings for R.M. showing skeletal changes from initial to after 15 months of
functional appliance therapy (solid line, initial; broken line, 15 months) (A). End of phase 1 (functional
appliance) to immediately presurgery (solid line, 15 months; broken line, presurgery) (B). Presurgery to
immediately postsurgery (solid line, presurgery; broken line, postsurgery) (C). Postsurgery to final (solid line,
postsurgery; broken line, final) (D). The radiographs were all taken in natural head position.
The ort hognat hi c surgical opt i on provi ded
i mproved esthetics and function, and the patient
expressed pleasure at the desired out come. The
esthetic i mprovement was the result of mor e
forward proj ect i on of the lower anterior part of
the face which provided i mproved facial balance.
Number of Pati ents Wi th Potenti al Need
for Orthognathi c Surgery
Previous investigations have cited the difficulty
estimating the prevalence of severe skeletal mal-
occlusions requiring ort hognat hi c surgery for
2 2 0 Bailey, Proffit, a n d Whi t e
cor r ect i on of a dent of aci al def or mi t y. 1 I n t he
exi st i ng l i t er at ur e of t he epi demi ol ogy of mal oc-
cl usi on, t her e ar e ver y few dat a t hat r e por t on
faci al char act er i st i cs or skel et al di scr epanci es.
Summar i es of t he exi st i ng l i t er at ur e have ext r apo-
l at ed t he pr eval ence of dent of aci al def or mi -
ties. 1,11 Most publ i cat i ons descr i be mal occl us i on
pr eval ence f or adol escent s, 12 a nd onl y r ecent l y
has i nf or ma t i on rel at i ve to t he adul t popul a t i on
b e c o me avai l abl e. The Nat i onal He a l t h a nd Nu-
t r i t i on Est i mat es St udy ( N- Hanes I I I ) c onduc t e d
by t he US Nat i onal Ce nt e r f or He a l t h Statistics
descr i bes occl usal traits f or a wi der age r ange
(age 8 to 50 years).13,14 Because t he maj or i t y of
pat i ent s who ar e candi dat es f or or t hogna t hi c
s ur ger y ar e adul t s wi t h no r e ma i ni ng gr owt h
pot ent i al , t hese statistics s houl d be r eadi l y avail-
abl e becaus e of t he i ncr eas ed usage of or t hodon-
tic t r e a t me nt by bot h chi l dr en a nd adul t s dur i ng
t he past t hr ee decades.
Proffi t et aP 4 s umma r i z e d t he mos t r e c e nt
dat a avai l abl e on occl usal charact eri st i cs, assum-
i ng t he mos t sever e char act er i st i cs a c c ompa ny an
under l yi ng skel et al di screpancy. Usi ng t hese dat a
t o est i mat e t he pot ent i al n u mb e r of pat i ent s
r equi r i ng or t hogna t hi c s ur ger y r equi r es s ome
f ur t he r as s umpt i ons a b o u t p r o b l e m severity.
Ear l i er r epor t s suggest t he condi t i on f or whi ch
pat i ent s ar e mos t likely to pr e s e nt f or or t hog-
nat hi c surgi cal eval uat i on is ma ndi bul a r deft-
ciency. 15 The pr e s e nc e of severe over j et is hi ghl y
c or r e l a t e d wi t h a Class I I mal occl usi on, whi ch is
suggest i ve of ma ndi bul a r defi ci ency. 9,16
I t a ppe a r s severe Class I I mal occl usi on, wi t h 7
mm or mo r e of overj et , affect s a ppr oxi ma t e l y 2%
of t he popul a t i on a nd is mo r e pr eval ent in bl acks
a nd Hi s pani cs t han whites. N- Hanes I I I suggest s
t her e have be e n no ma j or changes in or t hodon-
tic t r e a t me nt n e e d dur i ng t he last 30 years, 14
a l t hough t he ear l i er sur vey was onl y of chi l dr en
and yout hs. I f it is as s umed onl y t he mos t severe
mal occl usi ons (with at l east 7 mm of overj et )
woul d be candi dat es f or or t hogna t hi c surgery,
t he n a ppr oxi ma t e l y 1 mi l l i on i ndi vi dual s in t he
US popul a t i on woul d be candi dat es f or s ur ger y
f or a Class I I pr obl e m, wi t h a ppr oxi ma t e l y 24,000
cases a dde d each year (Tabl e 1). l
Usi ng r ever se over j et as an i ndi cat or of Class
I I I mal occl us i on suggest s severe Class I I I pr ob-
l ems ar e r ar e in chi l dr en but occur equal l y
Tabl e 1. Prevalence of Severe Mandibular Deficiency
Requiring Surgery
Parameter PercEntage* Numberf
Pr e va l e nc e o f skel et al Cl ass II mal -
oc c l us i on 12 32, 400, 000
Ap p r o p r i a t e age f or t r e a t me n t 65 21, 060, 000
Sever e e n o u g h t o wa r r a n t s u r g e r y 5 1, 053, 000
Ma n d i b u l a r a d v a n c e me n t 57 600, 210
Maxi l l ar y s et back 2 21, 060
Bot h 41 431, 730
New pa t i e nt s a d d e d to p o p u l a t i o n
annual l y+ + 0. 6 24, 000
*Bas ed o n f i gur es f r o m Proffi t et al. 14
t At 270, 000, 000 US p o p u l a t i o n .
+At 4, 000, 000 live bi r t hs p e r yea1:
a mo n g yout hs a nd adul t s. Agai n, severe Class I I I
pr obl e ms ar e mo r e pr eval ent in Hi spani cs and
bl acks t han whites. Class I I I skel et al pr obl ems ,
ei t her ma ndi bul a r pr ogna t hi s m or maxi l l ar y de-
ficiency, do not r e s pond to or t hodont i c camou-
fl age and gr owt h modi f i cat i on as well as mandi bu-
l ar defi ci ency. I t has be e n pr evi ousl y suggest ed
t hat one t hi r d of t he pat i ent s wi t h at l east 3 mm
of r ever se over j et ar e pr oba bl y severe e n o u g h to
r equi r e surgery. 1 Tabl e 2 shows t hat wi t h this
as s umpt i on, a ppr oxi ma t e l y 580,000 i ndi vi dual s
in t he Uni t e d States have a Class I I I mal occl us i on
severe e n o u g h t o r equi r e surgi cal cor r ect i on,
wi t h a ppr oxi ma t e l y 12,000 cases a dde d each
year.
Tr ends in Class I I I surgi cal t r e a t me nt i ndi cat e
f ewer i sol at ed ma ndi bul a r set backs (t he pr edomi -
na nt pr oc e dur e in t he 1970s) ar e be i ng per-
f o r me d f or cor r ect i on of this t ype of mal occl u-
sion. A r e c e nt st udy r e p o r t e d an i ncr eas ed
n u mb e r of two-jaw a nd maxi l l ar y a d v a n c e me n t
cases f or t he cor r ect i on of Class I I I dent of aci al
def or mi t i es. 17 Less t han 10% of t he pat i ent s wi t h
Tabl e 2. Prevalence of Severe Class III Problems
Requiring Surgery
Parameter Percentage* Number~
Pr e va l e nc e o f skel et al Cl ass III
ma l oc c l us i on 1 2, 700, 000
Appr opr i a t e age f or t r e a t me n t 65 1, 755, 000
Sever e e n o u g h t o wa r r a nt s u r g e r y 33 579, 150
Maxi l l ar y a d v a n c e me n t 40 231, 660
Ma n d i b u l a r s et back 9 52, 124
Bot h 51 295, 367
New pa t i e nt s a d d e d t o p o p u l a t i o n
annual l y+ + 0. 3 12, 000
*Bas ed o n f i gur es f r o m Proffi t et al. 14
t At 270, 000, 000 US popul a t i on.
++At 4, 000, 000 live bi r t hs p e r year.
Assessment of Orthognathic Surgery Patients 221
a skel et al Class I I I mal occl us i on now recei ve an
i sol at ed ma ndi bul a r set back, wher eas maxi Uar y
a d v a n c e me n t al one is now us ed in mo r e t han
40% of t hese pat i ent s. As l at e as 1985, 50% of
Class I I I s ur ger y was ma ndi bul a r set back al one.
The r eas on f or t he dr amat i c c ha nge is be t t e r
st abi l i t y a nd be t t e r est het i cs wi t h maxi l l ar y sur-
gery.
Pat i ent s seeki ng or t hogna t hi c surgi cal consul -
t at i on f or a vert i cal p r o b l e m pr e s e nt as t he t hi r d
mos t f r e que nt r eas on to ma n d i b u l a r defi ci ency, ~3
wi t h bot h shor t - f ace a nd l ong- f ace pr obl e ms
oc c ur r i ng equally. Previ ous r epor t s es t i mat ed
a ppr oxi ma t e l y 220, 000 wi t h a l ong- f ace p r o b l e m
severe e n o u g h to wa r r a nt surgery, wi t h appr oxi -
mat el y 6,000 a dde d to t he popul a t i on annual l y. 1
Based on c ur r e nt popul a t i on est i mat es, this fig-
ur e has c ha nge d ver y little, wi t h a ppr oxi ma t e l y
4,000 pat i ent s a dde d each year (Tabl e 3).
Al t hough ot he r skel et al pr obl e ms (such as
s hor t face, asymmet r i es, a nd pos t er i or cross-
bi t es) r equi r i ng s ur ger y exist, i f we def er t o t hi s
ear l i er r epor t , m t hese condi t i ons col l ect i vel y ap-
pr oxi ma t e t hose f or t he l ong- f ace pr obl e m. I t is a
best guess to suggest a ppr oxi ma t e l y 219,000 of
t hese " o t h e r s " will al so r equi r e surgery.
Th e o r t h o d o n t i c c o mmu n i t y has l ong
s t r uggl ed wi t h t r e a t me nt of c o mb i n e d vert i cal
a nd a nt e r opos t e r i or pr obl e ms . The r e f or e , it
mi ght be s ur mi s ed t hat ma n y of t he Class I I or
Class I I I pat i ent s woul d over l ap wi t h t he l ong-
face or ot he r cat egori es, such as as ymmet r i es a nd
crossbi t es. Thi s pr evi ous r e por t s ugges t ed a 60%
over l ap bet ween t he Class I I / Cl as s I I I a nd l ong-
f a c e / o t h e r groupsm; i f this f i gur e is used, t he
c ur r e nt n u mb e r of per s ons in t he Uni t e d St at es
who woul d n e e d or t hogna t hi c s ur ger y to c or r e c t
t hei r severe mal occl us i on is a ppr oxi ma t e l y 1.8
mi l l i on, or t he c o mb i n e d t ot al (Tabl e 4).
Table 3. Prevalence of Long-Face Problems
Requiring Surgery
Parameter Percentage* Numbert
Prevalence of severe anterior
open bite 0.5 1,350,000
Appropriate age for treatment 65 877,500
Severe enough to warrant surgery 25 219,375
New patients added to population
annually + 0.1 4,000
*Based on figures from Proffit et al. 14
tAt 270,000,000 US population.
,+At 4,000,000 live births per year.
Tabl e 4. Numbe r of Pot ent i al Or t hognat hi c Surgery
Pat i ent s
Class II 1,053,000
Class III 579,150
Long face 219,375 (less 60% overlap) 87,750
Other 219,375 (less 60% overlap) 87,750
The n u mb e r of i ndi vi dual s i n t he Uni t e d
States popul a t i on who woul d r equi r e surgi cal
i nt e r ve nt i on f or sat i sfact ory cor r ect i on of a den-
t ofaci al def or mi t y is i mpr essi ve, despi t e t he cur-
r ent t r end f or t hi r d- par t y cover age to deny surgi-
cal benefi t s. The d e ma n d f or surgi cal or t hodont i c
t r e a t me nt will also c ont i nue to i ncr ease unt i l t he
n u mb e r of i ndi vi dual s who can benef i t f r om
t r e a t me nt versus t he n u mb e r of t hose receipting
this t r e a t me nt mo r e closely a p p r o a c h each ot her.
References
1. Ackerman JL, Proffit WR. Communication in orthodon-
tic treatment planning: Bioethical and informed consent
issues. Angle Orthod 1995;65:253-261.
2. Phillips C, Griffin T, Bennett E. Perception of facial
attractiveness by patients, peers, and professionals. Int J
Adult Orthod Orthognath Surg 1995;10:127-135.
3. Ackerman JL, Proffit WR. Soft tissue limitations in
orthodontics: TreaUnent planning guidelines. Angle Or-
thod 1997;67:327-336.
4. Vanarsdall RL. Periodontal/orthodontic interrelation-
ships. In: Graber TM, Vanarsdall RL (eds). Orthodontics:
Current Principles and Techniques. St Louis, MO: Mosby,
1994;712-749.
5. WennstromJL. Mucogingival considerations in orthodon-
tic treatment. Semin Orthod 1996;2:46-54.
6. Okeson JE Management of Temporomandibular Dism~
ders and Occlusion (ed 3). St Louis, MO: Mosby, 1993;
1-593.
7. Williamson EH. Occlusal concepts in orthodontic diagno-
sis and treatment. In: Johnston LE (ed): New Vistas in
Orthodontics, Philadelphia, PA, Lea & Febiger, 1985;
122-147.
8. Proffit WR, AckermanJL. Diagnosis and treatment plan-
ning. In: Graber TM, Swain BF (eds). Current Orthodon-
tic Concepts and Techniques. St Louis, MO: Mosby, 1982;
3-100, chapter 1.
9. Proffit WR, Phillips C, TullochJFC, Medland PH. Surgi-
cal versus orthodontic correction of skeletal Class II
malocclusion in adolescents: Effects and indications. Int
J Adult Orthod Orthognath Surg 1992;7:209-220.
10. Proffit WR, White WR. Who needs surgical-orthodontic
treatment? Int J Adult Orthod Orthognath Surg 1990;5:
81-89.
11. McLain JB, Proffit WR. Oral health status in the United
States: Prevalence of malocctusion.J Dent Educ 1985;49:
386.
222 Bai l ey, Pr of f i t , a n d W h i t e
12. Kelly J, Harvey C. An assessment of the occlusion of teeth
of youths aged 12-17 years. National Center for Health
Statistics, Public Health Service, US Department of
Health Education, and Welfare Publication No (HRA)
77-1644, Government Printing Office, 1977.
13. BrunelleJA, Bhat M, LiptonJA. Prevalence and distribu-
tion of selected occlusal characteristics in the US popula-
tion 1988-1991.J Dent Res 1996;75:706-713.
14. Proffit WR, Fields HW, Moray LJ. Malocclusion preva-
lence and orthodontic treatment need in the United
States: Estimates from the N-Hanes III survey. IntJ Adult
Orthod Orthognath Surg 1998;13:97-106.
15. Proffit WR, Phillips C, Dann CD IV. Who seeks surgical-
orthodontic treatment? I nt J Adult Orthod Orthognath
Surg 1990;5:153-160.
16. McNamara JA. Components of Class II malocclusion in
children 8-10 years of age. Angle Orthod 1981 ;51:177.
17. Bailey LJ, Proffit WR, White WR. Trends in surgical
treatment of Class III skeletal relationships. Int J Adult
Orthod Orthognath Surg 1995;10:108-118.