Wolford, Karras, and Mehra
American Journal of Orthodontics and Dentofacial OrthopedicsFebruary 2001
patients is the displaced articular disk. Significant prob-lems can occur when orthognathic surgery is performedin the presence of untreated disk displacement.
Before surgery, 36% of patients had some pain or dis-comfort, but 2 years after mandibular advancement,88% of the patients had pain with increased intensity.After surgery, condylar resorption occurred in 30% of the patients, which resulted in redevelopment of a jawdeformity and malocclusion.
Other TMJ pathologicconditions that may affect treatment outcomes includecondylar hyperplasia, condylar hypoplasia, idiopathiccondylar resorption, osteochondroma, reactive arthritis,rheumatoid arthritis, psoriatic arthritis, systemic lupuserythematosus, scleroderma, and ankylosing spondyli-tis. TMJ pathology must be assessed and properly man-aged to provide healthy, stable TMJs for a sound foun-dation and the achievement of predictable results.The tongue is an important factor in jaw growth anddevelopment. Microglossia can cause underdevelop-ment of the jaws with lingual collapse of the dentoalve-olar structures. Macroglossia can result in overdevelop-ment of the jaws, especially the dentoalveolus. Theetiology of macroglossia may be congenital (eg, mus-cular hypertrophy, lymphangioma, or glandular hyper-plasia) or acquired (eg, cyst, tumor, acromegaly, oramyloidosis). The most common cause of macroglossiais muscular hypertrophy.The tongue usually reaches its approximate adultsize when a child reaches the age of 8 years.
An eval-uation of the tongue should include clinical, radi-ographic, and functional assessments relative to inter-ference with speech, mastication, airway, and treatmentstability. Surgical reduction of the tongue can improvethe stability and predictability of surgical outcomes incases of absolute macroglossia. Wolford et al
previ-ously described the diagnosis of macroglossia and theindications for reduction glossectomy.Determination of growth rate and vector can bechallenging. Because the jaws grow in all 3 dimen-sions, growth disturbances can also occur in more than1 dimension. A good understanding of facial growthtendencies of the specific anatomical facial types (eg,brachycephalic, normocephalic, or dolicocephalic)gives the clinician important information about subse-quent growth. Evaluation of the patient’s medical andfamily history, as well as serial clinical and radi-ographic examinations, are helpful to identify growthimbalances in jaw structures. Comparison of serial lat-eral and anteroposterior cephalograms, and cephalo-metric tomograms that include the TMJ and posteriormandible can be extremely helpful in assessment of jaw growth. Specialized radiography (eg, computedtomography [CT] scans, magnetic resonance imaging[MRI], or nuclear scintigraphy) are indicated in cer-tain cases, especially for identification of TMJ pathol-ogy. Hand-wrist films may be useful in determiningthe growth potential in some patients but are of littlebenefit in skeletal Class III patients with condylarhyperplasia. Serial dental models help in monitoringocclusal and dental changes.
MANDIBULAR DEFORMITIESMandibular hypoplasia
is defined as retruded man-dibular position resulting in a Class II skeletal relation-ship with either a normal or a deficient mandibulargrowth rate.
Normal growth rate.
In patients with normalmandibular growth, the mandible grows from aretruded position relative to the normally positionedmaxilla, or it may be smaller. With normal rates of maxillary and mandibular growth, the same Class IIskeletal and occlusal relationship is maintainedthroughout growth.
This deformity can be correctedsurgically during growth, with predictably stableresults, by using the mandibular ramus osteotomiesdiscussed below. With healthy TMJs and proper use of these techniques, the rate of growth is essentially unal-tered by surgery, and harmonious postoperative maxil-lary and mandibular growth can be expected withmaintenance of the surgical result.
Deficient growth rate.
Patients experiencing defi-cient mandibular growth are initially seen with pro-gressively worsening mandibular retrusion and Class IImalocclusion, as normal maxillary growth outpaces thedeficient mandibular growth. If the deformity is cor-rected surgically during growth, a Class II skeletal andocclusal relationship can be expected to recur, as themaxilla continues to grow normally and the mandiblemaintains its deficient growth rate.
However, surgeryduring growth may be indicated in cases of severedeformities that adversely affect function (eg, malnu-trition resulting from masticatory dysfunction, airwaycompromise, or speech disorders) or psychosocialdevelopment. Under these circumstances, surgery dur-ing growth may improve the quality of life, but thepatient and parents must be made aware that additionalsurgery will probably be necessary. Patients with defi-cient mandibular growth may have an associated TMJpathology that requires surgical correction to achieve astable outcome. Any of the ramus osteotomies dis-cussed below could be used in deficient growth cases.
With any of the following surgical procedures, thepreoperative rate of growth can be maintained after