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Considerations for Orthognathic Surgery During Growth, Part 1 - Mandibular Deformities

Considerations for Orthognathic Surgery During Growth, Part 1 - Mandibular Deformities

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95
Q
estions often arise regarding the appropriatetiming for orthognathic surgery in growingpatients and the possible effects of suchsurgery on subsequent facial growth. Approximately98% of facial growth is usually complete in girls by age15, and in boys by, approximately, age 17 or 18.
1,2
Some growing patients with dentofacial deformitiesexhibit proportionate growth between the maxilla andmandible, but others exhibit disproportionate growthwith progressive worsening of the deformity. The sur-gical procedures required to correct these deformitiesmay affect subsequent facial growth and dentofacialdevelopment. Thus, both surgical procedures andgrowth factors may affect the quality of the outcome.Facial appearance is a fundamental factor in deter-mining interpersonal relationships.
3,4
Thus, earlyorthognathic surgery may hold important psychosocialimplications for some patients. Teenagers with signifi-
From the Baylor University Medical Center and the Department of Oral andMaxillofacial Surgery, Baylor College of Dentistry, Texas A&M UniversitySystem, Dallas.
a
Clinical Professor of Oral and Maxillofacial Surgery and in Private Practice.
b
Former Fellow in Oral and Maxillofacial Surgery and currently in Private Prac-tice, Chicago, Ill.
c
Fellow in Oral and Maxillofacial Surgery.Reprint requests to: Larry M. Wolford, 3409 Worth St, Suite 400, SammonsTower, Dallas, TX 75246.Submitted, February 2000; revised and accepted, May 2000.Copyright © 2001 by the American Association of Orthodontists.0889-5406/2001/$35.00 + 0
8/1/111401
doi:10.1067/mod.2001.111401
CLINICAL REVIEW
Considerations for orthognathic surgery duringgrowth, Part 1: Mandibular deformities
Larry M.Wolford, DMD,
a
Spiro C. Karras, DDS,
b
and Pushkar Mehra, DMD
c
Dallas, Tex
Management of the growing patient with mandibular dentofacial deformities presents a unique and challengingproblem for orthodontists and surgeons.The surgical procedures required for correction of the deformity mayaffect postsurgical growth and dentofacial development. Further, facial growth may continue postoperativelyand negate the benefits of surgery performed, resulting in treatment outcomes that are less than ideal. Fromindividual patient characteristics, the type of deformity, and the indications for early surgical intervention, it ispossible to effectively treat many cases during growth. A thorough understanding of facial growth patterns isessential, and each case needs to be evaluated individually. Surgery is often undertaken with the expectationthat additional treatment, including more surgery, may be required after the completion of growth.The materialpresented here is based on the available research and the senior author’s clinical experience of more than 25years in the correction of mandibular deformities in the growing patient. Advantages and disadvantages ofspecific surgical techniques for correction of common mandibular deformities and pertinent age and surgicalconsiderations are discussed. The material should be viewed as a general outline that provides broadguidelines for management of these patients. The management of maxillary deformities will be discussed inPart 2 of this article. (Am J Orthod Dentofacial Orthop 2001;119:95-101)
cant dentofacial deformities are often perceived as beingless attractive by their peers, and differences of behaviortoward attractive and unattractive people have been welldocumented.
5,6
Choosing nonsurgical compromisedtreatment or delaying orthognathic surgery until growthis complete could be damaging to the patient’s self-image. Delaying treatment until adulthood can exacer-bate problems related to pain, speech, airway, anatomy,occlusion, esthetics, temporomandibular joint (TMJ)function, masticatory function, and psychosocial factors.This 2-part article discusses the more commondentofacial deformities, the surgical techniques applic-able for each, and the earliest age at which these surg-eries can be performed with predictable results. Part 1deals with surgical treatment of mandibular deformitiesin growing patients, and Part 2 will focus on surgicalcorrection of maxillary deformities and double-jawsurgery in growing patients. There are, of course,exceptions to these general guidelines based on indi-vidual patient characteristics, hormonal or other factorsaffecting growth, the presenting deformity, co-existingdisease, other local or systemic factors, and the ortho-dontist’s and surgeon’s clinical abilities.The TMJs are the foundation for orthognathicsurgery. If the TMJs are not stable and healthy, orthog-nathic surgical results may be unstable, with increasedTMJ dysfunction and pain as a result.
7
The TMJs mustbe appropriately evaluated before surgery. The mostcommon TMJ disorder seen in orthognathic surgery
CE
 
96
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.
7,8
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.
8
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.
9
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
10
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
Mandibular 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.
11
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.
12-14
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.
15
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.
Treatment modalities
With any of the following surgical procedures, thepreoperative rate of growth can be maintained after
 
American Journal of Orthodontics and Dentofacial Orthopedics
Wolford, Karras, and Mehra
97
Volume
119
, Number 
2
surgery. These techniques should neither stimulate norhinder mandibular growth, provided that the TMJs arehealthy, the growth centers of the condylar heads arenot damaged, and the articular disks are not displacedas a result of surgery. The vector of facial and mandibu-lar growth, however, may be altered by a change in theorientation of the proximal segment, and thus thecondyle.
16
With any of the following techniques, if the proximal segment is rotated forward, an increasedvertical growth vector will be seen after the operation.Likewise, rotation of the proximal segment backwardwill result in a more horizontal growth vector post-surgically. Compared with nonrigid fixation, the useof rigid fixation with all of the following techniqueswill improve immediate and long-term stability.
17
Sagittal split ramus osteotomy.
The sagittal split ramusosteotomy (SSRO)(Fig 1) is more difficult to perform onyounger patients because of greater bony elasticity, thethinness of the cortical bone, the presence of uneruptedmolar teeth, and the relatively shorter posterior verticalmandibular body height, as compared with adults. It doeshave the advantages of easy application of rigid fixation aswell as better positional control of the proximal segment.SSRO is best reserved for patients over the age of 12years—that is, after the eruption of the permanent secondmolars, so that damage to these teeth during surgery canbe avoided. Although the senior author (L.W.) has suc-cessfully performed this procedure on patients as youngas 8,
12,13
we recommend waiting until at least age 12.
Inverted “L” osteotomy.
The inverted “L” osteotomy(ILO) (Fig 2) can be used to advance the mandible and ver-tically lengthen the ramus, but it may require bone or syn-thetic bone grafting to control the positional orientation of the proximal segment and to fill the bony voids betweensegments. The use of rigid fixation is recommended.
Vertical ramus osteotomy.
The vertical ramusosteotomy (VRO) (Fig 3) can be used to advance themandible and vertically lengthen the ramus with appro-priate bone or synthetic bone grafting as indicated tocontrol the positional orientation of the proximal seg-ment and fill bony voids. The amount of mandibularadvancement and vertical lengthening possible withthis technique is limited by the temporalis muscleattachment and interference of the coronoid processeson the zygomatic arch. Thus, for larger movements acoronoidectomy may be needed, or the clinician mayneed to revert to other surgical options.The ILO and VRO can be performed on patients of virtually any age because the design of the osteotomiesavoids developing teeth. However, care must be takento avoid damage to developing teeth during applicationof rigid fixation.
Fig 1.
The SSRO procedure can be used to
(A
and
B)
advance the mandible or reposition it backward.
Fig 2.
The ILO procedure can be used to advance themandible or reposition it backward.When used to advancethe mandible, the gap created between proximal and distalsegments requires grafting with bone or synthetic bone.
Fig 3.
The VRO procedure can be used to advance themandible or reposition it backward. The coronoidprocess limits the extent of movement. When used toadvance the mandible, the gap created between proxi-mal and distal segments requires grafting with bone orsynthetic bone.

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