J Oral Maxillofac Surg 53:1258-1267, 1995

Functional and Morphologic Alterations Secondary to Superior Repositioning of the Maxilla

HOOMAN M. ZARRINKELK, DDS,* GAYLORD S. THROCKMORTON, PHDJ EDWARD ELLIS III, DDS, MS,* AND DOUGLAS P. SINN, DDS
Purpose: The purpose of this investigation was to 1) compare morphological characteristics and functional performance of a sample of patients with vertical maxillary excess (VME) with controls, and to 2) examine how the patients oral motor function adapts to surgery. Materials and Methods: Fifteen female VME patients were compared with 26 female controls before and up to 3 years after maxillary intrusion surgery. Measures of skeletal morphology, mandibular range of motion, maximum isometric bite force, and levels of electromyogram (EMG) activity in some of the muscles of mastication were made on all subjects over time. One-way analysis of variance (ANOVA) was used to compare the controls with the patients before and after surgery. Univariate repeated measures ANOVA was used to study longitudinal changes in the patients. Results: Preoperatively, the patients possessed morphological measurements characteristic of vertical maxillary excess. Superior repositioning of the maxilla averaged 3.3 mm. Concurrently, most skeletal measures were brought closer to normal values. Masseter muscle mechanical advantage was significantly lower in the patients than in controls both before and after surgery (P 5 .05). There was no significant difference between patients and controls for other biomechanical measurements. Mandibular hypomobility was apparent at 6 weeks after surgery, but returned to control values within 6 to 12 months. Before surgery, the patients had maximum isometric bite forces significantly less than those of controls. Bite forces steadily increased after surgery, approaching normal values within 2 years. Before surgery the patients muscle activity levels per unit of bite forces were equivalent to those of controls or somewhat lower. After surgery some of the patients muscles had significantly lower levels of muscle activity per unit of bite force than did controls. Conc/usions: The results of this study suggest that correction of vertical maxillary excess with maxillary intrusion surgery improves some characteristic functional deficits.

Le Fort I osteotomy for repositioning the maxilla has long been used by oral and maxillofacial surgeons for correction of vertical maxillary excess (VME).- Success of this and other orthognathic manipulations
Received from the University of Texas Southwestern Medical Center. * Research Fellow, Oral and Maxillofacial Surgery. t Associate Professor, Cell Biology and Neuroscience. $ Professor, Oral and MaxillofacGi Surgery. $ Professor and Chairman, Oral and Maxillofacial Surgery. This research was supported by a grant from the American Associ-

is often subjectively determined by patient satisfaction and evaluation by the surgeon. That functional benefits of surgery are seldom evaluated is exemplified by the paucity of available literature on this subject. Although
ation of Oral and Maxillofacial Surgeons. Address correspondence and reprint requests to Dr Ellis: Division of Oral and Maxillofacial Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas TX 75235-9109. 0 1995 American Association of Oral and Maxillofacial Surgeons

0278-2391/95/5311-0004$3.00/0

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some investigators have studied single parameters of function in dentofacial deformity patients undergoing orthognathic surgery, few have studied patients undergoing isolated maxillary surgeries.4- It has been demonstrated that before corrective surgery of dentofacial deformities patients have maximum bite forces that are lower than that of controls.5.4.5 It has also been shown that patients with excessive facial height possess masticatory muscles that are weaker and smaller than those of normal individuals.6-20 Whether the muscular patterns are the cause or effect of the facial characteristics is the subject of much speculation. Proffit et al showed that long-faced individuals increase their maximum bite force within 1 year after superior maxillary repositioning.6 Aragon et al and Zimmer et al4 showed that isolated maxillary surgery does not result in changes in mandibular mobility, whereas ORyan and Epke? observed long-term reduction of mandibular mobility. The relationship between myoelectric activity in the masticatory muscles and bite force has been extensively studied.7,2,22-27 Morphologic studies have also attempted to correlate various skeletal configurations to bite force and electromyographic activity.,22 Much of our current understanding of masticatory function is based on general knowledge and extrapolation from incomplete research. There is a lack of complete understanding of the masticatory system because most previous efforts have concentrated on a single modality such as range of motion or activity of a few jaw muscles. Mandibular range of motion, levels of occlusal bite force, electromyographic activity of masticatory muscles, and morphologic changes need be studied simultaneously. All of these modalities are tightly linked, and study of only one can produce misleading results. The purpose of this study was to concurrently study skeletal morphology, biomechanical measurements, mandibular mobility, muscular activity, and occlusal force generation in a group of patients both before and after superior repositioning of the maxilla.
Subjects and Methods

oral and physical examination before surgery and before initiation of trials. These patients presurgical records have been used in previous studies.7*8,5 All patients underwent functional testing after initiation of presurgical orthodontics, but before surgery. A Le Fort I osteotomy was used to superiorly reposition the maxilla, and rigid internal fixation without postsurgical maxillomandibular fixation was used for all patients. The patients were tested again at 6 weeks, 6 months, 1 year, 2 years, and 3 years after surgery. However, bite forces were not measured at the 6-week interval. Patients were compared with 26 female control subjects, selected from among staff, residents, and students of The University of Texas Southwestern Medical Center. The mean age of the control group at the time of their first trial was 25 years, with a range of 22 to 33 years. None of the controls had any noteworthy medical, neurologic, or dental history, nor any symptoms of masticatory apparatus or temporomandibular joint disease. The members of the control group were all free of gross dental or periodontal disease. The controls all had skeletal and dental Class I relationships. The control group is a subset of groups used in previous studies at this institution.8,5 The controls underwent functional testing three times, approximately 6 months apart, using the same testing procedures as for the patients. Informed consent was obtained from every subject in accordance with institutional review board policy at The University of Texas Southwestern Medical Center.
MORPHOLOGIC AND BIOMECHANICAL MEASUREMENTS

Fifteen female patients (mean age, 2.5 years; range, 14 to 42) treated by isolated maxillary intrusion at The University of Texas Southwestern Medical Center were selected. None of the surgical procedures included mandibular ramus surgery; however, half of the patients received genioplasties. None of the patients had any notable past or current medical or neurologic histories. All patients presented with functional and esthetic indications for surgical correction of vertical maxillary excess (VME). Before surgery, patients possessed skeletal and dental relationships characteristic of patients with VME.28 They were given a complete

Standardized lateral cephalometric radiographs were obtained from each control subject at the initial visit. Standardized lateral cephalometric radiographs were also taken of patients preoperatively and at several months postoperatively. All radiographs were taken on the same machine, a Quint Sectograph-200 (Quint Co., Inc., Los Angeles, CA). The radiographs were subsequently digitized by the same operator (EE) using Dentofacial Planner software (Dentofacial Software, Inc., Toronto, Canada) and stored in an IBM-AT computer (IBM Corp. Boca Rotan, FL). From each digitized image, 22 standard cephalometric measurements and 8 mandibular biomechanical measurements were made (Table 1). Biomechanical measurements included moment arm lengths and mechanical advantage values for three masticatory muscles at the incisor and molar bite positions.
MANDIBULAR RANGEOF MOTION

Mandibular range of motion during various voluntary efforts was measured using a Sirognathograph, a magnetic jaw tracking device (Siemens Corp. Bens-

Table
of PostoperativePreoperative Diff
SD x P P P

1.
Significance of Difference Between Control & Preoperative Significance of Difference Between Control & Postoperative Significance PreoperativePostoperative Change

Morphological

and

Biochemical

Variables

for Patients

and

Controls

Controls (n = 26) x
SD f SD x

Preoperative (n = 15)

Postoperative (n = 14)

Variable

89.43 80.57 78.05 88.43 119.27 22.15 2.53 1.93 108.84 84.15 3.59 2.99 52.67 131.14 26.20 80.02 69.85 53.60 44.00 121.69 80.45 7.55

3.24 3.66 3.44 2.69 4.54 4.51 1.57 1.59 5.06 4.78 0.81 1.09 9.30 6.71 2.23 4.23 5.59 2.56 1.93 4.13 4.14 3.11

91.56 82.08 76.51 86.11 115.04 30.53 5.59 2.84 108.75 82.27 4.26 0.45 68.57 119.28 27.15 75.14 76.02 52.85 42.14 126.97 83.57 12.17

4.91 4.34 3.10 3.79 5.76 6.93 2.64 1.58 7.47 8.00 1.55 2.40 17.73 8.94 1.86 7.18 4.24 2.63 2.38 6.20 5.62 5.76

91.57 82.07 76.91 88.82 117.64 27.08 5.15 2.60 105.34 83.84 3.16 1.66 64.59 128.39 23.81 75.36 74.67 50.44 41.04 125.39 81.71 10.52

5.03 5.02 3.70 3.60 5.86 6.83 2.14 0.98 6.72 6.73 0.83 1.06 17.28 6.29 2.43 7.05 5.63 3.33 2.91 7.20 4.81 5.84

0.01 -0.01 0.40 2.71 2.60 -3.45 -0.44 -0.24 -3.41 1.57 -1.10 1.21 -3.98 9.11 -3.32 0.22 -1.35 -2.41 -1.10 -1.59 -1.86 -1.65

0.434 0.693 0.497 0.126 0.063 0.000 0.000 0.249 1 .ooo 0.820 0.252 0.000 0.004 0.000 0.553 0.052 0.003 0.829 0.066 0.020 0.175 0.021

0.449 0.711 0.740 0.982 0.772 0.055 0.003 0.533 0.425 0.999 0.646 0.132 0.053 0.753 0.010 0.078 0.035 0.005 0.001 0.189 0.844 0.247 1.000 1.000 0.988 0.114 0.524 0.373 0.947 0.973 0.473 0.921 0.046 0.279 0.862 0.024 0.001 1.000 0.898 0.090 0.561 0.864 0.706 0.789

91.34 0.41 0.23 0.53 4.43 0.04 0.04 0.04 0.66 0.55 0.29 0.05 0.04 0.06 66.72 3.84 0.03 0.48 0.05 0.5 66.50 0.53 0.3 0.68 0.02 0.03 0.40 0.21 0.04 0.03 0.39 0.22 0.05 0.03 0.04 5.08 0.05 0.04 0.06

4.29

92.30

5.27

90.85

5.95

-1.45 -0.01 0.01 0.02 -0.22 -0.02 0.01 0.02

0.935 0.492 0.496 0.000 0.913 0.295 0.361 0.000

0.991 0.263 0.819 0.012 0.961 0.050 0.534 0.003

0.865 0.977 0.968 0.641 0.999 0.849 0.996 0.882

65.80 0.57 0.31 0.74

Skeletal/Dental FH-NA () SNA () SNB () Fat Plane Ang c) MANDLENG (mm) MP - FH () ANB () Wits (mm) Ul-PP () IMPA () Inc overJet (mm) Inc overbite (mm) AFI-UPFH (%) UI-LI () PNS-FH (mm) PFH (-) Ix-l mu lJFH (ml@ uFH/TFH W) Gonial angle () FH-Ramus () Functional OP-FH () Biomechanics Incisor Incisor moment arm Anterior temp mech adv Post temp mech adv Superf mass mech advantage Molar Molar moment arm Anterior temp mech adv Post temp mech adv Superf mass mech advantage

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heim, Germany). The subjects were comfortably seated in a chair with their heads in an unsupported natural position. A small (5 X 7 mm, 5 g) special magnet (version 2, Bio-pack, Bio-Research Associates, Milwaukee, WI) was fixed to the attached gingiva in the mandibular incisor region as previously described.29 The magnet was first enclosed in a small amount of warmed dental compound (Mizzy, Inc., Clifton Forge, VA) and was then attached to the gingiva using a small amount of Stomadhesive (SquibbKonvatec, Princeton, NJ). Care was taken during placement of the magnet so that it would not interfere with occlusion or motion in any way. The magnetic sensor array was then placed on the subjects head and adjusted so that the magnet would be at its center when the mouth was halfway open. The magnets position, to the nearest 0.1 mm, was recorded in real time along three orthogonal axes. The magnets motion tracing was simultaneously viewed on the screen and saved on floppy computer discs using an IBM AT computer. Each mandibular motion was measured in the sagittal and frontal planes at a rate of 250 samples per second. Maximal and average numerical values for motion along the three axes were displayed automatically on the computer screen. The subjects were instructed to perform four voluntary movements of the mandible: maximum opening, maximum right excursion, maximum left excursion, and maximum protrusion. Patients were instructed to perform each movement to their maximum extent without causing discomfort. Each of the mandibular movements was repeated five times and the maximum value for each of the following measurements were recorded: voluntary interincisal opening, vertical displacement on opening, lateral deviation on opening, posterior movement on opening, right lateral excursion, left lateral excursion and protrusion. These measurements have been shown to be reproducible to the nearest 2 mm in the same individual.2 The subjects were then given a constant bolus (Gummi-Bears, HARIBO, Bonn, Germany) and instructed to chew the bolus in a habitual manner for at least 10 cycles. Maximum vertical, lateral, and anteroposterior excursions during mastication were measured and recorded. The test was repeated a second time with a fresh bolus. BITE FORCEMEASUREMENTS Teenier et al have previously described in detail our protocol for measurement of bite forces.24 A dual-arm bite transducer with tapered ends was used to measure unilateral bite force. The ends of the transducer were covered with propylene tubing to avoid damage to the occluding teeth and then adjusted for an interocclusal opening of 15 mm. A standard analog voltmeter served

as visual feedback to the subjects for maintenance of the required force level. While seated comfortably, the subjects were instructed to bite to the instructed force level and maintain it for 1 second while electromyographic data were recorded. Maximum bite forces were recorded at eight tooth positions: right and left central incisors, canines, first premolars, and first molars. At the right incisor and both molar positions, subjects were instructed to bite to five submaximal force levels. Electromyographic activity at approximately at lo%, 20%, 40%, 60%, and 80% of the maximum voluntary bite force at that tooth position was recorded.
ELECTROMYOGRAPHY

Teenier et al have previously described in detail our protocol for electromyography measurements.24 The electromyographic activity (EMG) of three pairs of muscles were recorded bilaterally. The posterior temporalis, anterior temporalis, and masseter muscles were palpated bilaterally and the skin over the muscles was lightly rubbed with an alcohol pad to increase conductance. Self-adhesive, disposable, pre-gelled Ag/AgCl surface electrodes were placed over the bulk of the muscles to be tested. A headband retained the posterior temporalis electrodes in the hair-bearing areas. A ground electrode was placed on the left stemocleidomastoid muscle approximately at the level of the hyoid bone. EMG activity was measured using a set of six amplifiers with a band pass of 40 to 1,000 Hz and was digitized in real time at a sampling rate of 500 Hz per channel. Common 60 Hz or other interference signals were filtered using a high common mode rejection (2,000,OOO: 1, Bio-pak, Bio-Research Associates, Milwaukee, WI). The computer screen displayed the signals immediately after the activity and calculated a mean EMG value (pV> for each muscle. EMG activity was recorded during isometric maximal and submaximal contractions as well as during normal mastication of the constant bolus. To compare muscle activity between subjects and trials, a least squares regression line was fitted by Systat using the EMG readings at the six bite force levels at each tooth position (Systat, Inc. Evanston, IL). The same linear relationship was established for working and nonworking muscle groups. The slope of this line indicates a muscles recruitment rate when generating isometric forces and the intercept indicates the muscles resting activity level.25~26The EMG/force slopes and intercepts from multiple trials for each muscle of each patient were averaged to calculate the preoperative and the postoperative values.
STATISTICALANALYSIS

Analysis of variance (ANOVA) was used first to detect intergroup differences. Tukey HSD (honest sig-

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Table 2. Range of Mandibular
Controls (n = 26) Variable Maximum Excursions During opening Interincisal dimension Vertical excursion Posterior excursion Lateral deviation Maximum Excursions Right Lateral Left Lateral Protrusion Excursions During Mastication Interincisal dimension Vertical excursion Posterior excursion Lateral excursion * Indicates significant Voluntary
x SD

FUNCTION

AFTER

MAXILLARY

IMPACTION

Motion

for Controls

and

Patients

(mm)
1 Year (n = 11)
x SD

Preoperative (n = 15) x
SD

6 Weeks (n = 9)
f SD

6 Months (n = 12) x
SD

2 Years (n = 9)
x SD

3 Years (n = 6)
x SD

49.71 39.77 23.52 4.97 12.53 11.84 8.76

7.46 7.03 5.93 3.12 2.65 2.39 1.55

42.92 34.60 21.52 4.60 10.26 10.36 8.85

8.73 7.07 5.79' 3.29 2.22 2.32 2.33

37.19* 31.41 16.58 4.00 8.60* 9.31 9.04

7.82 7.07 5.90 2.00 1.81 1.89 2.50

40.59 33.06 20.38 4.45 10.35 10.47 9.03

7.74 6.61 5.77 2.24 2.26 2.15 2.43

41.47 34.34 20.72 3.98 10.32 9.85 7.52

5.29 3.53 4.99 2.16 2.59 2.59 1.79

42.59 36.40 19.54 3.64 10.31 9.76 6.95

6.13 4.59 4.28 2.03 2.08 2.36 1.76

42.23 36.76 18.82 5.67 10.47 9.46 5.87

5.99 4.27 3.28 2.54 2.45 1.97 1.95

18.29 16.45 7.79 15.37 difference

3.99 3.65 2.34 3.65 from

20.40 17.79 9.65 13.96

5.65 5.05 3.67 3.13

16.98 14.81 8.01 11.39*

4.31 4.30 2.33 1.82

17.69 15.41 8.30 12.97

3.93 3.87 2.80 4.05

18.36 16.29 8.31 12.31

3.81 3.07 2.79 2.40

17.89 15.83 8.14 13.59

6.23 6.05 2.42 2.20

15.46 13.23 7.69 13.18

2.60 2.37 2.62 2.36

controls

at P 5 .05.

nificant difference) multiple comparisons were used to derive a post hoc matrix of pairwise probability comparison for each of the test components. This matrix was used to determine statistical significance between patients and controls. If patient measurements were significantly different from two or more of three control trials, it was considered statistically significant. Univariate repeated measures ANOVA was used to detect intragroup changes between trials within patients. Because some patients were not available for all trials, the sample sizes were smaller for the longitudinal statistical analysis (see section on Maximum Voluntary Bite Force). Statistical comparison of the morphologic measurements before and after surgery was performed with the paired t-test. Statistical significance was defined as P 5 .0.5.
Results MORPHOLOGICAL MEASUREMENTS

Before surgery, the patients showed morphologic measurements characteristic of WVIE.~~ As expected, when compared with controls of the same age-group and gender, the patients showed a significantly greater gonial angle, steeper mandibular plane angle, smaller incisal overbite, higher ANB angle, smaller interincisal angle, greater lower facial height, and a greater ratio of the anterior to posterior facial height (Table 1). Intrusion of the maxilla increased the overbite an average of 1.21 mm. The significant preoperative difference in overbite between patients and controls

was no longer significant postoperatively. Incisor overjet and excessive lower facial height significantly decreased with surgery (P -= .05). The AFH/ PFH ratio decreased an average of 4% with surgery, making it no longer significantly different than controls . The perpendicular distance between posterior nasal spine and Frankfurt horizontal plane significantly decreased with surgery (X = 3.3 mm; P 5 .05). The angle between the ramus and Frankfurt horizontal plane (FHRamus) also decreased with surgery, indicating counterclockwise rotation of the mandible. The steep mandibular plane angle decreased with surgery, and it was no longer significantly different from the controls. Overall, a normalization of morphologic measurements occurred with surgery (Table 1). Before surgery, the incisor and molar moment arms were not significantly different from controls, and they remained unchanged with superior repositioning of the maxilla. Presurgical values of mechanical advantage for the superficial masseter muscles, at both incisor and molar bite positions, were significantly lower than in controls, but those for the anterior and posterior temporalis were not. Generally, superior repositioning of the maxilla had little effect on the biomechanical characteristics of patients (Table 1). Although mechanical advantages for superficial masseter at both bite positions increased with surgery, they remained significantly lower than controls (P 5 .05). The anterior temporalis mechanical advantage for the molar bite position decreased slightly with surgery and became significantly lower than controls (P c: .05).

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A
20 ,
Trial 1

Incisor
Trial 2 Triai 3 T

Canine
Trial 1 Trial 2 Trial 3

0 C
40

I
PIWp. 6 mos. 1 yr. 2yn. 3 yrs.

Preop.

6 mos.

1 yr.

2 yrs.

3 yrs.

Premolar
Trial 1 Trial 2 Trial 3

D
50

Molar
Trial T 1 Trial 2 Trial 3

I 0 Preop. 6 mos. 1 yr. 2 yrs. 3 yru. 5 Pre0p. 6 mos. 1 yr. 2 yrs. 3 yrs

FIGURE 1. Graphs showing the mean bite forces for all four bite positions measured for controls (!J) and patients (0). A, incisor bites; B, canine bites; C, premolar bites; D, molar bites. Error bar signifies SD. * indicates significant difference from controls at P 5 .05. Note: 31 values represent the number of bite force measurements at each time interval, not the number of patients (right and left sides were combined).

MANDIBULAR

RANGE OF MOTION

was significantly different from normal values by the 6-month postoperative visit. MAXIMUM VOLUNTARY BITE FORCE There were no statistically significant differences between right and left side maximum bite forces in either patients or controls. Therefore, values for right and left side bites were combined for statistical analysis. Before surgery, patients had maximum bite forces that were significantly lower than for controls at all bite positions (P s .05) (Fig. 1). A steady increase in bite forces for all tooth positions occurred after surgery. However, repeated measures analysis showed significant increases in bite forces only at the incisor, canine, and premolar positions (P 5 .05, n = 7, n = 9, n = 10, respectively). The molar bite force tended to increase over time but was not statistically significant (P = .42, n = 10). At 6 weeks, 6 months, and 1 year postoperatively, although all bite forces were higher than preoperative values, they still were sig-

Measurements of mandibular movement for controls and patients are presented in Table 2. Preoperative measurements of mandibular border movements for patients were not significantly different than for controls. The maximum voluntary opening and vertical excursion in maximal opening measurements were both significantly lower than those of controls at 6 weeks after surgery (P 5 .05), but returned to normal values at the 6-month visit. Controls showed no significant changes in maximum voluntary excursions between trials. Overall, mandibular movements during mastication were not affected by surgery. Maximum lateral excursions during mastication were significantly lower than for controls at 6 weeks postoperatively (P 5 .05). In fact, the major trend in all of the mandibular movement measurements was toward a decrease at 6 weeks postoperatively, but only few reached significance when compared with controls. None of the measurements

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Table 3. EMG/Bite Force Slopes

FUNCTION AFTER MAXILLARY

IMPACTION

Controls (n = 26) Variable Incisor Bites Rt Ant Temporalis Lt Ant Temporalis Rt Post Temporalis Lt Post Temporalis Rt Masseter Lt Masseter Right Molar Bite Rt Ant Temporalis Lt Ant Temporalis Rt Post Temporalis Lt Post Temporalis Rt Masseter Lt Masseter Left Molar Bite Rt Ant Temporalis Lt Ant Temporalis Rt Post Temporalis Lt Post Temporalis Rt Masseter Lt Masseter x 2.95 1.99 1.45 1.75 4.78 5.75 2.49 2.11 2.75 1.48 3.08 3.13 1.97 2.59 1.52 2.78 3.29 3.10
SD

Preop (n = 13)
x SD x

Postop (n = 13)
SD

Significance of Difference Between Controls & Preoperative

P

Significance of Difference Between Control and Postoperative

P

Significance of PreoperativePostoperative Change

P

1.50 0.40 1.00 2.50 2.56 3.19 1.16 0.90 1.58 1.01 1.94 1.91 0.91 1.12 1.10 1.85 1.94 1.98

3.78 4.44 1.36 1.34 4.22 5.13 3.68 1.62 2.16 1.16 2.30 2.44 1.89 2.79 1.39 2.30 2.56 2.19

2.51 2.72 1.51 1.59 3.52 13.82 2.82 0.78 1.33 1.41 1.49 1.28 0.91 2.19 1.09 3.60 1.31 1.04

3.51 3.29 0.99 0.50 5.70 5.44 3.06 1.97 1.40 0.49 2.53 2.96 2.27 2.23 0.66 1.37 2.62 2.38

1.35 1.06 1.26 1.27 1.48 2.35 0.99 0.75 0.80 0.78 P.37 1.13 0.83 0.72 0.44 0.78 1.14 1.03

t t3

* Statistically significant difference for intercept of EMG/FORCE line at P 5 .05. t Statistical& significant difference at P 5 .05. $P < .Ol.

nificantly lower than for controls (P 5 .05). At 2 and 3 years postoperatively, patients exerted bite forces, except at the incisors, that were no longer significantly different from those of controls. The controls showed no significant change in bite force between trials.
MUSCLE ACTIVITY

controls. The slopes for the patients muscles were not significantly different than controls either before or after surgery. Except for the masseter muscles, the slopes decreased with surgery. All measured muscles tended to become less active except for the masseters, which became more active; however, none of the changes were statistically significant.
Molar Bites

Analysis of the slopes of the EMG/bite force regression line between patients and controls did not provide any recognizable pattern preoperatively or postoperatively. Individual muscle data comparisons did not show any coherent pattern of change with surgery. To enhance our ability to analyze the data and reduce some of the intrasubject variability in slopes and intercepts, the values for multiple trials preoperatively and postoperatively were averaged (Table 3).
Incisor Bites

Before surgery, patients tended to show lower intercept values than controls, ie, lower EMG readings at rest, but only the left posterior temporalis intercept was significantly lower (P c: .05). After surgery intercepts tended to decrease from their preoperative value and the right masseter was significantly lower than that of

Preoperatively the patients generally had higher intercept values and lower slope values than controls at the molar positions. Preoperatively the contralateral anterior temporalis showed a significantly different intercept than for controls during right molar bites. There were no significant changes in the intercept values between preoperative and postoperative measurements. Postoperatively, the slope values for the ipsilateral anterior temporalis and both posterior temporalis muscles decreased. The slope values for the other three muscles increased. The postoperative slopes for both posterior temporalis muscles were significantly lower than controls (P I .05). There were no significant changes in the intercept values between preoperative and postoperative measurements. These results generally indicate that after surgery the posterior temporalis muscles and

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the contralateral anterior temporalis were less active during molar bites, whereas the masseter muscles became more active.
Discussion

Mandibular mobility is perhaps the simplest functional modality to measure, requiring only a ruler. A number of investigators have studied this parameter in detail.4,9- I I,23,30 Athanasiou et al showed that patients with dentofacial deformities had significant differences in mandibular movements when compared with controls.?l Agerberg reported the mean maximal interincisal opening in young adult females (mean age, 20.5 years) with normal skeletal and dental relationships to be 53.3 2 5.7 mm, with a range of 42 to 75 mm, similar to our controls (49.71 + 7.46 mm). Our patients mouth opening (42.92 ? 8.73 mm) was close to the lower range reported by others., The pattern of change in mandibular mobility encountered after surgery was expected and had been reported by others., ,21 In general our results confirmed a short-term decrease in all measurements of mandibular mobility with surgery followed by recovery from any temporary limitations within a relatively short period. A short-term reduction in mandibular range of motion has been correlated with the duration of maxillomandibular fixation (MMF).2 In spite of the fact that our patients were not put into MMF, at 6 weeks postsurgery some decrease in mobility was noted. This reduction of mobility was most likely attributable to voluntary limitation of function due to edema and pain caused by the surgery. ORyan and Epker reported reduction in all measurements of mobility 2 years after surgery, but did not provide any statistical analysis of their data.2 Aragon et al reported long-term limitation of only mandibular protrusion with isolated maxillary surgery. Our study also showed some reduction in protrusion at 1 or more years after surgery. In a study of mandibular range of motion before and after orthognathic surgery, Zimmer et al have shown that Le Fort I osteotomy has little or no effect on maximum incisal opening or other excursions but, if combined with mandibular surgery, reduction in mobility occurs similar to that observed in cases with mandibular surgery alone.4 Our study also suggests that significant long-term reduction of mandibular mobility does not occur with isolated maxillary surgery. Patients with vertical maxillary excess have weaker facial and masticatory musculature than normal individuals.5*6-20 It has been postulated that the weaker musculature may contribute to the development of the characteristic facial skeleton.-5 Our mean values for patients preoperative maximum bite forces were very close to values reported by other authors.5,7z5Proffit et

al reported that VME patients who underwent superior repositioning of the maxilla had a substantial increase in their maximum molar bite force 1 year after surgery.6 This supports the results seen in our study where our patients at 1 year had significantly higher bite forces than preoperatively and were no longer deficient when compared with controls. In our study, bite forces increased by 18% at the molar position over 2 years. For all bite positions combined, the forces increased an average of 52.3% over the 3-year study. The canine positions showed the highest increase (82%) and the molar position the lowest (18%) (Fig 1). One factor contributing to the lower preoperative force levels could be the effects of the presurgical orthodontics. In a cross-sectional study, Thomas et al showed that the presence of orthodontic appliances and active treatment lowers the maximum bite force by as much as 53% at the incisor and 21% for all bite positions averaged.29 Preoperatively our patients had maximum bite forces that were only 37% of controls at the incisor position, and an average of 47% at the other positions. Therefore, our patients had 6% lower maximum incisor bites and an average of 32% lower maximum bite forces at the other positions than would be expected from presurgical orthodontics alone. After surgery our patients had a 58% increase in bite force at the incisor position and an average 51% increase for all other bite positions. Therefore, our patients had 5% greater increase for incisor bites and an average of 30% greater increase for bite forces at the other positions than would be expected from temnnation of orthodontic treatment. These results suggest that some of the significant increase of bite force seen in our study may be attributable to recovery from orthodontic treatment, but part of the increase, especially at posterior tooth positions, resulted from orthognathic manipulation of the jaw or increased efficiency of the muscles. Absolute values for electrical activity (EMG) generated by individual muscles of mastication are directly proportional to the isometric bite force being generated. Therefore, comparison of muscle activity levels among subjects must take bite force magnitudes into account. The slope of the least squares regression of EMG levels per isometric bite force indicates a muscles recruitment rate during generation of an isometric force.25,26A higher slope may indicate a less efficient muscle, ie, the muscle produces higher levels of activity to build up the same isometric bite force as a muscle with a lower slope. The y-intercept of the regression line represents the EMG activity at rest. By studying slopes and intercepts one can estimate the muscular effort at any isometric bite force as well estimate the magnitude of bite forces during mastication. Johnston et al reported mixed changes in electrical activity of masticatory muscles after superior reposi-

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AFTER

MAXILLARY

IMPACTION

tioning of the maxilla; however, they studied muscular activity in only three patientsz7 After surgery, an overall decrease in the slopes of the masticatory muscles, particularly the contralateral side anterior temporalis muscles and bilateral posterior temporalis muscles, were detected in our patients. A similar trend was also observed by Ellis et al in a small sample of anterior open bite patients.6 Thomas et al showed no change in muscle activity with initiation of orthodontic treatment; therefore, we conclude that the lower levels of electrical activity seen in our patients do not result from orthodontic effects.29 Johnston et al also showed that superior repositioning of the maxilla improved the mechanical advantage in five of six muscles of mastication.27 In our patients, surgery slightly decreased the mechanical advantage for the anterior temporalis muscles and slightly increased that of the masseter muscles. None of the changes were statistically significant. These results were essentially the same as those reported by Proffit et al6 In our patients, autorotation of the mandible shortened the temporalis moment arm by posterior movement of the coronoid process and lengthened the masseter moment arm by anterior movement of gonion. The model of Throckmorton et al predicted that the mechanical advantage of both the temporalis and masseter would be increased, based on the assumption that the center of mandibular rotation is at the condyle.** In real patients, autorotation of the mandible occurs at a point close to the mandibular foramen, resulting in a decrease in temporalis mechanical advantage and a smaller increase for the masseter than predicted by the model. Preoperatively our patients had a significantly lower masseter mechanical advantage than controls. This coincides with the lower preoperative bite force levels. After surgery, the masseter mechanical advantage remained significantly lower than controls even though the bite forces increased significantly. Therefore, the lower mechanical advantage for the masseter muscle could not be the sole reason for lower preoperative force levels. The question we must answer is what role do morphologic characteristics play in determining the level of muscular activity. Throckmorton et al have previously shown that mechanical advantage alone is an unreliable determinant of the level of muscular activity.** It was determined that the relative slopes of the muscles of mastication correspond more closely to their relative size than to their relative mechanical advantage.** However, in our study, the superficial masseter slope increased at every tooth position in spite of an increase in mechanical advantage. The anterior temporalis muscle had decrease in slope for the incisor and ipsilateral molar bites in spite of decreased me-

chanical advantage. We can therefore conclude that mechanical advantage is an unreliable predictor of changes in muscle recruitment after surgery. Possible explanations for the slight improvement in muscle efficiency and significant improvement in bite force could include the contribution of other muscles involved in mastication but not measured in this study. It is well known that the medial pterygoid is involved in adduction of the mandible, and it could have increased its level of activity after surgery. However, in isolated maxillary surgery, the muscles of mastication are only minimally traumatized and a compensatory increase in activity of a muscle to offset the effects of trauma is unlikely. If the lower preoperative slope levels were attributable to increased activity of unmeasured muscles, with recovery the slopes of the measured muscles should have increased, but this was clearly not the case. The results of this study show that VME! patients have various functional and morphologic deficits when compared with controls and that superior repositioning of the maxilla does not impair the patients functional or morphologic parameters. Correction of the excess vertical facial height by superior repositioning of the maxilla produces improvement in a number of the functional parameters, some more than others. References
1. Bell WH: Le Fort I osteotomy for correction of Maxillary deformities. J Oral Surg 33:4-12, 1975 2. Bell WH. McBride KL: Correction of long-face svndrome bv LeFort I osteotomy. Oral Sug Oral Medcbral Path01 44:493, 1977 3. Fish LC, Wolford LM, Epker BN: Surgical-orthodontic correction of vertical maxillary excess. Am J Orthod 3:241, 1978 4. Zimmer B, Schwestka R, Kubein-Meesenburg D: Changes in mandibular mobility after different procedures of orthognathic surgery. Eur J Orthod 14:188, 1992 5. Proffit WR, Fields HW, Nixon WL: Occlusal forces in normal and long-face adults. J Dent Res 62(5):566, 1983 6. Proffit WR, Turvey TA, Fields HW, et al: The effects of orthognathic surgery on occlusal force. J Oral Maxillofac Surg 47~457, 1989 7. Tate GS, Throckmorton GS, Ellis E, et al: Masticatory performance, muscle activity and occlusal force in pm-orthognathic surgerv uatients. J Oral Maxillofac Surg 52:476, 1994 8. Tate &,*Throckmorton GS, Ellis E, et al: &imatedmasticatory forces in patients before orthognathic surgery. J Oral Maxillofat Surg 52:130, 1994 9. Boyd SB, Karas ND, Sinn DP: Recovery of mandibular mobility following orthognathic surgery. J Oral Maxillofac Surg 49:924, 1991 10. Ehmer U, Broll P: Mandibular border movements and masticatory patterns before and after orthognathic surgery. Int J Adult Orthod Orthognath Surg 7:153, 1992 11. Aragon SB, Van Sickels JE, Dolwick MF, et al: The effects of orthognathic surgery on mandibular range of motion. J Oral Maxillofac Surg 43:938, 1985 12. Clark GT, Carter MC, Beemsterboer PL: Analysis of electromyographic signals in human jaw closing muscles at various isomehic force levels. Arch Oral Biol 33:833, 1988 13. Throckmorton GS, Johnston CP, Gonyea WJ: A preliminary study of biomechanical changes produced by orthognathic surgery. J Prosthet Dent 51:252, 1984

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26. Lindauer SJ, Gay T, Rendell J: Electromyographic-force characteristics in the assessment of oral function. J Dent Res 70:1417, 1991 27. Johnston CP, Throckmorton GS, Bell WH: Changes in electromyographic activity following superior repositioning of the maxilla. J Oral Maxillofac Surg 42:656, 1984 28. Schendel SA, Eisenfeld J, Bell WH, et al: The long face syndrome: Vertical maxillary excess. Am J Orthod 70:398, 1976 29. Thomas GP, Throckmorton GS, Ellis E, et al: The effects of orthodontic treatment on isometric bite forces and mandibular motion in patients prior to orthognathic surgery. J Oral Maxillofac Surg 53:673, 1995 30. Agerberg G: Maximal mandibular movements in young men and women. Swed Dent J 67:81, 1974 31. Atbanasiou AE, Melsen B, Mavreas D, et al: Stomatognathic function of patients who seek orthognathic surgery to correct dento facial deformities. Int J Adult Orthod Orthognath Surg 4:239, 1989 32. Aragon SB, Van Sickels JE: Mandibular range of motion with rigid/non-rigid fixation. Oral Surg 63:408, 1987 33. Proffit WR, Gamble JW, Christiansen RL: Generalized muscular weakness with severe anterior open-bite. Am J Orthodont 54:104, 1968 34. Steinhauser EW, Lines PA: Correction of severe open-bite associated with muscular disease. Oral Surg 39509, 1975 35. Hamada T, Ymauchi K, Yamada S, et al: Roentgen-cephalometric analysis of open-bite in patients with progressive muscular dystrophy. Hiroshima J Med Sci 26:161, 1977 36. Ellis E, Throckmorton GS, Sinn DP: Functional characteristics of patients with anterior open-bite before and after surgical correction. Br J Oral Maxillofac Surg, March 1995 (submitted)

14. Ow RKK, Carlsson GE, Jemt T: Biting forces in patients with craniomandibular disorders. J Craniomandib Pratt 7: 119, 1989 15. Dean JS, Throckmorton GS, Ellis E, et al: A preliminary study of maximum voluntary bite force and jaw muscle efficiency in pre-orthognathic surgery patients. J Oral Maxillofac Surg 50: 1284, 1992 16. Sassouni V: A classification of skeletal facial types. Am J Orthod 55:109, 1969 17. Sassouni V, Nanda S: Analysis of dentofacial vertical proportions. Am J Orthod 50:801, 1964 18. Weijs WA, Hillen B: Relationship between masticatory muscle cross-section and skull shape. J Dent Res 63: 1154, 1984 19. Gionhaku N, Lowe AA: Relationship between jaw muscle volume and craniofacial form. .I Dent Res 68805, 1989 20. van Spronsen PH, Weijs WA, Valk J, et al: A comparison jaw muscle cross-sections of long-face and normal adults. J Dent Res 71:1279, 1992 21. ORyan F, Epker BN: Surgical orthodontics and the temporomandibular joint I. Superior repositioning of the maxilla. Am J Orthod 83:408, 1983 22. Throckmorton GS, Dean JS: The relationship between jaw-muscle mechanical advantage and activity levels during isometric bites in humans. Arch Oral Biol 39:429, 1994 23. Throckmorton GS, Teenier TJ, Ellis E, et al: Reproducibility of mandibular motion and muscle activity levels using a commercial computer recording system. J Prosthet Dent 68:348, 1992 24. Teenier TJ, Throckmorton GS, Ellis E: Effects of local anaesthesia on bite force generation and electromyographic activity. J Oral Maxillofac Surg 49:30, 1991 25. Hagberg C, Agerberg G, Hagberg M: Regression analysis of electromyographic activity of masticatory muscles vs. bite force. Stand J Dent Res 93:396, 1985