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13
Standard Analytic Model Planning

for Orthognathic Surgery
JEFFREY C. POSNICK, DMD, MD
• Controversies Surrounding Model Planning Unlike most surgical procedures, orthognathic surgery
for Orthognathic Surgery involves not just the thorough medical assessment of the
• Standard Facial Records for Orthognathic patient but also precise preoperative dental, radiographic,
Surgery and facial aesthetic planning. e surgeon must carry out a
• Key Measurements Obtained via Direct Visual detailed face-to-face examination of the patient to deter-
Examination to De ne Planned mine variations from normal (Fig. 13-1).
Maxillomandibular Surgical Change Immediate presurgical records include the following:
1) dental impressions of the maxilla and mandible 2) an
• Face-Bow Registration and Transfer to the accurate bite registration in centric relation (CR) 3) a face-
Semi-Adjustable Articulator bow recording of maxillary orientation in relationship to
• Use of the Erickson Model Table to De ne the the condyles and the upper face and 4) the measurement of
Spatial Orientation of an Articulator- speci c facial landmarks that includes deviations from
Mounted Maxillary Unit normal (Figs. 13-2 and 13-3).
• Use of the Erickson Model Table to De ne the e maxillary model is mounted on a semi-adjustable
Spatial Orientation of an Articulator- articulator in accordance with the face-bow recording. e
Mounted Mandibular Unit mandibular model is occluded to the mounted maxillary
cast with the use of the CR bite 1,2,14,17,18,21,30,52,62,63 (Fig.
• Separation of the Maxillary Cast from the 13-4). e mounted dental casts are then used to complete
Articulator Base model planning12,50 (Figs. 13-5 through 13-8). Splints made
• Segmentation of the Maxilla of acrylic are fabricated and used intraoperatively to further
• Use of the Erickson Model Table ensure the reliable execution of predetermined facial aes-
Measurements to Reorient the Maxillary Cast thetic and functional objectives (Figs 13-9 through 13-11).
Although clinical decision making regarding the pre-
• Intermediate Splint Construction for the
ferred aesthetic reorientation and repositioning of the jaws
Positioning of the Maxilla During Operation in the operating room remains both an art and a science
• Reorientation of the Mandibular Cast to (see Chapter 12), the technical aspects of planning should
Register the Final Occlusion be precise and consistent. Analytic model planning and the
• Final Splint Construction for the Positioning use of prefabricated splints continue to represent the stan-
of the Mandible During Operation dard of care for bimaxillary and segmental maxillary
osteotomies.8,9,15,16,22,26,44,55,77,78,80,85,86
• Finishing of the Prefabricated Acrylic Splints Despite the bene ts of this time-honored approach,
• Accuracy of the Described Analytic Model there is the potential to introduce error. For example, during
Planning Technique: Review of Study bimaxillary surgery, if an inaccurate bite registration is
• Conclusions obtained from the patient preoperatively in the clinic
setting, this will be transferred to the articulated models;
this leads to inaccurate splint construction and then to
intraoperative errors when the splints are relied on during
surgery. e surgeon’s ability to obtain an accurate and
reproducible bite registration in CR during the immediate
Text continued on p. 405
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CHAPTER 13 Standard Analytic Model Planning for Orthognathic Surgery 375
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• Figure 13-1 A 19-year-old man of Asian descent presented with a maxillary de cient and relative mandibular
excess growth pattern. He has an Angle Class III anterior open bite with negative overjet malocclusion as well as
a lifelong history of obstructed nasal breathing. The maxillofacial dysmorphology causes dif culties with speech,
chewing, swallowing, breathing, and lip closure/posture, and it also negatively affects his facial aesthetics. The
upper facial skeleton is symmetric and proportionate; the soft-tissue envelope is distorted but not malformed. There
is a good range of motion of the neck and mandible without temporomandibular disorder. After evaluation, a
comprehensive orthodontic and surgical approach was discussed and approved. Orthodontic (dental) decompen-
sation required 10 months of active treatment. No extractions were required. Six weeks before surgery, the patient
returned for a direct visual examination and the taking of records that included alginate impressions of the maxilla
and mandible, centric bite registration, face-bow registration, and the transfer of the data to a semi-adjustable
articulator. Decisions were made regarding critical measurements for the surgical repositioning of the jaws. The
procedures carried out included the following: a Le Fort I osteotomy in segments (horizontal advancement, cant
correction, arch expansion, and clockwise rotation); bilateral sagittal split ramus osteotomies (mandibular adjust-
ment); osseous genioplasty (minimal vertical shortening and horizontal advancement); and septoplasty and inferior
turbinate reduction. A, Frontal view in repose and occlusal views before treatment. B, A Panorex radiograph. This
is useful to assess basic condylar morphology and to look for mandibular and dental pathology, including root
resorption. Continued
376 S E CT IO N 2 Planning, Surgical Technique, & Complications
Assess intranasal anatomy

• Septal deviation? “Yes”
• Inferior turbinate hypertrophy? “Yes”
• Tight nasal inlet? “Yes”
• Elevated nasal floor? “No”
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• Figure 13-1, cont’d C, The patient’s history of lifelong nasal obstruction—in combination with an intranasal
speculum and a sinus computed tomography scan examination—con rms a deviated septum (bone and cartilage)
and hypertrophic inferior turbinates. Both of these conditions required surgical correction to improve the airway.
D, Frontal view with smile and occlusal views with orthodontic decompensation in progress.
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Maxillary Surgical Plan
Frontal View:
Maxillary midline No change needed

1 mm (L)
Cant correction 2 mm 1 mm (R)
Anterior vertical No change needed
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5mm
3mm
3mm
F
Maxillary clockwise rotation (3 mm) to enhance profile aesthetics
• Figure 13-1, cont’d E, A frontal facial view con rms that the maxillary midline matches the upper facial midline; that
there is a satisfactory lip–tooth relationship in repose and with smile; and that there is canting of the maxilla at the molars
(2 mm) as compared with the upper face. F, Analysis of the facial pro le and the lateral cephalometric radiograph before
surgery provides useful information about facial height, incisor inclination, A-point to B-point relationship, maxillary and
mandibular projection, and chin morphology. Continued
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Profile View:
Anterior vertical no change
Posterior vertical 3-mm intrusion
Horizontal 5-mm advance
G
Maxillary clockwise rotation (3 mm) to enhance profile aesthetics
Maxillary Surgical Change
Horizontal change at incisors 5
Vertical change at incisors 0

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Midline change at incisors 0
Cant correction -TOTAL 2
↑ 1 on right ↓ 1 on left
Maxillary plane change -TOTAL 3

Clockwise - Counterclockwise
Vertical change at T#3 (right) molar 0 1 3 4

(Base Cant Plane)
Vertical change at T#14 (left) molar 0 1 3 2

H (Base Cant Plane)
Measurements are used to spatially reposition the maxilla. The

mandible is then set into occlusion with the repositioned maxilla.
• Figure 13-1, cont’d G, The direct visual examination of this patient in pro le as well as Andrew’s analysis
con rms the following: an advantage of horizontal advancement at the maxillary incisors (5 mm); no need for vertical
change at the maxillary incisors; an advantage of 3-mm clockwise rotation of the maxillary plane (3-mm intrusion
at the rst molars); and no need for horizontal change at the mandibular incisors. Note that 5-mm horizontal
advancement at the incisors will correct the negative overjet and that 3-mm clockwise rotation of the maxillary
plane (intrusion at the rst molars) will be helpful to restore pro le aesthetics and to overcome maxillary incisor
procumbancy. H, The planned maxillary surgical change is recorded on the orthognathic data sheet. These mea-
surements will be used to spatially reposition and reorient the maxilla rst on the articulator for intermediate splint
construction and then at the time of Le Fort I osteotomy. During surgery, through sagittal split ramus osteotomies,
the mandible will then be set into occlusion with the repositioned maxilla.
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“Chin-point guidance” technique for centric relation
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B
“Chin-point guidance” technique for centric relation
• Figure 13-2 The chin-point guidance technique is used to capture (register) the centric relation bite.
The patient is seated upright and in the natural head position. The chin-point guidance technique is
accomplished by using one hand to apply pressure to the subject’s chin and the other hand to apply
counter pressure to their occiput. This allows the clinician to apply posterior and superior “vectored” force
on the anterior aspect of the mandible. By doing so, the condyles will be seated in a superior-anterior
location within each glenoid fossa (i.e., centric relation). A, The registration of the patient’s maxillary occlu-
sion into soft wax. B, Applying pressure to the chin with the patient’s muscles relaxed. The condyles are
seated, and the mandible is rotated up until the teeth rst occlude. It is essential to avoid a shift (slide)
from the centric relation into a centric occlusion. This may occur in a patient with malocclusion if he or
she is allowed to fully clench the teeth together. Continued
Centric relation (CR) bite (wax)
C
Wax wafer Bite registration
• Figure 13-2, cont’d C, Wax wafer before and after bite registration.
Face-bow registration For transfer of relationships to articulator
Condyles/ear canals
Register spacial orientation between Maxilla/maxillary occlusal plane
Skull base/facial plane
• Figure 13-3 A, Bite fork with soft wax placed on the upper side is demonstrated. The face-bow apparatus is shown from both
the bird’s-eye view and the worm’s-eye view.
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Register patient’s maxillary occlusion into soft wax on bite fork
Even pressure Orrth

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of ear prongs
Thumb screws
Approximating infra-orbital rims (profile)

Temporal bars Consistent with NHP (profile)
Parallel to pupils (frontal)
• Figure 13-3, cont’d B, The patient’s maxillary occlusion is registered into soft wax on the bite fork.
C, The face bow apparatus is held in place through even pressure of the ear prongs in each ear canal.
The three thumbscrews are then tightened. Continued
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Thumb screws Even pressure
of ear prongs
Approximating infra-orbital rims (profile)

Temporal bars Consistent with NHP (profile)
Parallel to pupils (frontal)
Ear prongs
Thumb screws secure ear prongs

(once the face bow is in place)
• Figure 13-3, cont’d D, The temporal bar is set parallel with the interpapillary line and consistent with the natural head posi-
tion. E, A close-up view is shown of the thumbscrews that secure the ear prongs in place.
Orthognathic Surgery; J.C. Posnick

Temporal bar
Vertical rod
T-screws
T-screws secure bite fork to vertical rod of face bow
Face-bow apparatus removed from patient

Ready to place on semi-adjustable articulator
• Figure 13-3, cont’d F, T-screws secure the bite fork to the vertical rod of the face-bow apparatus. The T-screws are turned clockwise
to secure the face bow after con rming that the temporal bar extensions are parallel to the interpupillary line (frontal view) and consistent
with the natural head position (pro le view). G, With the T-screws tight, the thumbscrews are loosened to release the face-bow apparatus
from the patient. The face bow is now ready to place on the articulator. Continued
Alginate impressions of mandible and maxilla
Use vibrator to
limit air bubbles
I
Pour up alginate impressions in green dental (die) stone
• Figure 13-3, cont’d H, Impression trays are selected to t the patient’s arch form. The alginate is mixed, placed in the
trays, and then taken to the maxillary and mandibular arches, in turn. Negative impressions of the dentition are recorded
in the alginate. I, The alginate impressions are “poured up” in green dental (die) stone. The use of a vibrator during this
process will limit air bubbles.
Base forms are helpful
Incorporate at least 30 mm of stone base
Trim each model
First molar cusp tip

Measure (25-30 mm) down from Canine cusp tip
Central incisor cusp tip
• Figure 13-3, cont’d J, Base formers are useful when incorporating additional dental stone to achieve at least 30 mm of height for each
dental cast. K, After the die stone is set (≈30 min), the models can be trimmed to achieve a consistent 25-mm base on the maxillary cast
and a 30-mm base on the mandibular cast.
Bite fork
support
A
Mounting maxillary cast on articulator using white plaster Base plate
bite fork support prevents sagging
Base plate
Plaster
Bite fork
support
B
Maxillary cast secured to base plate with plaster
Base plate
Add plaster
Mandibular
• Figure 13-4 A, The trimmed dental casts are cast
then mounted on the semi-adjustable articulator
with the use of the face-bow apparatus. The tem-
poral arms of the face bow are maintained parallel
to the upper aspect of the articulator and the
counter top. Base plates for the maxillary and CR wax bite
mandibular units are secured to the articulation. A
bite-fork support is useful to prevent the sagging
of the face-bow apparatus when mounting the
maxillary cast. B, The plaster is mixed and added
in between the maxillary dental cast and the
base plate. C, With the maxillary unit initially set
(≈15 min), the articulator is turned upside down. C
The centric relation wax bite is occluded to the
maxillary cast. The trimmed mandibular cast is With maxillary unit dry – turn articulator upside down
then occluded to the other side of the wax bite. Use CR wax bite to occlude mandibular cast to maxillary unit
• Figure 13-4, cont’d D, With the base plate secured to the

articulator, the space that separates the mandibular dental cast
from the base plate is lled with white plaster. E, The maxillary
and mandibular units are removed from the articulator and
taken to the grinder for trimming. F, The mounted dental casts
are shown on the semi-adjustable articulator before and after
trimming.
Mandibular and maxillary casts secured to articulator
Remove maxillary and mandibular units from articulator, trim each independently on grinder
F
Prior to trimming After trimming
Placement of maxillary unit horizontal reference lines
- 1st reference line in green stone

- 2nd reference line (15-20 mm down) in white plaster
Placement of maxillary unit vertical reference lines
B C
At mesiobuccal groove of each first molar Between central incisors

Perpendicular to horizontal lines Perpendicular to horizontal lines
• Figure 13-5 Marking horizontal and vertical reference lines on the articulated dental casts. A, The maxillary unit horizontal reference lines
are placed parallel to the base plate. The rst horizontal reference line is placed entirely in the green stone. The second is placed entirely in
the white plaster, with 15 mm to 20 mm of separation between the lines. B, A maxillary unit vertical reference line is placed at the mesiobuc-
cal groove at each rst molar, perpendicular to the horizontal lines. C, The next maxillary unit vertical reference line is placed between central
incisors, perpendicular to the horizontal lines.
Placement of maxillary unit vertical reference lines
D E
At cusp tip of each canine Posteriorly at tuberosity regions

Perpendicular to horizontal lines 2 reference lines on each side – at alveolar ridge
• Figure 13-5, cont’d D, Additional maxillary unit vertical reference lines are placed at the cusp tip of each canine, perpendicular
to the horizontal lines. E, Vertical maxillary unit reference lines are also placed posteriorly in the tuberosity regions. Two reference
lines are generally placed on each side, adjacent to the alveolar ridges. Similar horizontal and vertical reference lines are placed
on the mandibular unit.
Erickson Model Table – Measurements
A
Mark four spacial reference points on maxilla
T#3 T#8 T#9 T#14
• Figure 13-6 The Erickson Model Table (EMT) is used to register the baseline
maxillary orientation in all three planes in space. The baseline measurements
are then used to assist with the accurate repositioning and reorienting of the
maxilla in accordance with clinical requirements. A, With a Sharpie marking
pen, a reference dot is placed at the mesiobuccal cusp tip of each maxillary
rst molar and the midpoint of each maxillary central incisor. Continued
B
Articulated dental casts with reference lines
• Figure 13-6, cont’d B, The articulated dental casts with horizontal and vertical reference lines already marked
are now ready for baseline maxillary reference measurements taken from the EMT. C, The maxillary unit is attached
to the EMT base mount from which measurements will be made.
ORTHOGNATHIC SURGERY : ANALYTIC MODEL PLANNING

Data entry form
Patient name: Surgical wire date:
Surgical date: Final model date:
Orthodontist: Dentist:
ERIKSON TABLE MEASUREMENTS MAXILLARY SURGICAL CHANGE
MAXILLARY HORIZONTAL Horizontal change at incisors
Baseline (mm) Change (mm) Final Vertical change at incisors
Right #8 Midline change at incisors
Left #9 Cant correction-Total
↑↓ on right ↑↓ on left
MAXILLARY VERTICAL
Maxillary plane change-Total
Baseline (mm) Change (mm) Final Clockwise - counterclockwise
Right #3 Vertical change at T#3 (right) molar

(Base cant plane)
Right #8
Vertical change at T#314 (left) molar
Left #9 (Base cant plane)
Left #14
OCCLUSAL EQUILIBRATION/MISSING TEETH

MAX-MIDLINE (Right-side down)
Upper right Upper left
Baseline (mm) Change (mm) Final 8 9 10 32 17
7
6 11
#ML 31 18
5 12
4 30 19
13
MAX-MIDLINE (Left-side down) 3 14 29 20
2 15 28 21
Baseline (mm) Change (mm) Final 27 26 22
1 16 25 24 23
Lower right Lower left
#ML
OVERALL SURGICAL PLAN

MAX TRANSVERSE (Arch width)
Baseline (mm) Change (mm) Final Le Fort I 2 seg 3 seg

Sagittal splits of mandible
#6-11 Genioplasty
Septoplasty
#3-14
Reduction of inferior turbs
Wisdom teeth removal
MANDIBULAR HORIZONTAL
Anterior neck rejuvenation
Baseline (mm) Change (mm) Final Graft required
Iliac Allograft HA
#ML
C
• Figure 13-6, cont’d C, The standard orthognathic surgery model-planning data sheet is shown.
Continued
Maxillary Horizontal
Baseline (mm) Change (mm) Final
Right #8 74.5 5 79.5
Left #9 74.5 5 79.5
Baseline (horizontal) position of incisors (mm)
Maxillary Anterior Vertical
Right #8 96.2 0 96.2
Left #9 95.8 0 95.8
E
Baseline (vertical) position of incisors (mm)
• Figure 13-6, cont’d D, The EMT is used to measure the baseline horizontal position of the incisors in mil-
limeters. This is the distance between the base of the EMT and the incisal edge of each maxillary central. The
millimeter number is recorded on the data sheet. The desired horizontal surgical change at the maxillary inci-
sors is also written on the data sheet. The nal preferred horizontal position of the maxillary incisors, as a result
of model planning, is calculated and recorded. E, The EMT is used to measure the baseline vertical position
of the incisors in millimeters. This is the distance between the base of the EMT and the incisal edge of each
maxillary central incisor. The millimeter number is recorded on the data sheet. The desired vertical surgical
change at the maxillary incisors is also written on the data sheet. The nal preferred vertical position of the
maxillary incisors, as a result of model planning, is calculated and recorded.
Maxillary Posterior Vertical
Right #3 93.1 3/ 1 89.1
Left #14 91.7 3/ 1 89.7
(plane/cant)
Baseline (vertical) position of first molars (mm)
Max-Midline (Right-Side Down)
#ML 43.6 0 43.6
Max-Midline (Left-Side Down)
#ML 41.1 0 41.1
Baseline transverse (midline) position of incisors (mm)
• Figure 13-6, cont’d F, The EMT is used to measure the baseline vertical position of each maxillary rst
molar. This is the distance between the base of the EMT and the mesiobuccal cusp tip of each maxillary rst
molar. The millimeter number is recorded on the data sheet. The desired vertical surgical change at each maxil-
lary rst molar is also written on the data sheet. The nal preferred vertical position of the maxillary molars, as
a result of model planning, is calculated and recorded. G, The EMT is used to measure the baseline transverse
midline position of each incisor in millimeters. This is an indication of the maxillary dental midline position from
both the right side down and left side down directions. The base measurement is recorded on the data sheet.
The desired transverse change at the maxillary incisor is written on the data sheet. The nal preferred transverse
midline position of the maxillary incisor, as a result of model planning, is calculated and recorded.
Remove the maxillary unit from the articulator

Then separate the maxillary cast from its base
3–segments? 2–segments?
B
Use die saw to segment maxilla
• Figure 13-7 The maxillary unit is now removed from the articulator. A, The maxillary cast is separated from its base. This is accom-
plished with the use of a die saw to cut a groove and a knife that is placed into the groove, which is then hit with a hammer. B, If
indicated, segmentation of the maxillary cast is carried out. This is done in accordance with patient-speci c needs to correct the maxil-
lary arch form. Segmentation is generally carried out either as two parts (i.e., between the central incisors and then through the hard
palate) or as three parts (i.e., between the lateral incisor and the canine on each side and then through the hard palate). The maxilla is
cut by hand with a die saw instrument.
3–segment alignment 2–segment alignment
C
Mandibular cast
• Figure 13-7, cont’d C, If segmentation of the maxillary cast is required, the cut segments are placed into the corrected arch form
by aligning the segments over the mandibular arch. It is important to maintain a physiologic orientation of the interdental papilla, with
tight contact between the teeth. Ideally, the adjacent roots are also parallel, with minimal divergence. The maxillary segments are secured
together in the corrected arch form with the use of hot glue from a glue gun.
NOTE: If occlusal equilibration is required to achieve the preferred articulation, it is completed on the casts
and recorded at this time. The actual occlusal equilibration procedure is completed during surgery.
Wax or clay to position

maxillary cast to base
Maxillary base
Maxillary cast
A
Maxillary cast is repositioned on maxillary base
according to clinical assessment/surgical plan
• Figure 13-8 A, The maxillary cast is next repositioned and reoriented on the maxillary base
in accordance with the clinical assessment and the surgical plan. The Erickson Model Table
(EMT) is used to ensure the correct spatial reorientation of the maxillary cast to achieve the
clinical objectives. Continued
Maxillary Horizontal
Right #8 74.5 5 79.5
Left #9 74.0 5 79.5
B
Maxillary horizontal change at incisal edge (5.0-mm advance)
Maxillary Anterior Vertical
Right #8 96.2 0 96.2
Left #9 95.8 0 95.8
C
Maxillary vertical change at incisal edge (no change)
• Figure 13-8, cont’d B, The EMT is used to accurately reposition the maxilla. For this patient (see Fig. 13-1), the
maxillary horizontal change at the incisal edge is a 5-mm advancement. C, In this case, the EMT also con rms that
no vertical change will occur at the maxillary incisal edge.
Maxillary Posterior Vertical
Right #3 93.1 3/ 1 89.1
Left #14 91.7 3/ 1 89.7
• Maxillary plane change

3.0 mm vertical (plane) change at right 1st molar
3.0 mm vertical (plane) change at left 1st molar
• Maxillary cant correction
1.0 mm vertical (cant) change at right 1st molar
1.0 mm vertical (cant) change at left 1st molar
Equal change at both tuberosities Check “yaw” effect

to avoid altering in yaw orientation at the occlusal level!!
• Figure 13-8, cont’d D, The EMT is used to accurately reposition the maxilla at the molars. The con rmation of correct positioning at
the mesiobuccal cusp tip of each rst molar is essential. The vertical change incorporates the desired three-dimensional roll and pitch
changes. E, When repositioning the maxilla, the EMT is useful to check for any yaw effect. Establishing equal side-to-side changes at both
tuberosity regions is required to avoid a yaw change of the posterior maxilla. The reoriented maxillary unit is placed back onto the articulator
for viewing. Continued
F
Desired A-pt B-pt alteration to enhance aesthetics (3 mm clockwise rotation of maxilla)
• Figure 13-8, cont’d F, The vertical pin on the articulator should remain neutral throughout the process.
NOTE: Before going forward with intermediate splint construction, con rming the
yaw orientation of the maxilla relative to the mandible is essential.
A B
Apply Vaseline to maxillary and mandibular teeth Use pink acrylic liquid and resin powder
• Figure 13-9 Construction of the intermediate splint. A, Apply a thin coat of Vaseline to the maxillary and mandibular teeth. B, Use pink acrylic
liquid and orthodontic resin powder, and mix them until the mass does not slump.
C D
Adapt mass to the maxillary occlusal surface • Close articulator until pin touches
• Mandibular occlusal imprint will result
Carefully trim soft acrylic with scissors
• Figure 13-9, cont’d C, Roll the mixed acrylic mass into a log shape. Adapt the mass to the maxillary occlusal surface. D, Close the
articulator until the vertical pin touches in a neutral location. A mandibular occlusal surface imprint will result. E, Limit “undercuts” from
brackets by carefully trimming the soft acrylic with scissors. Continued
F
Use lathe to trim excess hardened acrylic Maintain adequate strength!
G
Use Dremel drill (acrylic burr) to trim excess hardened acrylic
• Figure 13-9, cont’d F, When the acrylic is dry, use a lathe to trim excess hardened acrylic. Maintain adequate strength of the
splint to prevent bowing or breakage during surgery. G, Use a rotary drill (e.g., a Dremel drill) with an acrylic bur to further trim
excess hardened acrylic.
Mandibular cast
“Final” occlusion
secured with hot glue
Maxillary unit
A
Remove maxillary unit from articulator
Separate mandibular cast from plaster base
Articulate mandibular cast to maxillary unit in “final” occlusion
Replace casts on articulator Maintain articulator

pin in neutral position
Secure with hot

glue or plaster
Remove plaster
as needed
B
Secure mandibular cast to base with hot glue
Then separate max/mand casts and confirm “final” occlusion
• Figure 13-10 Construction of the nal splint. A, Remove the maxillary unit from the articulator. Separate the mandibular cast from the plaster
base as previously described for the maxillary unit (see Fig. 13-7, A). Next, articulate the mandibular cast with maxillary unit in the nal desired
occlusion. Secure the nal occlusion with hot glue from a glue gun. B, Secure the mandibular cast back to the base with the use of either hot glue
from a glue gun or white plaster. Maintain the articular pin in a neutral position to achieve this objective. It is generally necessary to remove as least
some plaster from the mandibular base during this process; only then is the hot glue or additional plaster used to secure the mandibular cast back
to the base. The dried glue that secured the occlusion together is now released. The desired occlusion is con rmed to be accurate before the
construction of the nal splint. Continued
C D
Use clear acrylic liquid and resin powder Adapt mass to the maxillary occlusal surface
Trim soft acrylic with scissors
• Figure 13-10, cont’d C, Use clear acrylic liquid and orthodontic resin powder for the nal splint. Mix the two together until the mass
does not slump. D, Roll the mixed acrylic mass into a log shape. Adapt the mass to the maxillary occlusal surface. E, Close the articula-
tor until the vertical pin touches in a neutral position. The mandibular occlusal surface will imprint into the acrylic as a result. Limit
“undercuts” from the brackets by carefully trimming the soft acrylic with scissors.
Paper clip wire
Use additional acrylic to place wire

to reinforce palatal aspect of splint as needed
G H
Drill holes (1.0-mm diameter) in both intermediate and final splints Polish splints on lathe
• Figure 13-10, cont’d F, Use additional acrylic to place a metal wire, if needed, to reinforce the palatal aspect of splint. This will prevent
bowing or breakage of splint when segmental osteotomies are carried out and when extensive arch expansion is required. G, Use a lathe and
a rotary drill (e.g., a Dremel drill) to trim excess acrylic from the hardened nal splint. Next, place each splint (i.e., intermediate and nal) in turn
on the maxillary cast, and determine the best location and direction for each interdental drill hole. Complete 1-mm drill holes with the use of a
rotary drill (e.g., a Dremel). H, Polish the splints on a lathe with the use of a cloth buf ng wheel (i.e., pumice and Acrilustre) (Robert Bosch,
1800 W. Central Road, Mt. Prospect, IL).
Intermediate splint Final splint
B
Preoperative articulated casts Maxilla repositioned Maxilla and mandible repositioned
• Figure 13-11 Dental casts on the semi-adjustable

articulator to demonstrate model planning and a view
of the nished splints. A, Intermediate and nal splints
nished and ready for use. B, Lateral views of articu-
lated dental casts rst mounted in a centric relation
bite and then after maxillary and nal mandibular repo-
sitioning. C, Frontal and side views of articulated
dental casts demonstrating model planning. In this
case, note the extent of the maxillary clockwise rota-
C tion (3 mm) needed to achieve a preferred A-point to
B-point relationship and also to overcome the procum-
Articulated dental casts after analytic model planning bency of the maxillary incisors.
presurgical clinical examination, is one of the essential steps maxillary occlusal plane to the Frankfort plane as measured
to avoid unintended errors.10,28-35,42,43,49,58,60,64,65,71-76,82 via lateral cephalometry. Of the three semi-adjustable artic-
ulators tested, the Whip Mix Quickmount 8800 came
closest to achieving the maxillary occlusal plane (with
Controversies Surrounding Model respect to the Frankfort plane) as measured via lateral ceph-
Planning for Orthognathic Surgery alometry; it attened the occlusal plane by only 2 degrees
(P < .05). e results of the Dentatus and Denar MkII
Articulator and Face-Bow Device Options articulators demonstrated attening of the occlusal plane by
Face bow devices were developed in conjunction with simple 5 degrees and 6.5 degrees, respectively. Ellis also demon-
and semi-adjustable hinge articulators to assist with the reg- strated how commonly used methods of face-bow registra-
istering of the maxillary arch position in relation to the axis tion may erroneously capture the spatial relationship of the
of the condylar hinge in three planes of space. e mechan- maxilla with the Frankfort horizontal plane.18 is is likely
ics of the face-bow device require a tripod localization. is to be problematic if the surgeon intends to use the Frankfort
includes two posterior references to approximate the tem- horizontal from the patient’s cephalogram as the reference
poromandibular joints and then an anterior point to relate plane from which facial aesthetic objectives will be planned.
the maxillary cast three dimensionally to a selected horizon- A critical step in model planning is the accurate record-
tal facial reference plane. e posterior reference points that ing of the relationship (i.e., angle and orientation) between
are generally used are the external auditory canals. e a designated facial plane and the maxillary occlusal plane. As
anterior point is often aligned with the orbitale (i.e., stated, capturing this orientation is accomplished with a
the infraorbital rims). Selection of the anterior point (e.g., face-bow device that is used in the clinic setting. (Note: I
the orbitale) governs the horizontal facial reference plane. use the #8645 Quick Mount Face-Bow, Whip Mix Prod-
is will in turn a ect the steepness of the recorded maxil- ucts, Louisville, KY.) e face-bow registration is then
lary occlusal plane on the articulator; this is discussed later transferred to the semi-adjustable articulator for the mount-
in this chapter. ing of the maxillary model. (Note: I use the #8500 Articula-
For orthognathic surgery, analytic model planning typi- tor, Whip Mix Products, Louisville, KY.)
cally involves the use of an articulator that provides an I prefer to judge the desired facial (surgical) change (i.e.,
approximation of the anatomic relationship between the horizontal, vertical, roll, pitch, and yaw) and register the
hinged axis and the incisors. is type of articulator mecha- face bow from the natural head position (NHP) rather than
nism is designed to approximate the individual’s actual the Frankfort horizontal plane.
mandibular autorotation. is is especially important for I prefer to use the NHP orientation as it is the same view
bimaxillary surgery, when autorotation of the maxilloman- from which aesthetics of the face are typically judged by
dibular complex helps to dictate the position of the maxilla others at conversational distance. Many clinicians prefer to
before the mandibular osteotomies are completed. Marko plan angular and linear surgical change for the patient’s face
conducted research to demonstrate that the mathematical from the Frankfort horizontal plane rather than the NHP.
di erence in the horizontal projection achieved when such If this is done, the surgeon should register the face bow as
advancement is carried out in combination with a maxillary precisely to the Frankfort line (i.e., the line between the
impaction of 5 mm is signi cantly a ected by the type of porion and the orbitale) as possible. He or she should then
articulator that is used.46 An average error of 2 mm was meticulously attempt to mount the cast to match the ori-
found with use of the Galetti articulator (simple hinge), entation of the maxilla with that of the Frankfort horizontal
whereas only 0.2 mm of error occurred with the Hanau plane.
articulator (semi-adjustable).46
NOTE: The importance of the face-bow semi-

NOTE: The use of a semi-adjustable articulator in adjustable articulator system to the process of accurately
bimaxillary surgery will be more accurate and is therefore capturing the occlusal plane with respect to Frankfort
preferred to the use of a simple hinge articulator. plane orientation is only relevant if the surgeon is
planning facial aesthetic changes according to a strict
cephalometric analysis (i.e. that also depends on
O’Malley and Milosevic compared three face-bow semi- Frankfort plane orientation).
adjustable articulator systems to measure any di erences in
the recorded steepness of the occlusal plane that was pro-
duced.52 e three articulators studied were the Dentatus Centric Relation: De nition and Capture
type ARL; the Denar MkII; and the Whip Mix Quick-
mount 8800. e recorded measurement of the steepness De nition of Centric Relation
of the occlusal plane was taken as the angle between the In 1987, the de nition of CR underwent a change in ter-
face-bow bite fork and the horizontal arm of the articulator. minology from being considered a mandibular position in
is measurement was then compared with the angle of the which the condyles are seated in the most “posterior
superior” position to one in which they are placed in the Class II mandibular retrognathism) are more likely to invol-
most “superior anterior” position in the glenoid fossa.72 For untarily posture the mandible forward during the swallow-
analytic model planning in preparation for orthognathic ing technique.32,33
surgery, de ning the position of the condylar head during e chin-point guidance technique is accomplished by
mandibular protrusion and lateral excursions is not critical. using one hand to apply pressure to the subject’s chin and
However, it is essential to locate a mandibular position that the other hand to apply counter pressure to their occiput.
is reproducible with the teeth in occlusion. is must be is allows the surgeon to apply posterior and superior
obtained without the assistance of the patient (i.e., with “vectored” force to the anterior aspect of the mandible. By
fully relaxed masticatory muscles), and it needs to be reli- doing so, the condyles will be positioned in a superior-
ably accomplished both preoperatively in the clinical setting anterior location within each glenoid fossa (i.e., CR) (see
and intraoperatively with the patient under anesthesia. is Fig. 13-2).
position of the mandible with the teeth in occlusion is
usually registered in wax (i.e., a wax bite) and then trans- Bite Registration Material
ferred to the articulator. is is an important step for ana- e material used to record CR (e.g., soft wax) is also con-
lytic model planning to be accomplished accurately. sidered as a potential source for the introduction of error.
An erroneous inconsistent recording of CR will lead to Adrien and Schouver studied mandibular model-mounting
the malpositioning of the maxilla or mandible during errors; they demonstrated that wax can create error and that
surgery. A survey study conducted by Truitt and colleagues the error is directly proportional to the wax’s thickness.2
con rmed that 98% of oral and maxillofacial surgeons ey suggest that the wax between the approximating teeth
de ne CR as the most posterior superior positioning of the be as thin as possible. In addition, the wax should not be
mandible.79 Interestingly, a majority of the orthodontists punctured, because this may result in sliding from CR to
surveyed agree with the surgeons’ de nition of CR, but centric occlusion (CO). e wax should also retain its rigid-
there was less consistency. 79 According to the survey, sur- ity to avoid the distortion of contact points. e wax bite
geons and orthodontists do agree that dental casts of the must be protected after it is removed from the mouth,
teeth for orthognathic planning should be mounted in CR. because it is easily deformed. Ideally, it is used without
signi cant delay to the time that the models are mounted
Capturing of Centric Relation on the articulator (see Fig. 13-2).
Hellsing and McWilliam used a subtraction technique to
assess the repeatability of the CR recorded with a one-
Inaccuracies of Osteotomy Site Measurements
handed push-back technique.31 ey found that the man-
dibular condyles can be seated in a reproducible position,
when used in Isolation to Reorient the Maxilla
in Bimaxillary Surgery
which is well suited for the registration of CR. Campos and
colleagues compared the swallowing technique with the chin- e face-bow device is used to spatially orient patients’ dental
point guidance technique with the patient in both upright models on a semi-adjustable articulator. e belief that mea-
and supine body positions and found that both techniques surements may then be made at the equivalent of the Le
established a physiologic CR in a reproducible manner.86 Fort I osteotomy site to accurately reposition or reorient the
Interestingly, when the chin-point guidance method was maxillary cast on the articulator without the use of the
used, the work of these authors suggested that reliability was Erickson Model Table is awed. e errors of this model
greater with the patient in the upright, seated patient as surgery and splint-construction approach would then be
compared with the supine position. further compounded if the surgeon relied on actual Le
Simon and Nicholls compared the chin-point guidance, Fort I osteotomy site measurements during operation as a
chin-point guidance with ramus support, and bimanual gauge of where to reorient the maxilla without the assistance
manipulation techniques.68 ey found that there were no of external facial reference landmarks and measure-
signi cant di erences in the range of mandibular positions ments.13,28,36,40,41,53,56,57,59,69 e use of these methods (i.e.
that were observed. Interestingly, their study patients did osteotomy site measurements) to reposition the maxilla in
not include individuals with jaw deformities. It is known the dental laboratory before splint fabrication and then
that patients with speci c patterns of jaw deformity (e.g., during surgery before plate and screw xation may work for
uncomplicated movements (e.g., limited horizontal and
vertical repositioning), but it is likely to become grossly
awed when trying to accomplish complex yaw, pitch, and
roll orientation changes of the midface.
NOTE: I nd the chin-point guidance technique—
when used both preoperatively in the clinic setting and
intraoperatively by the same surgeon—to be both Accuracy of Current Analytic Model-Planning
reliable and convenient for the orthognathic surgery Techniques to Achieve Desired Results
patient. This is the method that I have adopted and that
e Erickson Model Table is a device that is used to
I use successfully in clinical practice.
document the baseline three-dimensional orientation of
the mounted maxillary model on the semi-adjustable Review of Key Steps for Successful Analytic Model
articulator. (Note: I use the Erickson Model Block and Planning and Surgical Execution
Platform Model Measuring Kit designed by Great Lakes 1. e direct visual examination of the patient by the surgeon
Orthodontics Products, Tonawanda, NY.) e Erickson in the clinic setting. With the use of facial analysis, key
Model Table is then used to assist the three-dimensionally measurements of the individual’s maxilla in relationship
reposition and reorient the maxillary cast to the desired to the upper face (i.e., the forehead, external ears, and
facial (surgical) change.19,20 e reoriented maxillary orbits) are recorded. ese measurements will con rm
model on the articulator is then used to construct the inter- variations from normal and de ne the surgical objectives
mediate splint. In the operating room, the use of the pre- (see Fig. 13-1, H).
fabricated intermediate splint in conjunction with precise 2. e use of a face-bow device to record the spatial orientation
measurements of the anterior vertical dimension of the midface of the upper face and condyles with regard to the maxilla.
(e.g., direct vertical measurement from the medial canthus is is generally done with the use of the external audi-
to the maxillary incisor on each side of face) has eliminated tory meatus for two of the reference landmarks. e
many of the inaccuracies that were previously experienced anterior aspect of the face bow (i.e., the frontal view) is
during model planning and surgical execution (see Fig. adjusted to be parallel with the interpupillary line. With
13-6, C).20,27,36,40,41,51,53,56,57,66,81 the patient’s head and neck in the NHP, the lateral
Interestingly, the few studies published in the literature aspects of the face bow are then adjusted to orient the
show a wide range of variation between what was planned temporal arms to be parallel with the oor (see Fig. 13-3
by the clinician before surgery and what is then actually C and D).
achieved during operation with reference to the advance- 3. e transfer of the spatial orientation of the maxilla to the
ment of the maxilla after Le Fort I osteotomy during semi-adjustable articulator. is is done with the arms of
bimaxillary surgery. An exception is the study of Gil and the face-bow and the upper arm of the articulator paral-
colleagues,28 who completed a retrospective study to evalu- lel to the oor (counter top) (see Fig. 13-4 A).
ate the predictability of maxillary repositioning (i.e., vertical 4. e taking of an accurate CR bite registration of the patient
and horizontal change measured at the maxillary incisors) in the clinic setting. is is then used to orient the dental
after Le Fort I osteotomy during bimaxillary surgery. models to each other on the semi-adjustable articulator
ey used analytic model-planning techniques, including (see Figs. 13-2 and 13-4, C).
the following: 1) face-bow transfer 2) the use of a semi- 5. e use of the Erickson Model Table in the dental laboratory
adjustable articulator 3) the use of Erickson Model Table to establish the baseline spatial orientation of the maxillary
measurements 4) intermediate splint construction and 5) cast (see Fig. 13-6, C).
the use of external facial height reference points during 6. e use of the Erickson Model Table to accurately reorient
surgery. A consecutive series of patients (n = 32) were ana- the upper jaw model on the articulator into the desired
lyzed, with measurements taken with consistent lateral surgical position (see Fig. 13-8, A).
cephalometric radiographs before and 1 week after surgery.69 7. e fabrication of a splint for use during surgery to achieve
e results indicate less than a 1-mm di erence between the planned maxillary reorientation (see Fig. 13-9)
the planned and the early postoperative results for both 8. e use of external facial measurements (e.g., the distance
vertical and horizontal repositioning in all patients. from the medial canthus to the maxillary incisor) during
Stanchina and colleagues also carried out a retrospective operation to establish the baseline vertical position of the
study to measure the accuracy of external reference points maxilla within the upper face and then to accurately
in conjunction with model planning to reposition the reorient the upper jaw to achieve surgical objectives (see
maxilla during bimaxillary surgery.69 e study subjects (n Fig 15-18, A).
= 41) showed a surprisingly consistent mean di erence 9. e accurate location of the terminal hinge position of the
between predicted and achieved vertical repositioning of the condyles during operation. is is done to reproduce
maxilla (0.36 mm; standard deviation, 0.26 mm). eir the position of the condyles when taking the CR bite
success with horizontal repositioning was less accurate. e registration in the clinic setting, and it is essential before
mean horizontal variance was 1.4 mm (standard deviation, rigid xation is secured across each osteotomy site
1.63 mm). (see Fig 15-37, B).
COMMENT: The surgeon no longer attempts to

correlate millimeter changes at the Le Fort I osteotomy
NOTE: The reasons for variation between the site with the expected facial morphologic outcome.
planned and actual maxillary advancement in most When properly executed, the accuracy of analytic
published studies remain unclear. This is because the model-planning techniques as described for precise
descriptions of the key steps that they used are generally orthognathic surgery has been documented. This is
not fully described. discussed in more detail later in this chapter.
The Role of Computer-Aided Software Design Standard Facial Records for

and Model Planning Orthognathic Surgery
For a variety of reasons, some patients with complex maxil- • Standardized facial and occlusal view photographs
lofacial skeletal deformities undergo treatment that achieves • Lateral cephalometric radiograph
suboptimal results. Despite the surgeon’s best e orts, it can • Panoramic radiograph
be di cult to assess the preferred surgical spatial reorienta- • Alginate impressions of the maxilla and mandible
tion of the jaws for the achievement of ideal facial projec- • CR wax bite registration
tion and symmetry. Although standard analytic model • Face-bow registration for transfer to a semi-adjustable
planning (as described in this chapter) has proven to be articulator
e ective for most orthognathic surgical problems, three- • Facial measurements taken via a direct visual examina-
dimensional deformities of pitch, roll, and yaw continue to tion (Fig. 13-1H).
confound the ability to achieve predictable results in each • Analytic model planning data entry form (Fig. 13-6C)
and every patient. e current standard treatment planning • Cone-beam computed tomography scanning (patient
process is also felt to be time consuming and labor intensive, speci c)
especially for those clinicians who do not evaluate dentofa- • Full-mouth periapical radiographs (patient speci c)
cial deformities and execute orthognathic surgery as signi -
cant components of their practice.
Recently, surgeons have begun looking to computer- Key Measurements Obtained via Direct
aided design and computer-aided modeling software to
assist with the planning and implementation of orthogna-
Visual Examination to De ne Planned
thic procedures.3-5,7,11,23,24,25,45,47,48,61,67,70,83,84 ese technolo- Maxillary Surgical Change
gies allow clinicians to import two-dimensional computed
tomography data in a digital imaging format at a computer • Horizontal change at incisors _________ (mm)
work station and to then generate a three-dimensional rep- • Vertical change at incisors _________ (mm)
resentation of the patient’s skeletal and soft-tissue anatomy.
• Midline change at incisors _________ (mm)
e data set can be used to mill a stereolithographic model,
or it can be manipulated on the computer screen for pur- • Maxillary plane change (total) _________ (mm)
poses of analysis and treatment planning. e ability of
Clockwise—Counterclockwise
virtual model planning (as opposed to analytic model plan-
ning, as described in this chapter) to routinely achieve an • Maxillary cant correction (total) _________ (mm)
improved end result for the orthognathic patient has yet to
↑ ↓ _____on right ↑ ↓ _____on left
be con rmed. It is also unclear whether the higher costs of
virtual model surgery planning can be o set by savings in • Vertical change at T#3 (right) molar ___ + ___ + ___ = ___ (mm)
(Base + Cant + Plane)
the clinician’s time that would otherwise be required for
analytic model planning. • Vertical change at T#14 (left) molar ___ + ___ + ___ = ___ (mm)
A successful orthognathic outcome is often judged by the (Base + Cant + Plane)
achievement of a preferred occlusion, an open upper airway,
and enhanced facial aesthetics. Any methods that are proven
to better achieve these objectives over the long term with Face-Bow Registration and Transfer to
e ciency and reliability are welcomed. Unfortunately, the Semi-Adjustable Articulator
current virtual model surgery planning still requires that
alginate impressions of the maxilla and mandible be taken, An 18-year-old recent high school graduate who presented
that plaster models be made of the maxillary and mandibu- to this surgeon for the evaluation of an uncorrected
lar arches, and that ideal occlusion be hand articulated and dentofacial deformity that was characterized as maxillary
marked by the surgeon into the set nal occlusion. If seg- de ciency with relative mandibular excess is described.
mental osteotomies are required, the surgeon must also cut He is shown to demonstrate the technique of analytic
the plaster models and secure them together as required to model planning as typically carried out (see Figs. 13-1,
achieve the set nal position. Furthermore, a computer- 13-12, and 13-13).
generated surgical splint has not yet been proven to be fully
reliable for complex, double-jaw surgical cases.11 Problems
that remain to be addressed include the following: the iden-
Face-Bow Registration
(see Figs. 13-2, A, through 13-3, G)
ti cation of internal reference systems; the making of three-
dimensional measurements; the management of interferences • Place soft wax on upper side of the face-bow bite fork.
by metal (orthodontic) hardware; the orientation of com- • e midpoint between the central incisors (interproxi-
puted tomographic models to the NHP; and the necessity mal) should match the center of the bite fork.
of capturing the computed tomography data while the • Register the patient’s maxillary occlusion into the soft
patient is in CR. wax on the bite fork.
• Place an ear prong in each ear canal, and hold the tem- • In the pro le view, the face bow is adjusted to be parallel
poral extensions with even pressure medially, superiorly, with the oor while the patient is in the NHP.
and forward. Tighten the three thumb screws of the • If the ear canals are asymmetric, do not rely on them
temporal extensions. for face-bow orientation. For example, for a patient
• In the frontal view, the face bow is initially adjusted to with hemifacial microsomia, if the ear canal on one
be parallel with the pupils and in proximity to the infra- side is not present or is abnormally located, then
orbital rims. place the face-bow ear prong in the appropriate posi-
• If the orbits are asymmetric (e.g., in a patient with tion to approximate the contralateral ear canal. e
hemifacial microsomia or the Klippel–Feil anomaly), face bow should be parallel with the oor while the
do not use the interpupillary line as a frontal reference patient is in the NHP (i.e., the NHP is the reference
plane. Instead, use the NHP as the facial reference plane).
plane. Text continued on p. 415
Orth
Or
Orth
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athic
ic Su
Surrgerryy; J.C.
C. Pos
osn
snicck Orrth
Orthhogn
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i SSu
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ry;
y; J.C.
C. Po
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Orrth
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nat
athic
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Surgery
Sur ry; J.C
ry; C.. Posn
ossnic
ick Ortth
Or thog
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athiicc S
Suurgery
ry; J.C.
C. Pos
osniicck
• Figure 13-12 The patient is shown before and just 5 weeks after surgery. At this time, adequate
bone healing has occurred to allow for a return to a more normal diet and physical activity level. The
patient is also returned to the care of his orthodontist. A, Frontal views in repose before and 5 weeks
after surgery. B, Frontal views with smile before and 5 weeks after surgery. Continued
Orthognathic Surgery; J.C

C. Posnick Orthognathic Surgery
y; J.C. Posnick
Orthognathic Surgery; J.C. Posnick Orthognathic Surgery; J.C. Posnick
• Figure 13-12, cont’d C, Oblique facial views before and 5 weeks after surgery. D, Pro le views before and 5 weeks after surgery.
Prior to orthodontics
Pre surgery
E
5 weeks after surgery
Le Fort I
A pt.
Sagittal B pt.
splits
F
Genioplasty
• Figure 13-12, cont’d E, Occlusal views before treatment, immediately before surgery, and just 5 weeks after surgery at the time
of splint removal. F, Computed tomography scan views 5 weeks after surgery. The sites of the maxillary, mandibular, and chin oste-
otomies and the location of standard xation can be seen.

C. Posnick Orthognaathic Surgery; J.C. Posnick

C. Posnick Orthognathic Surgerry; J.C
C. Posnick
• Figure 13-13 The same patient is shown before and then 1½ years after surgery. A, Frontal views in repose before and 1½ years after
surgery. B, Frontal view with smile before and 1½ years after surgery.
Orthognathic Surgery; J.C. Posnick Orthognathic Surgery; J.C

C. Posnick
Orthognathic Surgery; J.C. Posnick Orthognathic Surgery; J.C. Posnick
• Figure 13-13, cont’d C, Oblique facial views before and 1½ years after surgery. D, Pro le views before and 1½ years after surgery.
Continued
Prior to orthodontics
Pre surgery
5 weeks after surgery
E
1½ years after surgery
• Figure 13-13, cont’d E, Occlusal views before treatment, immediately before surgery, and then 5 weeks and 1½ years after the
completion of treatment.
• Figure 13-13, cont’d F, Lateral cephalometric views before and after surgery.
• Firmly hold the bite fork to the maxillary occlusal • When the casts are dry (≈15 min), remove the alginate
surfaces (through the soft wax). Pressure is applied to and base former from each stone cast. Measure 30 mm
the bite fork by the patient with the use of a thumb of base on the mandibular cast and 25 mm of base on
from each hand. When this is accomplished, do the the maxillary cast. Measure up from the following
following: locations:
• Loosely connect the bite fork, (which is held rmly • e rst molar cusp tip on each side
to the patients maxillary teeth), to the face-bow appa- • e canine cusp tip on each side
ratus, (which is held in place by the clinician), with • e incisor cusp tip on each side
the use of the T-screws on the vertical rod. • Use a model grinder to trim at the 25-mm and 30-mm
• In pro le and with the patient in the NHP, adjust the circumferential markings, respectively, for the maxillary
face-bow temporal extensions to closely parallel the and mandibular casts.
oor. • Remove all blebs from the occlusal surface of the dental
• Tighten the two T-screws to secure the bite fork to casts.
the vertical rod of the face-bow apparatus.
• Now that the face-bow registration is complete, loosen
Face-Bow Transfer: The Orientation of
the three thumb screws of the temporal extensions to
the Dental Casts (Maxilla and Mandible)
release the ear prong from each ear canal. Remove the
on the Semi-Adjustable Articulator
face bow from the patient for transfer to the semi-
(see Fig. 13-4, A through F)
adjustable articulator.
• Secure the face-bow device to the semi-adjustable articu-
lator. Adjust both the face-bow device and the upper arm
Take Alginate Impressions, Pour the
of the articulator to be parallel to the oor and the
Impressions in Stone, and Trim the Casts
counter lap.
(see Fig. 13-3, H through K)
• Secure the plastic base plate to the dental articulator.
• Take accurate alginate impressions of the maxilla and the Place the maxillary cast on the bite-fork component of
mandible. the secured face-bow device. Use white plaster to mount
• Pour the alginate impressions in green stone, and the maxillary cast to the base plate.
incorporate at least 30 mm of base. Base formers are • Use the bite-fork support device to prevent the sagging
helpful to accomplish adequate base height. To limit air of the maxillary cast during this process. Let the plaster
bubbles, use a vibrator when pouring stone into alginate initially set (≈15 min), and then remove the face-bow
impressions. apparatus and the bite-fork support device.
• Turn the articulator upside down, and secure the man-
dibular cast to the maxillary unit with the use of the CR
NOTE: The use of stone rather than plaster improves
wax bite registration taken in the clinic setting. Further
strength, with less porosity and less breakage.
secure the occlusion in CR with two rubber bands to
compress the maxillary unit and mandibular cast together • e midpoint of the incisal edge of each maxillary
through the bite registration. central incisor
• Place the plastic base plate onto the dental articulator,
and then use white plaster to mount the mandibular Baseline vertical (maxillary) measurements: With the
cast to the base plate. Let the plaster initially set model block on its base, use the electronic caliper to
(≈15 min). measure the distance (in mm) at the following areas: (see
• Cut the rubber bands used to secure the occlusion, and Fig. 13-6 E and F)
remove the wax bite.
• Remove the maxillary unit from the articulator. With the • e incisal edge of each maxillary central incisor
use of a model grinder, trim the maxillary cast, plaster (#8, #9)
base and the base plate all as one unit. • e mesiobuccal cusp tip of each maxillary rst molar
• Remove the mandibular unit from the articulator. (#3, #14)
With the use of a model grinder, trim the mandibular
cast, the plaster base and the base plate all as one unit. Baseline horizontal (maxillary) measurements: With the
model block on its end, use the electronic caliper to measure
the distance (in mm) at the following area: (see Fig. 13-6D).
Placement of Reference Lines on
the Maxillary and Mandibular Units
• e incisal edge of each maxillary central incisor
(see Fig. 13-5, A through E)
(#8, #9)
• With the use of the Erickson Model Table, “score” two
horizontal reference lines on the maxillary unit and then Baseline dental midline (maxillary) measurements: With
on the mandibular unit. Locate the horizontal reference the model block on its side, use the electronic caliper to
lines on the maxillary and the mandibular units by doing measure the distance (in mm) at the following areas: (see
the following: Fig. 13-6G)
• Place the rst horizontal line within the green stone.
• Place the second horizontal line within the white • e dental midline
plaster. with the left side of the cast down
• Ideally, there will be 15 mm to 20 mm of separation • e dental midline
between these lines. with the right side of the cast down
• With the use of a thick, black Sharpie pen, mark the
“scored” horizontal circumferential reference lines on
both the maxillary and mandibular units. Use of the Erickson Model Table to
• With the use of a thick, black Sharpie pen, mark the De ne the Spatial Orientation of the
vertical reference lines on both the maxillary and man- Articulator-Mounted Mandibular Unit
dibular units. e vertical lines are located perpendicular
to the horizontal lines and in the following places: Baseline horizontal (mandibular) measurement: With the
• At the cusp tip of each canine model block on its end, use the electronic caliper to measure
• At the mesiobuccal groove of each rst molar the distance (in mm) at the following area:
• Between the central incisors (i.e., at the dental midline)
• Posterior at each tuberosity or retromolar area • e incisal edge of the mandibular central incisors
(#24/#25)*
Use of the Erickson Model Table to
De ne the Spatial Orientation of the Separation of the Maxillary Cast from
Articulator-Mounted Maxillary Unit* the Articulator Base (see Fig. 13-7, A)
(see Fig. 13-6)
• Remove the maxillary unit from the articulator. Separate
With the use of a thin, black Sharpie pen, locate speci c the maxillary cast from the plaster base over a protective
reference points from which measurements will be made. surface. You may rst use the die saw to cut a groove
Place a dot at the following reference points: in between the green stone and the plaster base. Insert
a knife into this groove, and tap the knife with a
• e cusp tip of each maxillary canine hammer.
• e mesiobuccal cusp tip of each maxillary rst molar
* e Erickson Model Table maxillary unit measurements that I nd useful * is is the only Erickson Model Table mandibular unit measurement
are outlined earlier in this chapter. Other measurements can be made in that I nd useful. Other measurements can be made in accordance with
accordance with the clinician’s preference. the clinician’s preference.
use of the Erickson Model Table. e key millimeter and

Segmentation of the Maxilla angular changes to be con rmed include the following:
(see Fig. 13-7, A, B, and C) • Maxillary (midface) projection
○ Horizontal change at incisors
Segmentation and Subsequent Reorientation
• Maxillary incisor shown in repose and with smile
of the Maxilla
○ Vertical change at incisors
• Use a die saw to segment the maxilla, as planned (i.e., • Maxillary plane change (pitch orientation) and cant
two pieces versus three pieces). correction (roll orientation), which are controlled by
• After the maxilla is segmented, align the segments over the following:
the mandibular arch into the preferred occlusion. Secure ○ Vertical change at incisors
the segments back together with the use of hot glue from ○ Vertical change at rst molars
a glue gun. • Maxillary midline position (yaw orientation)
• Occlusal equilibration may be indicated to achieve ○ Dental midline change (right side down)
the preferred occlusion (e.g., plunging palatal cusps ○ Dental midline change (left side down)
on maxillary molars, bicuspid cusp reduction to level • Considerations of lateral tuberosity position (yaw
the posterior arch). If so, use a sharp plaster knife to orientation)
complete adjustments on the occlusal surfaces of the ○ Analysis of lateral shift (change) at posterior maxilla
maxillary and mandibular casts. Use a red Sharpie pen (tuberosity region)
to mark the exact locations where enamel adjustments • Soft wax or clay is used in a tripod fashion to facilitate
were made. e actual equilibration is carried out in the initial placement of the maxillary cast back onto the
the operating room. plaster base on the articulator in the preferred position.
• When repositioning the maxillary segments into It is generally necessary to trim the stone or plaster before
occlusion with the mandibular arch, it is essential to repositioning. Fine tune the maxilla into the preferred
maintain the physiologic positioning of the interden- position with the use of the Erickson Model Table (i.e.,
tal papilla and the contact points of adjacent teeth at via horizontal, vertical, and transverse measurements).
all interdental osteotomy sites. If dental gaps are After these measurements are con rmed, fully secure the
created or if cervical margins are not reasonably preferred maxillary position to the plaster base with hot
aligned, then periodontal sequelae are more likely. glue from a glue gun.
• When repositioning the maxilla into the preferred
position, take into consideration the yaw orientation.
Measurement of the Maxillary Arch Width Control the yaw orientation to avoid unwanted asym-
Before and After Segmental Osteotomies
metric shifts, which would be visually noticeable in the
Transverse distance between maxillary molars (#3 to #14) cheeks of the midface and at the mandibular angles (see
• Initial _____ (mm) Chapter 12).
• After segmentation _____ (mm)
Transverse distance between maxillary canines (#6 to #11)
• Initial _____ (mm)
• After segmentation _____ (mm) Intermediate Splint Construction for
the Positioning of the Maxilla During
Operation (see Fig. 13-9, A through E)
• With the maxilla secured in the new preferred position
Use of the Erickson Model but without any changes yet made to the baseline man-
Table Measurements to dibular position, the intermediate (occlusion) splint is
Reorient the Maxillary Cast constructed.
(see Fig. 13-8, A through F) • Apply a thin coat of Vaseline to the maxillary and man-
dibular occlusal surfaces with a toothbrush.
• e repositioning of the maxilla on the articulator is • Use pink acrylic liquid and standard acrylic powder. Mix
meant to accurately match the desired surgical changes. these until the mass does not slump. Apply Vaseline to
ese changes have been determined in accordance with your hands, and roll the mass into a log shape. Adapt
the following: 1) the patient’s clinical objectives (i.e., pre- the mass to the maxillary occlusal surface, and close the
ferred facial aesthetics and improvements in function) articulator until the vertical pin touches. is will result
2) by taking into account any biologic skeletal, dental, or in an imprint of the mandible occlusal surfaces on the
soft-tissue limitations and 3) the surgeon’s clinical, dental, opposite side.
and radiographic analyses (see Chapter 12). • Maintain the acrylic just below the level of the base of
• After the key desired adjustments to the midface are the maxillary orthodontic brackets and just above the
reproduced on the maxillary unit, they are veri ed with base of the mandibular orthodontic brackets. Use sharp
• If segmental osteotomies are planned, maintain at least

NOTE: When making the intermediate splint,
3 mm to 4 mm of lingual acrylic behind the incisors to
maintain the vertical pin of the articulator in a neutral
prevent splint breakage or torque, which may otherwise
position, unless signi cant inferior positioning (i.e.,
occur in the operating room.
lengthening) of the maxilla is planned. If so, there are
two options: either take the initial CR bite (in the clinic
setting) with an increased freeway space (this is Reorientation of the Mandibular
equivalent to the clockwise rotation of the mandible Cast to Register the Final Occlusion
while the condyles remain seated in the fossa) or (see Fig. 13-10, A and B)
lengthen the vertical pin on the articulator (this is also
equivalent to the clockwise rotation of the mandible
• Separate the mandibular cast from the plaster base (as
while the condyles remain seated in the fossa) before
was done for the maxillary cast).
making the intermediate splint. Either approach can be
• Articulate the mandibular cast with the maxillary unit in
used without error as long as the mandibular opening
the desired nal occlusion, and secure the occlusion with
is limited to temporomandibular joint rotational
hot glue.
movement. If temporomandibular joint transitional
• With the vertical articulator pin remaining in a neutral
movement occurs, then the splint will no longer re ect
position, secure the mandibular cast back to plaster base.
the patient’s CR bite. If the clinician is uncomfortable
is may require the removal of interferences in the
with this approach, then a mandible- rst approach
plaster base or the addition of material (e.g., plaster,
to analytic model planning should be used (see
hot glue).
Chapter 14).
• Remove the glue that was used to secure the occlusion,
and con rm the accuracy of the nal occlusion.
scissors to remove gross excess. is will prevent “under-

cuts” of acrylic on the brackets. Final Splint Construction for the
• Continuously open and close the articulator until the Positioning of the Mandible During
acrylic sets (≈10 min). Maintain the vertical pin in a Operation (see Fig. 13-10, C through F)
neutral position and fully closed. is will ensure that
no “undercuts” remain. • Reapply Vaseline to the maxillary and mandibular occlu-
sal surfaces of the teeth with a toothbrush.
• Mix clear acrylic liquid and standard powder. Mix these
Trimming of Hardened Acrylic Intermediate
until the slumping stops. Vaseline your hands, roll the
Splint (see Fig. 13-9, F and G) acrylic into a log shape, and then adapt and readapt it
• Remove excess buccal (labial) acrylic when looking at the as described for intermediate splint construction.
model from a bird’s-eye view. Use a pencil to mark a line • Trim the nal occlusion splint as described for the inter-
parallel to and just outside of the maxillary orthodontic mediate splint. Smooth the lingual edges for patient
brackets. Draw a similar line outside of the mandibular comfort.
brackets. With a lathe and a circular white stone or an • If segmental osteotomies are planned, maintain at least
acrylic bur, trim excess acrylic, as marked. 3 mm to 4 mm of lingual acrylic behind the incisors to
• Prevent lingual ramping by removing excess acrylic in prevent splint breakage or torque, which may otherwise
the region of the mandibular anterior teeth. is limits occur in the operating room.
interferences that tend to occur as a result of the arc of
rotation of the mandible during mouth opening and
closing. NOTE: If greater strength is needed for the nal
• When viewing the splint from the side, mark with a splint (see Fig. 13-10, F), then reinforce with a palatal
pencil any areas that require further acrylic removal (e.g., wire (e.g., use a piece of a heavy paper clip) and
just below the base of the maxillary orthodontic brackets, additional acrylic.
just above the base of the mandibular orthodontic brack-
ets). With a lathe and a circular white stone or an acrylic
bur, trim excess acrylic, as marked. Finishing of the Prefabricated
Acrylic Splints (see Fig. 13-10, G
and H, and Fig. 13-11, A and B)
NOTE: If greater strength is needed for the
• Place each splint in between the maxillary and mandibu-
intermediate splint (see Fig. 13-10, F), then reinforce with
lar units to determine the ideal location and direction of
a palatal wire (e.g., use a piece of a heavy paper clip) and
each interdental hole placement. Mark these placements
additional acrylic.
with a pencil.
• Drill holes that are 1 mm in diameter in both the inter-

Radiographic Analysis
mediate and nal splints at each interdental location for
the ease of passage of the wires through the splint. For For each study patient, a presurgical standard cephalometric
ease of wire passage, the holes are located below the radiograph was obtained for later analysis. At 5 weeks after
maxillary orthodontic arch wire. surgery, a similar standard cephalometric radiograph was
• Polish the splints on the lathe with a cloth bu ng wheel also taken. is was timed to coincide with initial bone
using pumice (i.e., coarse, medium, and then ne) and healing and the removal of the surgical splint.
Acrilustre (Vogel Paint and Wax Co. Inc., 1020 Albany Four landmark points (i.e., the sella, the nasion, the
Place, SE; Orange City, Iowa) porion, and the orbitale) that remained unchanged after Le
Fort I advancement were used for this analysis. ese points
were used to create a consistent reference line from which
Accuracy of the Described Analytic linear measurements (e.g., a change in the horizontal posi-
Model Planning Technique: Review tion of the maxillary incisors) could be made and compared
of Study before and after maxillary advancement. To con rm the
consistency of the four designated points in the sequential
A research study was carried out to assess the accuracy of radiographs, a reference angle between SN and FH was
analytic model planning to achieve the desired maxillary veri ed to remain within 0.5 degrees.
advancement during bimaxillary orthognathic surgery.54 On each cephalometric radiograph, a perpendicular ref-
erence line passing through the sella, called the sella perpen-
dicular (S┴), was then dropped. From S┴, a direct linear
Material and Methods
measurement was made parallel to the Frankfort horizontal
A consecutive series of patients (n = 20) who underwent (FH) plane and extended to the maxillary incisal edge (U1)
at a minimum Le Fort I osteotomy with advancement (Fig. 13-14).
and sagittal ramus osteotomies of the mandible for the To accurately access the horizontal advancement of the
correction of dentofacial jaw deformities were included maxillary incisors accomplished during the operation and
in the study group. e sample consisted of female (n = 9) maintained at 5 weeks, the distance in millimeters from S
and male (n = 11) with a mean age of 21 years (range, ┴ to U1 was measured on both the preoperative and the
14 to 45 years). All study subjects underwent the following: 5-week postoperative lateral cephalogram. e measure-
1) preoperative and 5-week postoperative lateral cephalo- ments were then adjusted with the use of a metric reference
metric radiographs of acceptable quality with a metric refer- frame to correct for magni cation. Any di erence in length
ence frame for analysis; 2) consistent presurgical facial of these two data points corresponds with variations in
analysis by the surgeon, including millimeter decisions the preoperative and postoperative (i.e., at 5 weeks after
regarding planned horizontal and vertical repositioning surgery) horizontal positions of the maxillary central
and three dimensional reorientation (i.e., pitch, roll, and incisors.
yaw) of the maxilla; 3) consistent analytic model planning Comparisons between the planned and actually achieved
as described in this chapter 4) the construction of interme- (at 5 weeks after surgery) horizontal positions of the maxil-
diate and nal splints; 5) the use of the prefabricated inter- lary incisors were made with the paired t-test. Statistical
mediate splint to establish the maxillary positioning after signi cance was set at P < .05. Associations between the
Le Fort I osteotomy and before plate and screw xation, planned and postsurgical results were investigated with
and 6) the use of consistent intraoperative landmarks (i.e., Pearson’s correlation.
the distance between the medial canthus and the maxillary
central incisor measured in millimeters with the use of cali-
Results
pers) to con rm vertical orientation.
e determination of the preferred surgical reorientation e collected data for all study patients are presented in
of the jaws was based on a combination of the direct visual Table 13-1. In all cases, the surgically achieved and main-
examination of the patient in the clinic setting, the analysis tained (i.e., at 5 week postoperatively) horizontal advance-
of the lateral cephalometric radiograph, and the analysis of ment measured at the maxillary incisors was within 1.0 mm
the pro le facial photograph taken in the NHP during the of what was planned. ere was a strong correlation between
presurgical o ce visit. e extent of preferred maxillary the two data sets (R = 0.96) (Fig. 13-15). With the use of
horizontal advancement in millimeters was ultimately the absolute measurement values, the mean di erence
assessed by the surgeon with the patient in the NHP during between the planned and actual 5-week postsurgical hori-
the direct visual examination, with all gathered data taken zontal advancement of the maxilla was found to be 0.6 mm
into account. e fabrication of an intermediate splint to (range, 0.2 to 1.0 mm). According to the paired t-test, this
capture the preferred maxillary horizontal and other vector mean di erence was not considered to be statistically
movements (i.e., pitch, yaw, and roll) with the use of signi cant (P > .05).
consistent analytic model surgery planning methods was e distribution of the absolute di erence in millimeters
accomplished. between the planned, actually achieved, and then
SN 75.8mm SN 75.8mm
SN FH 10° SN FH 10°
S S
S U1 87.4mm
S U1 78.9mm
A B
• Figure 13-14 Example of lateral cephalometric radiographs and measurements taken in study patients showing maxillary
advancement in millimeters. Lateral cephalometric radiographs A, before and B, after Le Fort I advancement. From Park N,
Posnick JC: Accuracy of analytic model planning in bimaxillary surgery, Int J Oral Maxillofac Surg. 42:807-814, 2013.
Le Fort I horizontal advancement maintained maxillary advancement is presented in Table

10 13-2. For the majority of patients, the di erence fell within
9 0.4 to 0.8 mm. In 17 of the 20 patients (85%), there was
a small undercorrection; in 3 of the 20 patients (15%) there
Actual advancement (mm)
8
was a slight overcorrection.
7
e results of this study con rm that the described method
6
of analytic model planning in orthognathic surgery is reliable
5 in achieving the planned level of maxillary advancement in
R 0.96
4 bimaxillary procedures.
3
2 Conclusions
1
Orthognathic surgery requires a thorough head and neck
0
examination and precise preoperative dental, radiographic,
0 2 4 6 8 10 12
and aesthetic preparation. Although clinical decision making
Planned advancement (mm) regarding the preferred spatial reorientation of the jaws to
Series 1 achieve improved function and enhanced facial aesthetics
remains both an art and a science, the technical aspects of
• Figure 13-15 Data from study patients undergoing Le Fort I model planning should be precise and consistent. Current
advancement. The correlation between the planned and actual methods of analytic model planning and the use of prefab-
advancement at the maxillary incisors is shown (R = correlation coef- ricated splints represent the standard of care for bimaxillary
cient). From Park N, Posnick JC: Accuracy of analytic model planning
in bimaxillary surgery, Int J Oral Maxillofac Surg. 42:807-814, 2013.
and segmental maxillary osteotomies.
TABLE
13-1 Maxillary Incisor Vertical Change, Plane Change, and Incisor Horizontal Change: Planned and Actual
Horizontal Change
Planned Vertical Planned Plane Planned Actual Difference

Patient Change Change (mm) (mm) (mm)
1 −6 0 +8 +8.5 +0.5
2 −3 −3 +4 +3.2 −0.8
3 −2 0 +6 +5.3 −0.7
4 −3 0 +10 +9.0 −1.0
5 0 0 +10 +9.4 −0.6
6 0 +2 +5 +4.8 −0.2
7 −1 +3 +6 +5.2 −0.8
8 −6 0 +7 +6.2 −0.8
9 +2 +2 +5 +4.8 −0.2
10 0 +3 +8 +7.5 −0.5
11 −3 0 +7 +6.4 −0.6
12 −2 −3 +8 +7.6 −0.4
13 +2 +2 +5 +4.2 −0.8
14 +4 +1 +7 +6.8 −0.2
15 +1 +4 +9 +8.5 −0.5
16 −5 −4 +6 +5.2 −0.8
17 −4 0 +6 +6.5 +0.5
18 −5 −2 +8 +7.2 −0.8
19 +3 0 +8 +8.8 +0.8
20 + 0 +10 +9.1 −0.9

Vertical change: +, maxillary lengthening; −, maxillary shortening. Plane change: +, clockwise rotation; −, counterclockwise rotation of maxillary plane.
TABLE Distribution of Di erence Between the Planned and Actual Horizontal Advancement at
13-2 the Maxillary Incisors
Difference (mm)
0 to 0.2 +0.2 to 0.4 +0.4 to 0.6 +0.6 to 0.8 +0.8 to 1.0
No. of patients (%) 3 (15%) 1 (5%) 6 (30%) 8 (40%) 2 (10%)

From Park N, Posnick JC: Accuracy of analytic model planning in bimaxillary surgery, Int J Oral Maxillofac Surg. In press 2013.
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13

Standard Analytic Model Planning

Assess intranasal anatomy

Maxillary midline No change needed

Anterior vertical no change

Posterior vertical 3-mm intrusion

Horizontal 5-mm advance

Maxillary Surgical Change

Horizontal change at incisors 5

Vertical change at incisors 0

Cant correction -TOTAL 2

Maxillary plane change -TOTAL 3

Vertical change at T#3 (right) molar 0 1 3 4

Vertical change at T#14 (left) molar 0 1 3 2

Measurements are used to spatially reposition the maxilla. The

“Chin-point guidance” technique for centric relation

Centric relation (CR) bite (wax)

Face-bow registration For transfer of relationships to articulator

Register patient’s maxillary occlusion into soft wax on bite fork

Even pressure Orrth

Approximating infra-orbital rims (profile)

Approximating infra-orbital rims (profile)

Thumb screws secure ear prongs

Orthognathic Surgery; J.C. Posnick

T-screws secure bite fork to vertical rod of face bow

Face-bow apparatus removed from patient

Alginate impressions of mandible and maxilla

Base forms are helpful

Incorporate at least 30 mm of stone base

Trim each model

First molar cusp tip

• Figure 13-4, cont’d D, With the base plate secured to the

Mandibular and maxillary casts secured to articulator

Placement of maxillary unit horizontal reference lines

- 1st reference line in green stone

Placement of maxillary unit vertical reference lines

At mesiobuccal groove of each first molar Between central incisors

Placement of maxillary unit vertical reference lines

At cusp tip of each canine Posteriorly at tuberosity regions

Erickson Model Table – Measurements

ORTHOGNATHIC SURGERY : ANALYTIC MODEL PLANNING

Patient name: Surgical wire date:

Surgical date: Final model date:

ERIKSON TABLE MEASUREMENTS MAXILLARY SURGICAL CHANGE

MAXILLARY HORIZONTAL Horizontal change at incisors

Baseline (mm) Change (mm) Final Vertical change at incisors

Right #8 Midline change at incisors

Left #9 Cant correction-Total

Right #3 Vertical change at T#3 (right) molar

OCCLUSAL EQUILIBRATION/MISSING TEETH

OVERALL SURGICAL PLAN

Baseline (mm) Change (mm) Final Le Fort I 2 seg 3 seg

Baseline (mm) Change (mm) Final

Right #8 74.5 5 79.5

Left #9 74.5 5 79.5

Baseline (horizontal) position of incisors (mm)

Maxillary Anterior Vertical

Baseline (mm) Change (mm) Final

Right #8 96.2 0 96.2

Left #9 95.8 0 95.8

Maxillary Posterior Vertical

Baseline (mm) Change (mm) Final