Int. J. Oral Maxillofac. Surg.

2014; 43: 972–979

http://dx.doi.org/10.1016/j.ijom.2014.04.017, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Accuracy of perioperative A. M. Borbaa,b, O. Ribeiro-Juniora,

M. A. Brozoskia, P. S. Céb,
M. M. Espinosac, M. C. Z. Debonia,
M. Milorod, M. G. Naclério-Homema
mandibular positions in a
Department of Oral and Maxillofacial
Surgery, Faculty of Dentistry, University
of Sao Paulo – USP, Sao Paulo, Brazil;

orthognathic surgery b
Post-Graduate Department, Faculty of
Dentistry, University of Cuiabá – UNIC, Brazil;
c
Department of Statistics, Institute of Exact
and Earth Sciences, Federal University of
Mato Grosso – UFMT, Brazil; dDepartment of
A. M. Borba, O. Ribeiro-Junior, M. A. Brozoski, P. S. Cé, M. M. Espinosa, Oral and Maxillofacial Surgery, University of
M. C. Z. Deboni, M. Miloro, M. G. Naclério-Homem: Accuracy of perioperative Illinois, Chicago, IL, USA
mandibular positions in orthognathic surgery. Int. J. Oral Maxillofac. Surg. 2014;
43: 972–979. # 2014 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. Mandibular position is an important parameter used for the diagnosis of

dentofacial deformities, as well as for orthognathic surgery planning and execution.
Centric relation (anterior and superior relationship of the mandibular condyles
interposed by the thinnest portion of their disks against the articular eminencies),
centric occlusion (when lower teeth contact upper teeth at centric relation), and
maximal intercuspation (complete interdigitation of lower and upper teeth) are not
often addressed as factors that influence the results of orthognathic surgery,
although these relationships are critical to ensure accuracy during the surgery. The
present study assessed occlusal measurements taken before and after the induction
of general anaesthesia from consecutive orthognathic surgery subjects. The
variables assessed included the differences between these occlusal measurements,
patient age, gender, type of deformity, and type of proposed orthognathic surgical
procedure. The results demonstrated statistically significant differences for
mandibular retrusion from maximal intercuspation to centric occlusion position,
Keywords: dental occlusion; centric dental oc-
whereas the mandible appeared not to change significantly from centric occlusion
clusion; dentofacial deformities; orthognathic
after the induction of general anaesthesia. Patient age and the type of deformity surgery.
appeared to influence the results. While in most instances centric occlusion can be
adequately reproduced under general anaesthesia, for some specific orthognathic Accepted for publication 29 April 2014
cases more accurate results might be obtained if the mandible-first sequence is used. Available online 28 May 2014

The mandible and temporomandibular
joint (TMJ) apparatus is a complex struc-
ture commonly used by dentists and den-
tal specialists as an anatomical reference
in a number of different clinical situa-
tions. The complexity is evident in the
anatomy of the mandible with severe
bends and curves and the presence of
foramina, the intrinsic relationship of
the mandible to the surrounding struc-
tures, the complex opening and closing
jaw functions relative to the masticatory
muscles, and the presence of a pair of
independent but connected (to each other)
articulations to the cranial base through
the TMJ.1,2
Since the mandible provides the osseous
support for the mandibular dentition, its
range of motion allows dental occlusion to
adapt to functional requirements such as
mastication, speech, and swallowing.
Mandibular position can be defined at
the level of the TMJ as centric relation
(CR), which corresponds to an anterior

0901-5027/080972 + 08 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

and superior relationship of the mandibu-
lar condyles interposed by the thinnest
avascular portion of the respective disks
against the articular eminencies of the
temporal bone. At the level of the denti-
tion, mandibular position can be defined as
centric occlusion (CO) when the lower
teeth contact the upper teeth with the
TMJ positioned in CR. Finally, maximal
intercuspation (MI) is defined as the com-
plete interdigitation of the lower and upper
teeth, not necessarily coinciding with CO,
independent of any reference to the posi-
tion of the TMJ.3–7
Malocclusions are usually the result of
dental misalignment, which can be cor-
rected by orthodontic treatment. However,
in some instances, the dental malposition
may reflect discrepancies of the bony sup-
port structures including the maxilla and
mandible. In such cases, orthognathic sur-
gery is a commonly used surgical proce-
dure that enables the correction of skeletal
discrepancies, allowing orthodontic ther-
apy to correct the discrepancies in tooth
alignment.
Mandibular position is an important
parameter assessed in the diagnosis of
dentofacial deformities, as well as for
the planning and execution of orthog-
nathic surgery. In order to determine man-
dibular position, CO is used to observe the
difference between the maxillary and
mandibular teeth clinically, and to mount
the maxillary and mandibular dental cast
models for evaluation and in order to
perform model surgery. During the surgi-
cal procedure, it is essential to have the
mandible in the CO position in order to
allow the actual surgery to correspond to
the model surgery, especially for bimax-
illary surgical cases.8–17 It should be noted
that some authors have shown that the
mandible may assume a different position
to that which was recorded presurgery
when the patient is under general anaes-
thesia (GA) in a supine position, and that
this results in an altered CO position;
however, few studies have documented
this phenomenon clinically.8,9,17–19
The present study aimed to address the
following questions among patients with
dentofacial deformities undergoing
orthognathic surgery: (1) What is the dif-
ference between occlusal registrations
obtained in the CO and MI positions?
(2) Is there a difference in CO and MI
positions obtained in the awake and
upright patient position and in the supine
position under GA? Does the patient age,
gender, type of dentofacial deformity, or
type of surgical procedure influence any of
the above measurements and relation-
ships?
Mandibular position and orthognathic surgery 973
Materials and methods rial. Just prior to the third attempt at
maximal occlusion, impression material
The clinical data were collected prospec-
was placed over the mandibular teeth
tively from consecutive patients who
and the patient was instructed to bite in
underwent orthognathic surgery in the
a fashion similar to the first two attempts.
department of oral and maxillofacial sur-
For CO registration, the patient was
gery of the study hospital between July
positioned again in a semi-supine fashion.
2012 and April 2013.
The patient was asked to relax and posi-
The following variables were evalu-
tion his/her tongue gently against the
ated: gender (male or female), age (cate-
palate and to maintain it in that position;
gorized into three groups according to the
then, gentle manual pressure was applied
statistical distribution of the study group:
to the chin in order to achieve the most
24 years, 25–39 years, >39 years), type
anterior and superior position of the man-
of dentofacial deformity (class II or class
dibular condyles, moving the mandible
III), and type of orthognathic surgery per-
until the first contact of opposing teeth
formed (single-jaw (maxilla or mandible)
was noted. This technique was performed
or double-jaw (maxilla and mandible)).
twice without any registration; just prior to
The inclusion criteria were the follow-
the third attempt, impression material was
ing: age 18 years, overall good systemic
placed over the mandibular teeth while the
health (American Society for Anesthesiol-
jaw manipulation was repeated and the
ogists (ASA) classification I or II), cogni-
bite registration was performed.
tive understanding of the orthognathic
Occlusal registration under GA was
surgery to be performed, and voluntary
accomplished with the patient in a supine
consent of acceptance to be enrolled in
position immediately following the induc-
the proposed research project. Exclusion
tion of GA (propofol and fentanyl) and
criteria were concomitant or prior TMJ
nasotracheal intubation (preceded by the
surgery, absence of mandibular central
use of atracurium as the neuromuscular
incisors, absence of at least one mandib-
blocking agent). This particular time was
ular molar on each side, and refusal to
chosen since the influence of the muscles
participate in the research project.
of mastication would be minimized or
After a discussion including a compre-
eliminated with muscular paralysis. The
hensive explanation of the proposed sur-
tongue was carefully positioned towards
gical procedure as well as the
the posterior hard palate, and gentle pres-
methodology of the research protocol,
sure was applied to the chin in order to
patients who agreed to participate signed
achieve the most anterior and superior
an informed consent agreement. Three
position of the mandibular condyles, with
oral and maxillofacial surgeons performed
movement of the mandible until the first
all of the surgical procedures as part of
contact of opposing teeth was noted. This
work for the Brazilian public health sys-
technique was performed twice without
tem.
any bite registration; during the third
This study was performed in accordance
attempt, impression material was placed
with the principles of the Declaration of
over the mandibular teeth and the techni-
Helsinki and is registered at Clinical-
que repeated and the bite registration was
Trials.gov under the identifier
performed. Pharyngeal packing with
NCT01486069. Ethics committee
gauze was performed only after the occlu-
approval was obtained.
sal registration process had been com-
Dental occlusion registration
pleted.
Dental occlusion was registered for three
Measurement of mandibular position
distinct clinical positions: MI in a semi-
supine position, and CO in a semi-supine Each patient had two maxillary and two
position and in a supine position while mandibular dental cast models, which
under GA. Condensation silicone was were mounted on a semi-adjustable articu-
used as the impression material (Silon2 lator (model 4000-S; Bio-Art, São Carlos
APS; Dentsply, Santiago, Chile). The SP, Brazil) based upon an organized
same examiner was responsible for per- mounting sequence. The face-bow was
forming each MI and CO bite registration levelled to make it parallel to the inter-
for all patients at all time points. pupillary plane (axis–orbital plane), and
For MI registration, the patient was the forehead support was used as a three-
positioned in a dental chair in a semi- dimensional reference to mount the first
supine fashion (inclined at an angle of maxillary cast on the articulator. The CO
458 to the horizontal plane) and voluntary registration was then used to mount the
maximal dental occlusion was observed first mandibular cast model; next, the first
twice without the use of impression mate- maxillary model was removed and the
974 Borba et al.
Fig. 1. Mandibular cast model marked with
anatomical references for the anterior region,
right posterior region, and left posterior
region.
second maxillary model was mounted over
the same first mandible. Following this, the
first mandibular model was removed and
the second mandibular model was mounted
under the second maxillary model using the
MI registration. The mounting of the max-
illary models was checked for accuracy,
and if positive, orthognathic model surgery
was ready to be performed.
Dental anatomical references were
marked on the mandibular models in the
anterior region (mesio-incisal angle of the
left central incisor), the right posterior
region (distobuccal cusp of the most pos-
terior right molar), and the left posterior
region (distobuccal cusp of the most pos-
terior left molar) (Fig. 1). Subsequently,
the casts were measured with an electronic
calliper attached to a granite platform
(Erickson Model Block). For the antero-
posterior (AP) axis, measurements were
obtained from the three reference marks in
Fig. 2. Mandibular cast models set for measurements, illustrating positive and negative interpretation of the difference from the mandibular
positions evaluated (CO–MI and GA–CO) for (a) anteroposterior (AP), (b) vertical, and (c) transverse (T) axes.
the anterior region and the right and left
sides with the posterior region of the
mandibular model facing down. For the
vertical (V) axis, measurements were
obtained from the same three points with
the base of the mandibular model facing
down. For the transverse (T) axis, mea-
surements were obtained only from the
anterior region with the left side of the
mandibular model facing down (Fig. 2).
Model surgery for single-jaw proce-
dures was done using a Galetti articulator.
Double-jaw procedures required model
surgery that was performed according to
a pre-determined sequence8,9: the maxil-
lary model was placed in the desired final
position, the second mandibular model
(mounted on MI) was then set into occlu-
sion with the ‘operated’ maxilla thus pro-
viding a final occlusion and allowing
fabrication of the final splint; the ‘oper-
ated’ mandibular model was left in place
while the ‘operated’ maxillary model was
removed and replaced by the unoperated
maxillary model, thus providing an inter-
mediate occlusal relationship and allow-
ing the fabrication of the intermediate
splint. All double-jaw procedures were
planned to have the surgery begin with
the mandible-first sequence.
After surgery, a mandibular model was
remounted against the unoperated maxil-
lary model, this time using the GA regis-
tration and allowing the proposed
measurements to be performed. Consider-
ing that different individuals possess vari-
able mandibular dimensions, the absolute
measurement was not recorded, but rather
a mathematical equation was used to
determine the difference between two dis-
tinct moments for the same patient: the
difference between CO and MI (CO–MI)
and the difference between GA and CO
(GA–CO). Hence, the interpretation of the
data was accomplished according to the
determinations for the AP, V, and T axes
as detailed below.
AP: positive values for CO–MI indicated
that the mandible was found in a more
anterior position at CO when compared to
MI; for the GA–CO measurement, posi-
tive values indicated that the mandible
was in a more anterior position at GA
when compared to CO. Negative values,
on the other hand, indicated that the mand-
ible was in a more posterior position at CO
when compared to MI; for the GA–CO
measurement, negative values indicated
that the mandible was in a more posterior
position at GA when compared to CO
(Fig. 2a).
V: positive values for CO–MI indicated
that the mandible was found in a more
superior position at CO when compared to
MI; for the GA–CO measurement, posi-
tive values indicated that the mandible
was in a more superior position at GA
when compared to CO. Negative values,
on the other hand, indicated that the mand-
ible was in a more inferior position at CO
when compared to MI; for the GA–CO
measurement, negative values indicated
that the mandible was in a more inferior
position at GA when compared to CO
(Fig. 2b).
T: positive values for CO–MI indicated that
the mandible was found deviated to the
right at CO when compared to MI; for
the GA–CO measurement, positive values
indicated that the mandible was found
deviated to the right at GA when compared
 Mandibular position and orthognathic surgery 975

Table 1. Overall descriptive results. The descriptive results for the differ-
Variable Group Number of patients (n) ences for the GA–CO measurements are
presented in Table 4. It can be observed
Gender Female 21
Male 9 that all mean values were less than
0.5 mm; however, the standard devia-
Patient age 24 years 8 tion values were, in general, greater than
25–39 years 18 those observed for the CO–MI difference.
>39 years 4
Statistical analysis of the measurements
Type of deformity Class II 16 with consideration to the variables demon-
Class III 14 strated a significant result only in the
Type of orthognathic surgery Single-jaw 14 anterior region for the V axis for the type
Double-jaw 16 of the deformity variable; class II patients
maintained their tendency to have a super-
ior displacement from CO to GA, whereas
to CO. Negative values, on the other hand, posterior position at CO when compared class III patients generally maintained the
indicated that the mandible was found to MI. The T axis value demonstrated a mandible in the same position after induc-
deviated to the left at CO when compared slight shift to the right. For the V axis, the tion of GA (Table 5).
to MI; for the GA–CO measurement, nega- mean value was positive in the anterior
tive values indicated that the mandible was region and negative on the left and right
found deviated to the left at GA when Discussion
sides. All mean values were less than
compared to CO (Fig. 2c). 1 mm and the standard deviation was less The treatment planning and execution of
than 2 mm. orthognathic surgery is based upon the
The measurements were further ana- collection of a standard reproducible data-
Statistical analysis
lyzed with consideration to the study vari- base that is used consistently throughout
ables, demonstrating a significant result in the planning phases and surgical treat-
Data were analyzed descriptively using at least one of the axes for all of the ment. Since CR defines the position of
SPSS 15.0 (SPSS Inc., Chicago, IL, variables except gender (Table 3). With the mandible at the TMJ level, CO is its
USA). The results of the measurements regard to patient age, a statistical differ- counterpart with a relation to the dental
were compared for the proposed variables ence was demonstrated for the >39 years occlusion. On the other hand, MI is inde-
(age, gender, type of deformity, type of group, who displayed an increased poster- pendent of any relationship to the TMJ,
surgery) by bivariate comparison using a ior displacement of the mandible from MI and is based upon the maximum occlusal
Student’s t-test or by analysis of variance to CO. adaptation between the maxillary and
(ANOVA) associated with the Tukey test; The type of dentoskeletal deformity mandibular teeth.7 Each of these data
statistical significance was set at P < 0.05. demonstrated a retrusive behaviour (pos- measurements is critical to the overall
terior displacement) from MI to CO for success of orthognathic surgery, yet the
Results class II patients, whereas class III patients ability to accurately reproduce these mea-
did not show a significant change in the surements during all phases of diagnosis
The total study group comprised 30 position from MI to CO. For the V axis, and treatment may be compromised by
patients (mean age 30.5 years; median class II patients tended to have a superior factors such as patient positioning and
age 29.5 years). Patient age was categor- displacement from MI to CO, whereas the use of GA.
ized into three groups according to the class III patients displayed the opposite It is possible that the impression tech-
incidence of distribution of the sample: behaviour with inferior displacement from nique itself might be responsible for a
24 years, 25–39 years, and >39 years. MI to CO. discrepancy between CO, CR, and MI
The distribution of gender, age, type of The type of surgery variable exhibited a measurements, since the materials used
deformity, and type of surgery is detailed significant result for the anterior region of for bite registration may result in more
in Table 1. the mandible for the V axis, in which than 2 mm of discrepancy due to the
The differences for the CO–MI mea- double-jaw patients had a more inferior required thickness of the material itself.20
surements are detailed in Table 2. For the position of the mandible from MI to CO, This difference might be reflected in the
AP axis, the negative mean values demon- with the opposite result (superior displa- present study for the V difference, since it
strated that the mandible had a more cement) for single-jaw patients. is not possible to create a reproducible
thickness of the material used for each
given occlusal surface.
Table 2. Descriptive analysis for centric occlusion (CO)–maximal intercuspation (MI) differ- There is no consensus regarding the
ence.a most appropriate technique for the acqui-
Measurements Mean SD Minimum Median Maximum sition of CR or CO. Bimanual mandibular
AP anterior 0.816 1.669 5.020 0.600 1.760 manipulation produces satisfactory results
AP right 0.851 1.831 5.650 0.835 3.980 using the chin point guidance technique,
AP left 0.703 1.455 3.740 0.895 1.970 so it seems that an ideal technique could be
T 0.258 1.074 1.770 0.145 2.360 the one that the operator is used to per-
V anterior 0.235 1.784 3.150 0.435 3.580 forming on a regular basis; however, each
V right 0.139 1.073 1.740 0.365 1.980 clinician has his/her own individual pre-
V left 0.035 1.609 2.990 0.065 3.320 ferences thereby resulting in a lack of
AP, anteroposterior; T, transverse; V, vertical; SD, standard deviation. consistency between clinicians and also
a
Values in millimetres. within clinicians for different patients.5,6
976 Borba et al.

0.331 A (2.089)
A previous research study investigated

0.088 A (1.169)
0.278 (1.509)

0.599 (1.352)

0.535 (1.719)
orthodontists’ and oral and maxillofacial

0.00 A (2.60)
0.070 (1.674)

0.459 (1.691)

0.537 (1.306)
V left

surgeons’ understanding of the definition

of CR.21 The authors demonstrated that
0.584

0.837

0.068

0.063
only 3% of oral and maxillofacial sur-
geons and 14% of orthodontists defined
CR as consistent with the current accepted
definition. Moreover, approximately 30%
of both specialties believed that cast mod-
0.239 A (0.946)
0.385 A (1.661)
0.211 A (1.103)

els should be mounted on an articulator

0.141 (1.168)
0.132 (0.877)

0.763 (0.699)

0.117 (1.063)
0.163 (1.125)
Table 3. Results of statistical analysis of the measurements based on the variables for centric occlusion (CO)–maximal intercuspation (MI) difference; mean (SD).

0.408 (1.059)
V right

using the CO and not the CR reference.

However, the authors compared only CO
to CR; they should have been concerned
0.001c
0.981

0.560

0.911
about mounting the models using MI as
well. This is an example in the literature of
the confusion between the definitions of
CR, CO, and MI.
0.768 A (0.986)

It is difficult to determine whether the

0.271 A (2.129)
0.442 A (1.764)

0.237 (1.664)

0.414 (1.490)

preoperative CR relationship will be the

V anterior

0.171 (1.597)
0.383 (2.265)

0.648 (1.835)

0.976 (1.852)

same, or the appropriate relationship, fol-

lowing orthognathic surgery.18,22,23 How-
0.034c
0.804

0.487

0.177

ever, independent of any postsurgical TMJ

Analysis of variance (ANOVA) and Tukey test, in which different letters indicate statistical differences between categories.

adaptations, the CO measurement has

been shown to be a reliable determinant
of the appropriate occlusal relationship,
even under GA, and therefore should be
0.457 A (0.883)

used as the most appropriate reference for

0.225 A (1.106)
0.431 A (1.083)
0.146 (1.001)
0.430 (1.080)

0.187 (1.095)
0.339 (1.085)

0.378 (1.228)
0.120 (0.891)

orthognathic surgical planning.

The TMJ position is variable and may
T

not be consistent from one side to the

0.178

0.336

0.707

0.512

other, and this is demonstrated in the

present study by the different results
observed for each side.5 The right side
was the only one to show statistical sig-
1.275 A (1.190)
0.301 A (1.328)
1.370 A (2.180)

nificance for the CO–MI measurement

0.690 (1.438)
0.733 (1.582)

1.116 (1.604)
0.230 (1.142)

0.311 (1.401)
1.150 (1.433)

change for the AP axis, and both sides

AP left

demonstrated significance for the V axis

with the same measurement. Perhaps these
data also demonstrate the influence of the
0.994

0.182

0.090

0.118

operator (obtaining records from the right

side of the patient) as well as some mus-
AP, anteroposterior; T, transverse; V, vertical; SD, standard deviation.

cular influences from the awake patient,

although the operator would not be
0.219 A (1.961)
0.626 A (1.443)
3.130 B (1.830)

responsible for this finding since there

0.852 (2.038)
0.849 (1.332)

1.476 (2.044)
0.137 (1.277)

0.886 (1.324)
0.811 (2.336)

was no statistical significance with the

AP right

GA–CO measurement.
An earlier study demonstrated that neu-
0.018c

0.039c
0.996

0.916

romuscular blocking agents did not appear

to affect mandibular position, but rather
the GA itself was responsible for signifi-
cant alterations in mandibular position.19
However, an inclusion criterion in that
1.014 A (1.293)
0.204 A (1.353)
3.177 B (1.693)

study was that patients had coincident

0.949 (1.805)
0.508 (1.341)

1.552 (1.725)

0.759 (1.597)
0.882 (1.806)
AP anterior

0.024 (1.164)

CR and MI; this could be interpreted as

a drawback of the study, since such con-
Statistically significant.

cordance does not appear to be applicable

0.002c

0.006c
0.468

0.845

clinically between CR and MI.

The type of deformity has been consid-
Student’s t-test.
Type of deformity
Age group, years

ered to be a significant variable for

Type of surgery

patients with dentofacial deformities

Double-jaw

under GA. Most studies have used the

Single-jaw
Variables

Class III
P-valueb
P-valuea

P-valuea

P-valuea

Angle classification of class II and class

Class II
Gender
Female

25–39
Male

III, which addresses the discrepancy at the

24

>39

b
a

dental level, although orthognathic

 Mandibular position and orthognathic surgery
Table 4. Descriptive analysis for the general anaesthesia (GA)–centric occlusion (CO) differ-
ence.a
Measurements Mean SD Minimum Median Maximum
AP anterior 0.331 1.895 4.540 0.335 3.990
AP right 0.203 1.779 3.770 0.375 2.780
AP left 0.359 2.438 5.810 0.380 5.920
T 0.019 1.303 3.500 0.280 2.300
V anterior 0.498 2.670 8.190 0.225 4.380
V right 0.365 1.734 3.300 0.235 4.850
V left 0.390 2.133 4.550 0.180 3.680
AP, anteroposterior; T, transverse; V, vertical; SD, standard deviation.
a
Values in millimetres.
patients have problems that are related to previously by other studies. Single-jaw
the maxilla, the mandible, or both at the procedures are generally used to correct
skeletal level. In spite of the conflicting minor dentofacial skeletal abnormalities,
definitions of CR and CO, Bamber et al. while double-jaw surgeries are frequently
demonstrated a retruded pattern of the required to create major alterations in the
mandible under GA for class II patients.18 occlusal plane and to perform surgical
Similar findings were documented movements of greater magnitude and
recently, but variables such as gender, complexity in order to correct major den-
age, and type of orthognathic surgery have toskeletal problems. Since the only sig-
not yet been investigated.17 In view of the nificant result for this variable in this study
results of the present study, class II was found for the V axis at the anterior
patients do have a tendency to alter the region for the CO–MI measurement, this
mandibular position from MI to CO; how- might reflect the influence of the thickness
ever, this is not a concern following the of the material needed for the bite record,
induction of GA. without other significant contributing fac-
It is expected that class III patients tors.
would not have a significant change from As mentioned, the database for orthog-
MI to CO due to the forward mandibular nathic surgery includes not only the acqui-
position, but the present study demon- sition of a bite record, but also the correct
strated that these patients had a greater mounting of the casts on the articulator
mandibular retrusive behaviour than class and proper mock model surgery; of
II patients under GA. Thus, it may be course, the surgery itself can lead to inac-
possible that these patients still have some curacies in the proposed dentofacial mod-
muscular resistance during the acquisition ifications.8,11,12,31 However, such
of CO, and that class II patients were complexity related to the precision
effectively placed into CO position since required for orthognathic surgery rein-
their mandible did not appear to change in forces the requirement to pay careful
the AP axis following the induction of GA. attention to the many variables present
Patient gender was not a significant in the orthognathic database and treatment
variable in the present study. Although plan.
this may be due to either the limited Although precision in orthognathic sur-
patient sample or their mean age (approxi- gery is the ideal goal, the establishment of
mately 30 years), this finding is in contrast acceptable boundaries of imprecision may
to those of other studies which have cor- be a difficult task. It has been postulated
related female gender to alterations of the that 1 mm of inaccuracy for all axes
TMJ apparatus.24,25 It has also been except for the AP axis would result in
demonstrated that the TMJ is subject to up to 2 mm of overall discrepancy.32,33
normal as well as pathological changes Several studies have demonstrated favour-
over the years.26–30 Occlusal wear occurs able results between planned and com-
with the ageing process, requiring progres- pleted cases, although some variations
sive TMJ and muscular adaptations to can be found.10,34–36 Attention should be
maintain MI. This might be an explanation directed to differentiate double-jaw from
for the statistical significance found in this single-jaw procedures since they reflect
study in the >39 years age group for the different clinical situations with different
CO–MI measurements, not identifiable magnitudes of discrepancy that can result
with the GA–CO measurements, since in greater degrees of inaccuracy.34
no muscular influences were expected to It is unusual for the imprecision
be encountered. involved with orthognathic surgery to be
The type of orthognathic surgical pro- attributed to an inaccurate CO acquisition
cedure was a variable addressed in this or to a change in the position of the
study, since it had not been addressed mandible following induction of GA.
977
Sharifi et al. observed class III individuals
who underwent either double-jaw or a
single maxillary orthognathic surgery,
and verified that approximately one-third
of patients in both groups had a resulting
maxillary advancement of less magnitude
than that which was planned.16 Although
the authors did not report the bite registra-
tion used in their study (CO, CR, or MI),
they speculated that the mandible might
have changed its position following the
induction of GA and that this led to the
inaccurate final results. It may be sug-
gested that either they used MI as a refer-
ence for model surgery, or they
encountered difficulties in the acquisition
of a true CO registration. If the results of
this present study are used for such a
clinical scenario, based upon the mini-
mum and maximum values as well as
the standard deviation values, some
patients will certainly alter their mandible
position from CO to GA.
Accurate bite registration records are
not always simple to perform and may
not be consistent between examiners and
within examiners. Several clinical scenar-
ios may result in an unreliable bite record
at CO,8,9 including the absence of a man-
dibular condyle secondary to oncological
resection, or loss or atrophy of the man-
dibular condyle after fracture or malfor-
mation of the TMJ (e.g. hemifacial
microsomia). This unpredictable beha-
viour of the mandible in complex situa-
tions has led to several modifications to
conventional model surgery, as well as to
the orthognathic surgery itself. While tra-
ditionally the sequence of orthognathic
surgery is maxillary surgery first followed
by mandibular surgery, the appropriate
sequencing for double-jaw orthognathic
surgery remains controversial, although
this decision may be more appropriately
based upon the specific magnitude of the
skeletal discrepancy.8,9,37,38 Nearly 35
years ago, Lindorf and Steinhauser had
already suggested that for double-jaw
orthognathic surgery, model surgery
should be initiated in the maxilla, but,
interestingly, that the surgery itself should
start with the mandible.39 Throughout the
years, some authors have supported this
modified sequencing of surgery, using the
maxilla as a solid and reliable reference to
start the double-jaw orthognathic surgery,
although some modifications to the spe-
cific details of the model surgery have
been proposed.8,9,37 However, while the
accuracy of double-jaw orthognathic sur-
gery is important, data regarding accuracy
and reproducibility have been published
mainly with regards to the traditional max-
illa-first sequence.34,35
978 Borba et al.

0.148 A (2.253)
In this present study, the sample size,

1.194 A (1.874)

1.202 A (1.634)

0.391 (2.476)

0.119 (2.440)
and consequently the even smaller subdi-
0.144 (2.160)
0.963 (2.071)

1.072 (1.554)

0.835 (1.783)
V left

visions of patients, is a limitation to the

interpretation of the results. However, the
0.342

0.246

0.070

0.239
results are important as they provide data
that indicate, on an overall basis, that the
discrepancy between MI and CO is of such
importance that MI should not be recom-
mended for use as a bite registration refer-
0.036 A (1.480)
1.209 A (2.033)

0.482 A (2.035)
ence for orthognathic surgical planning.

0.012 (1.883)

0.026 (1.458)
0.422 (1.966)
0.232 (0.960)

0.696 (1.580)

0.708 (1.925)
V right

On the other hand, GA appears not to

Table 5. Result of statistical analysis of the measurements based on the variables for general anaesthesia (GA)–centric occlusion (CO) difference; mean (SD).

represent a major problem in general,

provided that the acquisition of CO is
0.728

0.245

0.279

0.246
straightforward and performed properly.
While patient gender and type of surgery
might not be major concerns according to
the group evaluated in this study, age and
1.036 A (3.232)

the type of deformity are important vari-

0.399 A (1.395)

0.125 A (0.874)
0.630 (2.444)
0.190 (3.279)

0.165 (3.082)

0.324 (2.522)
0.698 (2.912)

ables to take into consideration. Attention

V anterior

0.522 (1.779)

should be drawn to the minimum, max-

imum, and standard deviation values pre-
0.030c
0.724

0.411

0.712

sented in this study if the surgeon plans to

Analysis of variance (ANOVA) and Tukey test, in which different letters indicate statistical differences between categories.

rely on the correct position of the mand-

ible in order to perform accurate double-
jaw orthognathic surgery by the traditional
maxilla-first sequence. Based upon the
0.108 A (1.462)
0.487 A (0.831)

data presented, perhaps some orthognathic

0.416 A (1.091)
0.160 (1.314)

0.166 (1.531)

0.132 (1.467)
0.310 (1.292)

0.111 (1.102)

0.111 (1.128)

surgical cases may yield more accurate

results if the mandible-first sequence is
T

utilized in select cases.

0.378

0.490

0.580

0.614

Funding
None.
0.922 A (2.759)
0.680 A (0.455)
1.070 A (1.685)
0.570 (2.292)

0.781 (2.717)

0.281 (1.574)
0.447 (3.223)

Competing interests
0.133 (2.833)

0.011 (2.187)
AP left

None declared.
0.523

0.152

0.393

0.863

Ethical approval
AP, anteroposterior; T, transverse; V, vertical; SD, standard deviation.

The Ethics Committee of the University of

Sao Paulo–USP, under protocol number
47820, provided ethical approval for the
0.325 A (2.600)
0.267 A (1.934)
0.292 A (1.609)

proposed research.
0.258 (1.986)
0.074 (1.258)

0.256 (1.773)
0.143 (1.851)

0.049 (1.755)
0.379 (1.856)
AP right

Patient consent
0.763

0.826

0.866

0.622

Not required.

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0.655 A (2.107)

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Address:
Alexandre Meireles Borba
Hospital Geral Universitário
Divisão de Odontologia
Rua Treze de Junho, 2101
Centro, Cuiabá - MT
CEP 78025-000
Brazil
Tel.: +55 65 3315 7150.
E-mail: alex80@terra.com.br