SPECIAL ARTICLE

Occlusal plane alteration in orthognathic

surgery-part H: Long-te n stability of results
Peter D. Chemello, DDS," Larry M. Wolford, DDS, b and Peter H. Buschang, MS, PhD ~
Dallas, Texas

Alteration of the occlusal plane may be indicated in patients who present with either low occlusal
plane (LOP) facial type or the high occlusal plane (HOP) facial type. Surgical alteration with double
jaw surgery to increase or decrease the occlusal plane angulation may be required to achieve
optimal functional and esthetic results. This study evaluated the stability of results in two groups of
patients. Group 1 consisted of 14 patients who underwent surgical increase of the occlusal plane
angulation with a postsurgical follow-up average of 23 months. The average surgical increase-in
occlusal plane angulation was 5.6~ Several anatomic landmarks were evaluated relative to stability
of results. Postsurgical changes that were statistically significant included a postsurgical anterior
facial height change (-0.8 mm), ramus height change (-0.3 mm), and a change in mandibular
plane angle (-0.5~ These changes were due, in part, to the removal of the occlusal splint allowing
some autorotation of the mandible superiorly and settling in of the occlusion. There was no
significant change in any of the other parameters evaluated. Group 2 consisted of 27 patients, with
a mean follow-up of 21 months, that had an average surgical decrease in occlusal plane angulation
of 8.8 ~ with double jaw surgery. There was an 8 mm advancement of the mandibleat point B, and
a 10 mm advancement at pogonion. The maxilla was moved 3 mm superiorly at point A, and the
maxillary first molar showed no significant vertical movement. The postsurgical changes
demonstrated no statistically significant horizontal movement of the mandible. There were
significant changes for the horizontal position of point A (-0.5 mm) and maxillary depth (-0.5~
The posterior aspect of the maxilla settled superiorly an average of 1 mm. There was statistically
significant decreases for anterior facial height ( - 1.7 mm) and the vertical height of the ramus .
(-0.7 mm), which were at least partially due to the removal of the interocclusal splintand the
settling in of the occlusion. This study confirms the stability of increasing or decreasing the occlusal
plane angulation with double jaw surgery in the presence of healthy and stable temporomandibular
joints. (AM J ORTHODDENTOFACORTHOP1994;106:434-40.)

A l t e r a t i o n of the occlusal plane may be
indicated in patients who present with either an
increased or decreased occlusal plane angulation.
An abnormal occlusal plane angle can contribute
significantly to the esthetic and functional deformi-
ties of patients who may be considered for orthog-
nathic surgery. Discussion of the types of patients
who may benefit from surgical correction of the
occlusal plane, the rationale, and the surgical ap-
proach for this type of management have been
presented in Part I of this series?
=Former fellow in Oral and Maxillofacial Surgery at Baylor University
Medical Center, Dallas, Texas; currently Clinical Associate, Department
of Surgery, Section of Oral and Maxillofacial Surgery, University of
Chicago; private practice in Arlington Heights, I11.
bClinical Professor of Oral and M~,dllofacial Surgery at Baylor College of
Dentistry, Dallas, Texas; private practice at Baylor University Medical
Center, Dallas, Texas.
"Associate Professor, Department of Orthodontics, Baylor College of
Dentistry, Dallas, Texas.
Copyright 9 1994 by the American Association of Orthodontists.
0889-5406/94/$3.00 + 0 8/1/48281
434
A functional and occlusal plane angle is defined
as an angle formed by Frankfort horizontal (FH)
and a line tangent to the cusp tips of the lower
premolars and the buccal groove of the second
molar. The normal value for adults is 8 ~ _ 4~ 2
Surgical alteration of the occlusal plane may be
indicated in patients with either increased occlusal
plane angulation or decreased occlusal plane angu-
lation to obtain optimal treatment results. This
article will discuss the long-term stability of results
of patients who have undergone either downward
and backward (clockwise) or upward and forward
(counter-clockwise) rotation of the occlusal plane
to correct various types of facial deformities.
MATERIALS AND METHODS
Forty-one patients (9 males, 32 females) have been
included in this study. Each patient had surgery consist-
ing of multiple-piece maxillary step osteotomies with
rigid fixation through four bone plates and a minimum of
four bone screws in each plate (two screws above and two
below the osteotomy); and bilateral mandibular ramus
 American Journal of Orthodonticsand Dentofacial Orthopedics Chemello, Wolford, and Buschang 435
Volume 106, No. 4

Table I. Definition o f m e a s u r e m e n t s and

r a n d o m technical errors for replicate
cephalometric measurements
Method
Measurement Digitized points error*

17 OPA degree 14-15/17-3 0.3025

MPA degree 12-11/17-3 0.2665
P Maxillary depth degree
Mandibular depth degree
17-3/2-4
17-3/2-9
0.3748
0.1962
Gonial angle degree 13-12-11 0.6442
Upper increase angle 2-4/5-6 0.7716
degree
14 Lower increase angle 2-9/7-8 1.0982
5 degree
A point horizontal mm 4 .L 17-3 0.4359
B point horizontal mm 9 .s 17-3 0.3421
Pg horizontal mm 10 _1_17-3 0.3905
Upper molar horizontal mm 16..s 17-3 0.6340
A point vertical mm 4 .s (17 .s 17-3) 0.1432
Upper increase vertical mm 6 .s (17 .s 17-3) 0.1910
Upper molar vertical mm 16 .s (17.1_ 9 0.4135
Fig. 1. Cephalometric points digitized are illustrated. N-Me vertical mm 2-11 .s (17 .s 0.2855
Gonion vertical mm 12 .s (17 .s 17-3) 0.2449
Lower facial height mm 7-11 .s (17 .s 17-3) 0.3186

sagittal split osteotomies with bicortical rigid screw fixa- *Method error = ~/5" (Rl - R 2 ) 2

tion. Patients with alloplastic chin augmentations were Y 2n

also included, but not those with osseous genioplasties.
The surgery of all the patients was performed by the
same surgeon (L.M.W.), and all patients had healthy
temporomandibular joints (TMJ). Surgical movements
were performed as indicated by clinical and cephalo-
metric examination as described previously by Wolford,
Chemello, and Hilliard.' Most patients had light training
elastics for approximately 2 to 4 weeks after surgery.
Twenty-two patients h a d a n interocclusal splint present
after surgery for 2 to 6 Weeks: 6 in the group with an
increase of the occlusal plane ( l O P ) a n d 16 in the group
with a decrease in occlusal plane (DOP). The remaining
patients had no splint present at completion of surgery or
in the postoperative period.
The patients were divided into two groups: those
with a surgical increase of the occlusal plane (group lOP)
and those with a decrease in the occlusal plane (group
DOP) by rotation of the maxillomandibular complex.
Group IOP included 14 patients (4 male, 10 female) with
a minimum follow-up of 12 months and a mean follow-up
of 23 months. The mean age at the time of surgery was 31
9 years 4 months with a range of 15 years 3 months to 53
years 10 months. Group DOP included 27 patients (5
males, 22 females) with a minimum follow-up of 12
months and a mean follow-up of 21 months. The mean
age for this group at the time of surgery was 30 years 8
months with a range of 15 years 4 months to 44 years 6
months.
Lateral cephalograms were taken immediately before
surgery (T1), immediately after surgery (T2), and long-
term ('1"3) for each patient. The cephalograms were taken
with the same method; magnification was not adjusted.
All cephalometric radiographs were traced and digitized
by the same person. The points digitized are shown in
Fig. 1 and correspond to the definitions of Riolo et al?
(Table I). The occlusal plane was defined by the subjects'
mandibular molars and premolars. The reference planes
used to make all measurements were Frankfort horizon-
tal (FH) and a vertical line through porion perpendicular
to FH. The technical or method error was evaluated by
replication (Table I). Surgical and postsurgical changes
within groups (T1 to T2, T2 to T3) were computed by
subtraction. The skewness and kurtosis of each distribu-
tion were evaluated by using the respective standard
errors. Normal distributions were indicated for all mea-
surement except for the upper incisor angle in group IOP
long-term. Paired t tests were used to compare treatment
and posttreatment changes; incisal angle in the group
lOP Tz-T3 postsurgical 9 was analyzed by the
nonparametrie Wilcoxon matched pairs, signed-ranks
test.
RESULTS
T h e preoperative, postoperative, and long-term
follow-up m e a s u r e m e n t s were r e c o r d e d for the
groups w h o s e occlusal plane was surgically in-
creased (Table II) or decreased (Table III). T h e
surgical changes and postsurgical changes are de-
scribed in Tables I V and V. Recall that approxi-
mately 68% o f the values fall within 1 s t a n d a r d
436 Chemello, IVolford, and Buschang American Jo . . . . . l of Orthodontics and Dentofacial Orthopedics
October 1994

Table II. Descriptive statistics for g r o u p I O P

Preoperative Postoperative Long-term

Variable "~ I SD "~ [ SD "~ I SD
OPA 3.29 5.12 8.9 5.74 8.3 5.79
MPA 21.5 6.79 22.9 7.79 22.5 5.03
Maxillary depth 86.1 5.26 88.9 4.43 88.5 4.10
Mandibular depth 87.5 5.90 87.2 4.52 87.2 4.87
Gonial angle 125.5 8.61 130.8 5.42 130.8 5.62
UI angle 33.1 5.03 22.9 3.63 24.8 ***
L1 angle 21.1 6.13 24.0 4.39 22.7 3.87
A point horizontal 93.1 5.83 96.3 5.88 95.8 5.52
B point horizontal 92.8 9.26 92.6 7.91 92.5 7.71
Pg horizontal 99.1 10.60 97.1 8.63 97.6 8.56
U6 horizontal 70.2 5.19 72.2 4.72 71.7 4.70
A p t vertical 30.5 4.60 29.9 4.42 30.1 4.27
U1 vertical 51.5 5.98 51.4 4.98 51.3 4.96
U6 vertical 49.2 4.42 46.7 4.50 46.8 4,26
N-Me vertical 122.3 10.20 121.4 8.20 120.6 8.78
Gonial vertical 63.1 6.42 62.1 6.23 61.8 6.26
Lower facial height 40.4 3.84 40.8 3.81 40.9 3.84

9***Interquartile range 23.2 to 26.1.

Table III. Descriptive statistics for g r o u p D O P

Preoperative Postoperative Long-tenn

I
Variable "~ I SD I SD ~ . SD
OPA 14.9 5.12 6.1 4.06 6.3 4.21
MPA 35.4 6.19 30.8 4.81 30.2 5.33
Maxillary depth 87.2 3.26 88.3 2.89 87.9 3.00
Mandibular depth 80.9 5.04 85.1 3.00 85.2 3.47
Gonial angle 130.7 6.11 127.7 6.51 128.1 6.87
UI angle 21.5 9.51 22.3 6.85 22.1 6.21
LI angle 33.8 5.47 29.8 5.07 28.9 5.83
A point horizontal 94.1 7.23 95.4 7.12 94.9 6.95
B point horizontal 80.6 10.90 88.2 8.31 88.5 8.55
Pg horizontal 79.2 12.10 89.6 8.86 90.1 9.48
U6 horizontal 68.1 7.28 71.5 6.52 70.7 6.68
A point vertical 34.4 3.63 31.3 4.59 31.1 4.17
U1 vertical 58.3 3.10 55.4 3.57 55.0 3.62
U6 vertical 51.4 2.51 51.3 3.31 50.3 2.87
N-Me vertical 128.5 7.30 128.0 6.10 126.3 6.28
Gonial vertical 56.8 6.55 56.4 6.62 55.7 6.82
Lower facial height 40.5 3.96 43.1 3.24 42.7 3.31

d e v i a t i o n of the m e a n v a l u e a n d 95% are within 2 (U6). T h e r e was practically n o h o r i z o n t a l move-

s t a n d a r d deviations.
lOP group
F o r the 14 p a t i e n t s in the I O P g r o u p ( T a b l e I V
a n d Fig. 2), the average surgical c h a n g e ( T 1 to T2)
of the occlusal p l a n e angle was 5.6 ~ T h e r e was a
significant a n t e r i o r maxilla d i s p l a c e m e n t of 3.3 m m
at p o i n t A a n d 2.0 m m at the u p p e r first m o l a r
m e n t of the m a n d i b l e at p o i n t B ( - 0 . 2 mm), b u t
p o g o n i o n r o t a t e d posteriorly 2 m m . T h e maxilla
m o v e d s u p e r i o r l y 0.2 m m at the u p p e r incisor a n d
0.6 m m at p o i n t A. T h e u p p e r first m o l a r was raised
2.5 ram, w h i c h a c c o u n t e d for most of the i n c r e a s e
of the occlusal p l a n e a n g u l a t i o n .
Postsurgical c h a n g e s (T2 to T3) were statistically
significant for a n t e r i o r facial height ( - 0 . 8 m m ) ,
American Journal of Orthodontics and Dentofacial Orthopedics Chemello, Wolford, and Buschang 437
Volume 106,No. 4

Table IV. P a i r e d t t e s t s e v a l u a t i n g s u r g i c a l a n d p o s t s u r g i c a l c h a n g e s

GROUP lOP

Surgical changes T1-T2 Postsurgical changes T2-T3

Variable Difference p Difference P

OPA 5.6 2.8 0.7 7.5 <0.001 -0.6 1.5 0.4 - 1.5 0.164
MPA 1.4 3.2 0.9 1.7 0.120 -0.5 0.8 0.2- -2.3 0.041
Maxillary depth 2.9 1.7 0.5 6.4 < 0.001 - 0.4 1.0 0.3 - 1.5 0.148
Mandibular depth -0.3 2.4 0.7 -0.4 0.684 0.0 1.1 0.3 0.0 1.000
Gonial angle 5.2 5.4 1.4 3.6 0.003 0.0 1.2 0.3 0.I 0.949
U1 angle - 10.2 2.7 0.7 - 14.2 < 0,001 1.0 3.3 0.9 * 0.300
L1 angle 2.9 5.2 1.4 2.1 0.055 - 1.3 3.5 0.9 - 1.4 0.19_3
A point horizontal 3.3 1.9 0.5 6.6 < 0.001 - 0.6 1.2 0.3 - 1.8 0.099
B point horizontal - 0.2 3.9 1.0 - 0.2 0.825 - 0.1 1.7 0.5 - 0.2 0.852
Pg horizontal - 2.0 4.8 1.3 - 1.5 0.155 0.5 1.7 0.5 1.0 0.312
U6 horizontal 2.0 2.1 0.6 3.6 0.003 -0.5 1.2 0.3 - 1.5 0.158
A point vertical -0.6 2.7 0.7 -0.8 0.430 0.2 1.3 0.4 0.4 0.666
U1 vertical -0.2 2.8 0.8 -0.2 0.847 -0.1 1.3 0.4 -0.2 0.876
U6 vertical -2.5 2.5 0.7 -3.8 0.002 0.1 0.9 0.2 0.6 0.566
N-Me vertical - 0.9 3.1 0.8 - 1.1 0.294 - 0.8 1.2 0.3 - 2.7 0.020
Gonial vertical - 1.0 1.3 0.3 -2.8 0.014 -0.3 0.5 0.1 -2.5 0.028
Lx~wer facial height 0.4 1.4 0.4 1.0 0.323 0.1 0.7 0.2 0.5 0.615

*Wilcoxin z = - 1.036.

T a b l e V. P a i r e d t t e s t s e v a l u a t i n g s u r g i c a l a n d p o s t s u r g i c a l c h a n g e s

GROUP DOP

Surgical changes T1- T2 Postsurgical changes T2- T3

Variable Difference p Difference

OPA -8.8 3.3 0.6 - 13.7 <0.001 0.2 1.3 0.3 0.7 0.488
MPA -4.6 2.3 0.4 - 10.4 < 0.001 - 0.6 1.8 0.4 - 1.8 0.081
Maxillary depth 1.1 2.2 0.4 2.6 0.017 -0.5 1.0 0.2 -2.3 0.030
Mandibular depth 4.1 3.2 0.6 6.8 <0.001 0.1 1.2 0.2 0.5 0.607
Gonial angle -3.0 3.1 0.6 -5.0 <0.001 0.3 2.2 0.4 0.8 0.435
U1 angle 0.8 6.6 1.3 0.6 0.543 - 0.2 3.0 0.6 - 0.3 0.773
L1 angle - 4.0 4.3 0.8 - 4.8 < 0.001 - 1.0 3.0 0.6 - 1.7 0.094
A point horizontal 1.3 2.4 0.5 2.9 0.008 -0.5 1.1 0.2 -2.4 0.023
B point horizontal 7.7 5.8 1.1 6.9 <0.001 0.3 2.2 0.4 0.7 0.499
Pg horizontal 10.4 6.2 1.2 8.8 < 0.001 0.5 2.7 0.5 1.0 0.351
U6 horizontal 3.5 3.4 0.6 5.3 < 0.001 - 0.7 2.2 0.4 - 1.8 0.093
A point vertical -3.1 2.4 0.5 -6.7 <0.001 -0.3 1.1 0.2 - 1.2 0.253
U1 vertical -2.9 2.6 0.5 -5.9 <0.001 -0.3 1.3 0.3 - 1.3 0.2i0
U6 vertical -0.1 1.9 0.4 .. - 0 . 2 0.840 - 1.0 L6 0.3 - 3.3 0.003
N-Me vertical - 0.5 3.2 0.6 - 0.8 0.445 - 1.7 1.7 0.3 - 5.1 < 0.001
Gonial vertical -0.4 1.4 0.3 - 1.5 0.146 -0.7 1.6 0.3 -2.2 0.038
Lower facial height 2.7 1.6 0.3 8.8 < 0.001 - 0.4 0.9 0.2 - 2.4 0.025

ramus height (-0.3 mm), and the mandibular mean c h a n g e w a s g r e a t e r in t h e a n t e r i o r r e g i o n

plane angle (-0.5~ These changes were due, v e r s u s t h e p o s t e r i o r a r e a , r e s u l t i n g in a small b u t
primarily, to the removal of the interocclusal splint statistically significant half degree decrease of the
(6 o f 14 p a t i e n t s h a d interocclusal splints after mandibular plane angle. There was no significant
surgery) allowing a u t o r o t a t i o n o f the m a n d i b l e su- postsurgical change of the occlusal plane angle or
periorly and "settling-in" of the occlusion. The other parameters evaluated.
438 Chemello,Wolford, and Buschang American Journal of Orthodontics and Dentofacial Orthopedics
October 1994

Increase Occlusal Plane Angle

Group lOP (N = 14)
8-
6-

2-
0- ,__..j
-2-
-4-
i
-6 L

-8-
-10 -

OPA MPA MxDepth Apt Nor MdDepth Bpt Hor U1 Ang L1 Ang

[ ] T1-T2 [ ] T2-T3

Fig. 2. lOP group surgical changes (T1 to T2) and postsurgical changes (T2 tO T3) are illustrated.

Decrease Occlusal Plane Angle

Group DOP (N=27)

!I
-2-
~
:-6"

-10 ~
OPA MPA MxDepth Apt Hot MdDepth Bpt Hot U1 Ang LI Ang

[ ] TI-T2 [ ] T2-T3

Fig. 3. DOP group surgical changes 0"1 to T~ and postsurgical changes ('f2 to T3) are illustrated.

DOP group height of the ramus decreased 0.5 mm, primarily

For the 27 patients in the DOP group (Table V
and Fig. 3), the average surgical change (T 1 to "s
of the occlusal plane angle was 8.8*. There was an
8 mrn surgical advancement of the mandible at
point B and a 10 mm advancement at pogonion.
The maxilla was moved 3 mm superiorly at point A;
the first molar showed no significant vertical move-
ment. The maxilla was advanced 3.5 mm at the first
molar, but only 1.3 mrn at point A~ The vertical
because of slight upward and forward autorotation
of the proximal segment related to the surgical
design.
The postsurgical changes ('1"2to "1"3)of the DOP
group demonstrated no statistically significant hori-
zontal movement of the mandible. There were
significant changes for the horizontal position of
point A ( - 0 . 5 ram) and inaxillary depth (-0.5~
The vertical position of the maxilla was stable
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 106, No. 4
anteriorly, but the posterior aspect settled supe-
riorly an average of 1 mm. Significant decreases
were also evident for anterior facial height ( - 1 . 7
mm) and the vertical height of the ramus ( - 0 . 7
mm), which were at least partially due to the
removal of the interocclusal splint, (16 of 27
patients had interocclusal splints after surgery) and
"settling-in" of the occlusion with resultant au-
torotation of the mandible superiorly. This is con-
firmed by greater changes anteriorly than poste-
riorly.
DISCUSSION
It is evident that all the patients maintained a
stable result at an average of 23 months follow-up
for the lOP group and 21 months for the DOP
group.
In the lOP group, surgical change at point B
remained basically unaltered horizontally, while
pQgonion rotated posteriorly 2 mm. This is ex-
pected since the downward and backward (clock-
wise) rotation of the jaws causes pogonion to move
posteriorly relative to the more superior points.
-Point A and the perinasal structures moved for-
ward relative to all points inferior to them. The
upper molar moved superiorly approximately 2.5
mm, whereas the upper incisor edge moved up 0.2
mm and point A moved up 0.6 mm. This indicates
that maxillary incisors were uprighted significantly
with the surgery (-10.2~ which accounts for the
difference in the amount of vertical movement
between the incisor edges and point A. The center
of rotation to decrease the occlusal plane was
slightly anterior and inferior to the incisors. The
statistically significant postsurgical changes of this
group are primarily due to removal of the splint.
Tables IV and V and Figs. 2 and 3 summarize
the surgical and postsurgical changes that occurred
in each group. Decreasing the occlusal plane angle
magnifies the amount of mandibular advancement
since an upward and forward (counter-clockwise)
rotation requires that the chin rotates forward,
advancing a greater amount than the mandibular
incisors. The horizontal movement is greater at
pogonion than at point B because of the upward
and forward (counter-clockwise) rotation required.
Although there is no significant change in anterior
facial height (N-Me), lower facial height (L1-Me)
increases almost 3 mm. With the upward and
forward (counter-clockwise) rotation, menton
moves down and forward relative to the incisor
edges because of the posterior sloping of the sym-
physis in most cases. The lack of change in the total
Chemello, Wolford, attd Buschang 439
facial height is due to the anterior superior repo-
sitioning of the maxilla counteracting the relative
increase in lower facial height. In most cases, the
anterior maxilla was impacted to a greater degree
than the posterior maxilla that has the effect of
decreasing the occlusal plane. In patients where
this was not possible because of esthetic concerns,
the lengthened (downgrafted) posterior maxilla
was stabilized with bone plates and porous block
hydroxyapatite. 5"6 It is important to note that all
these patients underwent three-piece segmental
maxillary surgery. The anterior segment usually
consisted of the four incisor teeth, which allo'&s for
greater control of the incisor angulation and is
helpful in producing an optimal occlusion and
esthetic result. The difference in the vertical height
of point A as compared to the upper incisor is due
to the change in angulation of the incisor segment
necessary to obtain an optimal result.
The long-term stability for most-horizontal and
vertical measures in the DOP group was excellent.
Even with upward and forward (counter-clockwise)
movement of the mandible and closure of an open
bite primarily in the mandible there was only 0.3
mm of change at point B with a slight further
advancement probably related in part to splint
removal and "settling-in" of the occlusion. The
small long-term postsurgical changes in the DOP
group (due primarily to removal of the splint and
"settling-in" of the posterior maxilla) were the
maxillary depth (-0.5~ horizontal position of A
point ( - 0 . 5 mm), vertical position of the upper
first molar ( - 1.0 mm), and the lower facial height
( - 0.4 ram). The change in point A was most likely
due to further bony remodeling after routine sur-
gical removal of the anterior nasal spine and addi-
tional modification of the anterior maxilla to create
room for the nasal septum.
The purpose of this study was to evaluate sta-
bility after occlusal plane alterations. It is evident
that decreasing the occlusal plane and moving the
mandible anteriorly is a very stable procedure.
Importantly, the height of the posterior ramus was
not changed significantly in this study. However, if
indicated, the vertical height of the ramus can be
lengthened with either sagittal split osteotomies or
inverted "L" osteotomies, but the surgical design is
important since stretching the muscles of mastica-
tion may cause significant relapse. 7 Detaching the
sling from the mandible will allow the ramus to
lengthen down through the sling. The inferior bor-
der will eventually remodel back up to the level of
the muscles. In these cases, the pterygoid masse-
440 Chemello, Wolford, and Buschang American Jo . . . . . l of Orthodontics and Oentofacial Orthopedics
October 1994

teric sling should be incised to allow passive read-
aptation o f the muscles to the ramus while healing.
W e c o n c l u d e that selective occlusal plane
alterations in a d o w n w a r d and backward (clock-
wise) or u p w a r d and forward (counter-clockwise)
direction in d o u b l e jaw surgery in patients
with healthy TMJs, by using rigid fixation, is
stable.
REFERENCES
1. Wolford LM, Chemello PD, Hilliard FW, Occlusal plane
alteration in orthognathic surgery - Part I: Effects on Func-
tion and Esthetics. AM J ORTHOD DENTOFACORTttOP [in
press].
2. Ricketts RM. Cephalometric analysis synthesis. Angle
Orthod 1961;31:141-56.
3. Riolo ML, Moyers RE, McNamara JA, Hunter WS. An atlas
of craniofacial growth. Ann Arbor: Center for Human
Growth and Development, University of Michigan, 1974:12-
21.
4. Wolford LM, Wardrop RW, Hartog JM. Coralline porous
hydroxyapatite as a bone graft substitute in orthognathic
surgery. J Oral Maxillofae Surg 1987;45:1034-42.
5. Wardrop RW, Wolford LM. Maxillary stability following
downgraft and/or advancement procedure with stabilization
using rigid fixation and porous block hydroxyapatite implants.
J Oral Maxillofac Surg 1989:47:336-42.
6. Yellich GM, McNamara JA Jr., Ungerleiden JC. Muscular
and mandibular adaptation after lengthening, detachment,
and reattachment of the masseter muscle. J Oral Surg 1981;
39:656-65.
Reprint requests to:
Dr. Larry M. Wolford
3409 Worth St.
Sammons Tower, Suite 400
Dallas, TX 75246

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