J Oral MaxillofacSurg

51 (SuppI1):28-41,1993

Orthognathic Surgery:
The Correction of Dentofacial Deformities
LEWARD C. FISH, DDS, MS,* BRUCE N. EPKER, DDS, PHD,t
AND CHARLES R. 3JLLIVAN, DDS*

A dentofacial deformity can be defined as any con-
dition in which the facial skeleton is significantly dif-
ferent from normal, a malocclusion exists, and the fa-
cial appearance is adversely affected. Such deformities
may be minor, as with deficient chin projection, or
extreme, as in severe vertical maxillary excess or hemi-
facial microsomia. These facial, skeletal, and occlusal
deformities are corrected by a team usually composed
of a general dentist, a periodontist, an orthodontist,
and an oral and maxillofacial surgeon.
Repositioning of the dental and skeletal components
of the face by an oral and maxillofacial surgeon to im-
prove function and facial esthetics, is termed orthog-
nathic surgery. This area of oral and maxillofacial sur-
gery has evolved significantly during the past two
decades. Before the 196Os, the only skeletal condition
treatable by surgery was the prognathic mandible.
Currently, the oral and maxillofacial surgeon can cor-
rect virtually all deformities in the midface and man-
dible.
This article provides a brief overview of orthognathic
surgery, with emphasis on some recent advances that
have led to improved results, decreased patient incon-
venience, and increased professional and patient ac-
ceptance of this form of treatment.
Patient Selection
Orthognathic surgery, integrated with proper ortho-
dontic treatment, should be considered for any patient
for whom it would improve 1) masticatory function,
2) facial appearance, and 3) stability of the occlusal
result. Most patients can have their occlusion improved
Received from the Center for the Correction of Dentofacial De-
formities, John Peter Smith Hospital, Fort Worth, TX.
* Orthodontist and Co-director.
t Oral and Maxillofacial Surgeon and Co-director.
$ Orthodontist.
Address correspondence and reprint requests to Dr Fish: Center
for the Correction of Dentofacial Deformities, John Peter Smith
Hospital, 1500 South Main Street, Fort Worth, TX 76 104.
0 1993 American Association of Oral and Maxillofacial Surgeons
027%2391/93/5101-0104$3.00/O
by prosthetic or orthodontic treatment alone, but in
some the improvement in function is incomplete and
this isolated approach to treatment may even worsen
the facial appearance. Accordingly, the state ofthe art
is to provide comprehensive treatment by a team ap-
proach.
Treatment Goals of the Dental Team
The integrated correction of a dentofacial deformity
requires the teamwork and cooperation of several den-
tal disciplines. Most frequently, the general dentist and
the periodontist are first called on to restore the den-
tition and its supporting tissues to a healthy condition.
Caries and periodontal disease must be treated and
controlled. If the attached gingiva is inadequate to
withstand the orthodontic and surgical treatments that
will follow, gingival grafts should be placed. The most
common sites requiring gingival grafting are the lower
anterior area from canine to canine and the maxillary
canine region. When ceramic or gold restorations are
indicated, temporary restorations are made that will
last until completion of the orthodontic and surgical
treatment. Definitive dental restorations are best de-
ferred until the occlusion has been improved by surgical
and orthodontic treatment.
Once the patient’s dentition has been restored and
the periodontal condition has been stabilized, definitive
orthodontic-surgical treatment can be planned. After
careful evaluation of the patient’s facial appearance,
the expressed esthetic concerns, and an analysis of their
diagnostic cephalometric radiographs and dental mod-
els, the specific type of surgery that will optimally solve
the patient’s problems and the orthodontic treatment
needed to produce the dental changes required by the
surgeon to achieve the desired facial, esthetic, skeletal,
and occlusal changes is planned.
Patients with dentofacial deformities require both
presurgical and postsurgical orthodontic treatment.
Specifics of these treatments vary depending on the
nature of the patient’s deformity, the crowding of the
teeth, the dental changes that have occurred because
of the deformity, and the changes that must be affected
FISH,EPKER, AND SULLIVAN
by the orthodontist to allow the surgery to be done
successfully. Surgery should be planned from the be-
ginning of treatment. Orthodontic treatment accom-
plished without a surgical plan will frequently be in-
appropriate for the surgical procedure being considered.
The time required for presurgical orthodontic treat-
ment can range from a few months to over 1 year.
Some 4 to 8 weeks after orthognathic surgery, when
the surgeon is satisfied that the patient is well healed,
has achieved a stable correction of the dentofacial de-
formity, and has attained normal jaw function, the pa-
tient is sent back to the orthodontist for the final ad-
justment of the occlusion. Once the occlusion is refined,
orthodontic appliances are removed and retainers are
placed. Placement of definitive restorations and com-
pletion of periodontal treatment are usually delayed
until the patient has been in retention for at least 3
months.
The treatment sequence as outlined above produces
excellent results with long-term stability. Such results
can only be achieved, however, by the general dentist
and several dental specialties working together as a
team.
Recent advances not only make orthognathic surgery
more successful but also make it more convenient for
the patient. Significant changes have occurred in an-
esthetic techniques, use of rigid fixation, hospitalization
time, nutrition, and postoperative rehabilitation ofjaw
function.
Improved Anesthesia
Anesthetic techniques used during orthognathic
surgery performed on healthy individuals is exceedingly
safe, reduces blood loss, and permits rapid recovery.
In the past 10 years, none of our patients has required
blood replacement. Most patients return to their room
3 to 5 hours after surgery and do not require special
or intensive surgical care. Almost all patients have re-
covered sufficiently to leave the hospital the day fol-
lowing surgery.
Rigid Internal Fixation
Many patients can have orthognathic surgery with-
out having their jaws wired together. The surgically
mobilized bone and tooth segments are stabilized dur-
ing healing with titanium plates and screws (rigid in-
ternal fixation). Patients are able to speak and drink
more easily and return to school or work more rapidly.
However, rigid fixation does not accelerate bony heal-
ing and does not permit patients to chew food in the
early (1 to 4 weeks) postoperative period. Noncom-
pliant patients can overuse their jaws, displacing the
screws and plates and seriously compromising their
results. Most patients return to their normal lifestyles
29
with some exceptions, such as enjoying contact sports,
within 7 to 10 days after surgery.
Hospital Stay
Patients are evaluated medically during the week
prior to surgery and come to the hospital the day of
surgery. Over 98% of the patients are discharged in
good condition the day following surgery. This reduces
both cost and inconvenience.
Nutrition
The nutritional regimen for the postsurgery period
assures rapid recovery whether the patient’s jaws are
wired together or not. Weight loss is minimized with
a combination of food supplements and a balanced
blended diet.
Jaw Rehabilitation
Jaw rehabilitation after orthognathic surgery is an
important consideration. Rapid return to normal mas-
ticatory muscle and joint function following the use of
active home jaw exercises is now routine. The exercise
regimen consists of maximum mouth opening,
clenching, protruding the jaw, and performing excur-
sive movements three times daily for 5 minutes each
session. Once patients begin to exercise their jaws, most
return to the presurgical asymptomatic range of motion
in 7 to 14 days. If this does not occur, noncompliance
with the exercise program or internal derangement of
the temporomandibular joint must be suspected and
critically evaluated.
Illustrative Cases
The following cases demonstrate the typical facial
and occlusal changes that can be achieved by a team
effort in patients with various dentofacial deformities.
CLASS II DENTOFACIAL DEFORMITIES
Patients with a class II dentofacial deformity most
frequently have a deficient mandible (mandibular ret-
rognathism) and/or a maxilla that has grown long ver-
tically (vertical maxillary excess).
Case I: Mandibular Dejiciency
This28-year-old woman was concerned about an excessive
overbite (Fig 1). A detailed clinical, cephalometric, and oc-
clusal examination revealed a retruded chin, recessive man-
dible, and a class II, division 1 malocclusion with a deep
overbite. No dental restorative or periodontal problems ex-
isted. The patient felt that her chin was recessive, but she was
unaware that anything could be done to improve this aspect
of her facial appearance.
30 ORTHOGNATHIC SURGERY

FIGURE 1. Mandibular advancement before (A, C, E) and after (B, D. FJ treatment of a patient with mandibular deficiency and a class II,
division I malocclusion.
FISH, EPKER, AND SULLIVAN
The patient was offered an integrated treatment plan to
improve her appearance, occlusion, and function. After both
orthodontic and surgical consultation, she elected to proceed.
To optimize lower anterior tooth position and chin pro-
jection, the lower first premolars were removed and the lower
anterior teeth were maximally retracted orthodontically. The
upper second premolars were removed to facilitate maxillary
tooth alignment, and the remaining space in the maxillary
arch was closed by advancing the molars. Coordinated or-
thodontic arch wires were placed, and the patient was referred
for surgery.
Bilateral sagittal split osteotomies were performed and the
mandible was advanced into a class I skeletal and occlusal
relation. Alter an appropriate period of healing and rehabil-
itation of jaw function (6 weeks after surgery), the patient
was returned to the orthodontist, the final occlusal adjust-
ments were made, and retainers were placed. A good class I
occlusion with pleasing esthetics was achieved (Fig 1). Normal
jaw and joint function existed. The result has remained stable
for over 5 years, with no increase in overbite and overjet.
Case 2: mandibular Deficiency and Unesthetic
Neck Line
This 3 l-year-old woman was concerned regarding her
malocclusion (Fig 2). A comprehensive clinical examination
and analysis of diagnostic records revealed a very recessive
chin, small mandible, and a class II, division 2 malocclusion
with a deep bite. The maxillary position was normal, but the
arch was narrow in the posterior aspect. Excessive craniofacial
fat compromised her chin-neck esthetics.
The patient was offered an integrated plan of orthodontics
and surgery to optimally improve her dentofacial deformity,
and she elected to proceed. Orthodontic treatment proclined
the upper central incisors while the upper and lower arches
were aligned and leveled. Then the patient was referred for
orthognathic surgery. The maxillary arch was widened with
a IX Fort I osteotomy. Bilateral sagittal split osteotomies were
performed to advance the mandible into a class I occlusion
and cervical facial liposuction via an intraoral approach ad-
dressed her neck esthetics (Fig 2 A-D). Once jaw function
returned (8 weeks after surgery), the orthodontic treatment
was completed and retainers were placed.
A pleasing esthetic improvement was obtained, especially
in the cervicofacial area. Her class I occlusion has remained
stable, with no complications.
Case 3: Vertical Maxillary Excess
A 1Cyear-old girl could not close her lips and had excessive
exposure of upper teeth. She also had a deficient chin, a class
II malocclusion with bilateral posterior maxillary lingual
crossbite, a maxillary protrusion, crowding in the maxillary
arch and crowding in the mandibular arch (Fig 3). The patient
and her parents enthusiastically agreed on an integrated or-
thodontic-surgical approach for the correction of the girl’s
functional, skeletal, occlusal, and esthetic deformities.
The presurgical orthodontic treatment involved removal
of the right maxillary lateral incisor, the left maxillary first
premolar, and both mandibular second premolars. Both
arches were fully banded, leveled, aligned, coordinated, and
the spaces closed. The maxillary arch was slightly expanded
orthodontically before orthognathic surgery.
Le Fort I surgery superiorly repositioned the maxilla and
allowed the mandible to rotate upward and forward and ad-
vance the chin. Postsurgical orthodontic treatment for 5
31
months refined the occlusion. A marked esthetic, skeletal,
and occlusal improvement has been maintained 3 years fol-
lowing treatment (Fig 3).
Case 4: Vertical Maxillary Excess
with Mandibular Deficiency
A vertically excessive maxilla is accompanied frequently
by a mandible that is so recessive that there is the need not
only to superiorly reposition the maxilla but also to advance
the mandible and the chin. This is illustrated by the following
case.
A 27-year-old man was concerned with the appearance of
his teeth, inability to incise, and a recessive chin (Fig 4). Good
facial symmetry existed but the patient’s problems included
a long lower third of the face, unesthetic upper incisors, lip
incompetence, an everted lower lip, and a very recessive chin.
A class II, division 1 malocclusion was present, with consid-
erable crowding and many poorly restored teeth.
Evaluation of facial esthetics and cephalometric prediction
tracings showed that an optimal skeletal, occlusal, and esthetic
result would be obtained if the maxillary incisors could be
moved superiorly and the mandible and the chin simulta-
neously advanced. After consultation with the patient’s gen-
eral dentist, four second premolars were removed. Temporary
crowns were placed on several teeth and orthodontic treat-
ment was begun. The first premolars were retracted, followed
by retraction of the lower canines. The six upper anterior
teeth were aligned while the leveling and alignment of the
lower teeth was being completed. Orthognathic surgery con-
sisted of a Le Fort I maxillary osteotomy (in three segments)
for superior repositioning and widening, a bilateral sagittal
split for mandibular advancement. and augmentation genio-
plasty to advance the chin.
Postsurgically, 5 months of active orthodontic treatment
was followed by placement of retainers. The patient then was
referred for definitive restorative dentistry. Facial esthetics
were improved greatly by normalizing the upper tooth to lip
relation, increasing the chin projection, and reducing the
lower third face height. The patient had significant improve-
ment in masticatory function and a stable occlusion.
CLASSIII DENTOFACIAL DEFORMITY
For many years, a class III malocclusion was thought
to result from a mandible that was too large. This mis-
understanding was perpetuated by the fact that sur-
geons could only correct the condition by operating in
the mandible. Today, it is known that many individuals
with class III occlusal deformities are deficient only in
the anteroposterior position of the maxilla or that their
deformity is due to both an excessive (prognathic)
mandible and recessive (deficient) maxilla. The deci-
sion to correct the class III occlusion by surgery in the
mandible, the maxilla, or both jaws simultaneously is
based on a careful evaluation of the patient’s facial
esthetic features, the skeletal position of the jaws, and
how these will be changed by the proposed treatment.
The following patients illustrate the correction of
the class III occlusion by advancing, respectively, the
maxilla or the entire midface. No case of mandibular
setback is included due to the extremely common na-
ture of the procedure.
FIGURE 2. Mandibular advancement and submental lipectomy before (A, C, E) and after (B, D,F)treatment of a patient with mandibular
deficiency, excessive submental fat deposits, and a class II, division 2 malocclusion.

32
FISH, EPKER, AND SULLIVAN

FIGURE 3. Maxillary superior repositioning before (A, C, E) and after (B, D, F) treatment of a patient with vertical maxillary excess and a
class II, division 1 malocclusion.
 ORTHOGNATHIC SURGERY

FIGURE 4. Maxillary superior repositioning, mandibular advancement, and augmentation genioplasty before (A, C, .E) and after (B, D, F)
treatment of a patient with vertical maxillary excess, mandibular deficiency, and a class II, division 1 open-bite malocclusion.
FISH, EPKER, AND SULLIVAN
Case 5: Maxillary Deficiency
A 23-year-old woman was concerned with her occlusion
several years after completion of orthodontic treatment (Fig
5). She had a long lower facial third, excessive distance be-
tween her lips, excessive exposure of the upper anterior teeth,
recessive paranasal areas, and a prominent nose. A class III
malocclusion was present. Esthetic and cephalometric eval-
uations revealed that the lower jaw was not long; rather her
class III relation was the result of a deficient maxilla.
An integrated orthodontic-surgical treatment plan led to
a Le Fort I maxillary osteotomy for repositioning the maxilla
upward and forward and vertical reduction and straightening
of the lower border of the anterior mandible. Postsurgical
orthodontic treatment consisted of finishing and retention.
Excellent improvement in facial esthetics was achieved,
with facial balance. The nose appeared much less prominent
due to filling in of the paranasal areas. The class I occlusion
has remained stable for 9 years (Fig 5).
Case 6: Craniofacial Synostosis
A 12-year-old girl with Crouzon’s syndrome (craniofacial
synostosis) was evaluated to plan orthodontic-surgical cor-
rection of her severe midface deformity (Fig 6). She had a
severe class III malocclusion produced by retrusion of her
entire midface, including the maxilla, orbits, and nose.
With the esthetic findings, quantitative cephalometric
analysis, and detailed occlusal analysis, it was planned for
the patient to undergo nonextraction presurgical orthodontics
followed by a Le Fort III osteotomy and advancement of the
midface via a coronal flap approach to her midface. Ortho-
dontic treatment was completed after surgery.
Three years following treatment, a good class I occlusion
exists, with marked improvement in facial esthetics. There
has been normalization of the midface features, including
the areas around the eyes, nose, and cheeks (Fig 6).
Open-Bite Dentofacial Deformities
Patients with an open bite can have either a class I,
class II, or class III malocclusion, but virtually all skel-
etal open-bite malocclusions have a maxilla that is, for
reasons that are not well understood, vertically exces-
sive in the molar and premolar area. In addition, there
is often a transverse narrowing of the maxilla and pos-
terior dentition resulting in a bilateral posterior cross-
bite. The anterior-posterior occlusal relationship is de-
termined primarily by the adequacy of the mandible,
with the mandible being essentially normal in the class
I cases, deficient in the class II cases, and excessive in
the class III cases. Most often, the vertical and trans-
verse discrepancies in the maxilla are corrected by
moving the posterior maxillary teeth and bone supe-
riorly while simultaneously widening the maxilla to
correct the crossbite relationship. In patients with class
I malocclusion, and in some with class II, the mandible
rotates forward when the maxilla is moved superiorly
and an adequate chin and facial balance follow. In some
patients, however, the chin is still deficient and is cor-
rected with an augmentation genioplasty. Some severe
class II natients also require simultaneous mandibular
35
advancement. Patients with a class III relationship may
require a mandibular setback.
Case 7: Class I Open Bite
A 19-year-old woman complained that her front teeth
“stick out” and she could not bite through a sandwich (Fig
7). She had a long lower face and narrow alar bases. The
upper incisors hung down below the upper lip excessively
and the lips were separated at rest. A class I molar occlusion
was present, with an anterior open bite due to an excessive
curve of Spee in the upper arch.
Orthodontic appliances were used to align and level both
arches, with no attempt to close the open bite. Coordinated
arch wires produced similar arch shapes in both the upper
and lower jaws. The maxilla was then repositioned superiorly
with the posterior teeth moved more than the anterior teeth,
closing the open bite. Following a 3-week healing period, the
orthodontic treatment was finished and retainers placed. The
long tapering appearance of the face was corrected and the
profile improved. The class I occlusion has remained stable
(Fig 7).
Case 8: Class III Open Bite
A 32-year-old man presented with a class III malocclusion,
anterior open bite, left posterior lingual crossbite, mandibular
arch crowding, missing mandibular left second premolar, and
a mandibular midline deviated to the left (Fig 8). Cephalo-
metrically, the mandible was excessive in length.
Before surgery, the maxillary arch was aligned in four seg-
ments (the central incisor, lateral incisor, and canine on the
right and left sides, and the right and left posterior segments,
including the first premolars). The mandibular arch was
aligned in two segments (the left molars in one segment, the
other segment began with the left mandibular first premolar
and included all the remaining mandibular teeth). Each seg-
ment was independently leveled and aligned.
The surgical procedure consisted of a four-piece Le Fort I
osteotomy with superior repositioning and lateral expansion.
This was accompanied by bilateral sagittal split osteotomies
to set back the mandible and a left mandibular body ostec-
tomy to close the edentulous space that had been created by
the missing mandibular left second premolar. Postsurgery
orthodontic procedures perfected the occlusion. Quite sat-
isfactory esthetic, functional. and occlusal results were
achieved (Fig 8).
Asymmetric Dentofacial Deformities
Achieving good facial appearance and jaw function,
and a stable class I occlusion is most difficult when
there is an asymmetric deformity. There are a multi-
tude of causes for such a deformity, and many forms
of surgical treatment. Condylar hyperplasia and asym-
metry should be recognized by every dentist because.
if recognized and treated early, a more severe dento-
facial deformity can be avoided. The pathognomonic
feature is a progressively worsening unilateral posterior
open bite that can occur at any age. Early treatment
may involve only removal of the pathologic condyle.
If the process is allowed to progress undiagnosed, how-
ever, not only does the mandibular deformity worsen
36 ORTHOGNATHIC SURGERY

FIGURE 5. Maxillary advancement before (A, C, E) and after (B, D,F)treatment of a patient with anteroposterior maxillary deficiency, mild
vertical maxillary excess, and a class III malocclusion.
FISH, EPKER, AND SULLIVAN

FlGURE 6. Le Fort III midface advancement before (A, C, E) and after (B. D, F) treatment of a patient with Crouzon’s syndrome
38 ORTHOGNATHIC SURGERY

FIGURE 7. Maxillary superior repositioning before (A. C, E) and after (B, D,F)treatment of a patient with posterior vertical maxillary excess
and a class I, open-bite malocclusion.
 FISH. EPKER, AND SULLIVAN

FIGURE 8. Segmental maxillary superior repositioning and mandibular setback before (A, C, I$ and after (B, D. fl treatment of a patient
with posterior vertical maxillary excess, mandibular excess, and a class III, open-bite malocclusion.
 ORTHOGNATHIC SURGERY

FIGURE 9. Combined maxillary and mandibular osteotomies were employed to correct this patient’s asymmetry, mandibular prognathic
appearance, and malocclusion. A, C, E, Preoperative views. B. D. F. Postooerative views.
FISH, EPKER, AND SULLIVAN
but also the maxilla becomes involved with maxillary
canting, and tipping of the occlusal plane. To correct
this condition, surgery on the maxilla and mandible,
plus possible bony recontouring of the mandible to
offset the effects of the mandibular bowing may be re-
quired in addition to surgery on the condyle.
Case 9: Condylar Hyperplasia
A 36-year-oldwoman had a marked facial asymmetry with
the chin deviated to the left and a cant to the midface and
mandible. In profile she appeared prognathic. She had pre-
viously been treated orthodontically, had a recontouring op-
eration on her mandible, and had a unilateral facelift. Detailed
evaluation, including technetium scanning revealed that she
had active left unilateral condylar hyperplasia that had caused
her facial asymmetry.
A complex surgical procedure included excision of her
pathologic left condyle, replacement with an autogenous cos-
tochondral bone graft, a Le Fort I osteotomy to rotate and
level the maxilla, a right sag&al split osteotomy, and removal
of a lower incisor tooth and a body ostectomy through that
area to correct the 5-mm anterior tooth mass discrepancy.
This was followed by finishing orthodontic treatment.
41
Two years later, the patient had good facial symmetry, a
pleasing profile, and a stable class I occlusion (Fig 9).
Summary
The field of orthognathic surgery offers ever-im-
proving technology to better rehabilitate patients with
dentofacial deformities. Hospital stays have been re-
duced due to improved surgery and anesthesia. Rigid
internal fixation has increased comfort for many pa-
tients by eliminating the inconvenience of having the
jaws wired together. Most important has been the re-
alization that teamwork between the general dentist
and the various specialty disciplines is indispensable
for good patient care and the attainment of the very
best results.
Reference
1. Epker BN, Fish LC: Dentofacial Deformities: Integrated Ortho-
dontic-surgical Correction. St Louis, MO, Mosby. 1986