Section 3 Orthognathic Surgery
74
Surgical Planning in Orthognathic Surgery
and Outcome Stability
Larry M. Wolford, Joao R. Goncalves
KEY POINTS
• Dentofacial deformities affect approximately 20% of the
population with varying degrees of functional and esthetic
problems. Many patients with moderate to severe
dentofacial and occlusal deformities can benefit from a
combination of orthodontics and orthognathic surgical
treatment to obtain the best outcome results, functionally
and esthetically.
• To achieve the best treatment outcomes for patients, the
treating clinicians must be able to (1) diagnose existing
problems and deformities correctly, (2) establish an
appropriate treatment plan, and (3) perform the treatment
plan properly to completion.
• Patient evaluation for orthognathic surgery can be divided
into four main areas: (1) patient concerns, chief
complaints, and medical history; (2) clinical examination;
(3) radiographic and imaging analyses; and (4) dental
model analysis. These analyses provide the information
necessary to establish comprehensive diagnoses and
treatment plans.
• Accurate prediction tracings or virtual surgical planning
(VSP), dental model surgery, and performance of the
surgical procedures are paramount to achieve high-quality
functional and esthetic outcomes.
• The use of rigid fixation for mandibular and maxillary
osteotomies with appropriate bone grafting when
indicated, enhances the treatment outcome
predictability.
INTRODUCTION
Dentofacial deformities affect approximately 20% of the popu-
lation. Patients with dentofacial deformities may demonstrate
various degrees of functional and esthetic compromise. Such
malformations may be isolated to one jaw, or they may extend
to multiple craniofacial structures. Deformities may occur uni-
laterally or bilaterally and may be expressed to varying degrees
in the vertical, horizontal, and transverse facial planes. Many
patients with dentofacial deformities can benefit from correc-
1048
• The treating clinicians must understand the effects of
osteotomies on normal growth and development so that
the proper age can be selected to perform surgical
procedures for specific deformities in growing patients.
• In double jaw surgery, the selective alteration of the
occlusal plane may significantly improve the functional
and esthetic results.
• The temporomandibular joints (TMJs) provide the
foundation for orthognathic surgery. Undiagnosed and/or
untreated pre-existing TMJ dysfunction and pathosis can
result in unfavorable treatment outcomes, such as
postoperative pain, condylar resorption, malocclusion, jaw
dysfunction, and facial deformity.
• The TMJs should be evaluated properly, and any existing
TMJ conditions should be discussed with the patient.
Pre-existing TMJ conditions should be diagnosed
accurately and treated properly before or at the same time
as the orthognathic surgical procedures are performed to
maximize treatment outcomes and stability.
• Surgeons should know the common pathological TMJ
conditions and understand the indicated surgical
management of these conditions when orthognathic
surgery is required for patients to correct a coexisting
dentofacial deformity.
• VSP can significantly improve accuracy of surgical
movements and decrease the surgeon’s pre-surgical
preparation time.
tive orthognathic surgical treatment. This chapter focuses pri-
marily on diagnosing and planning treatment for the correction
of dentofacial deformities.
SURGICAL PLANNING IN ORTHOGNATHIC
SURGERY
Orthognathic surgery is the art and science of diagnosis, treat-
ment planning, and execution of treatment by combining
orthodontics and oral and maxillofacial surgery to correct
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
musculoskeletal, dento-osseous, and soft tissue deformities of
the jaws and associated structures. Successful orthognathic
surgery demands the understanding and cooperation of the oral
and maxillofacial surgeon, orthodontist, and general dentist.
They must provide a proper diagnosis and treatment plan,
perform the necessary treatment, and refer for necessary treat-
ment outside their respective areas of expertise. Support from
other dental and medical professionals may be necessary to
provide the optimal functional and esthetic outcome that
results in patient satisfaction. These specialists may include
periodontists, prosthodontists, endodontists, neurosurgeons,
ophthalmologists, otolaryngologists, plastic surgeons, psychia-
trists, speech pathologists, and others.
Moderate to severe occlusal discrepancies usually require
combined orthodontic treatment and orthognathic surgery to
obtain the most stable result with optimal function and esthet-
ics. The orthodontist is largely limited to the movement of teeth
and alveolar bone with little appreciable effect on basal bone.
The orthodontist’s role is to align and decompensate the teeth
in relation to the upper and lower jaws. The oral and maxillo-
facial surgeon can move the facial skeleton but cannot provide
detailed alignment and precise interdigitation of the teeth. The
oral and maxillofacial surgeon, therefore, repositions the jaws
and facial structures as dictated by the existing deformities and
therapeutic goals. For patients to receive state-of-the-art care in
correction of deformities, the orthognathic team must be able
to do the following:
• Correctly diagnose existing deformities
• Establish an appropriate treatment plan
• Execute the recommended treatment
Specific therapeutic goals for orthognathic surgery vary
from patient to patient. These goals are directed toward the
correction of specific musculoskeletal, dento-osseous, and soft
tissue deformities. The specific therapeutic goals may include
one or more of the following:
• Correct masticatory and/or swallowing abnormalities
• Establish a functional occlusion through normalization of
the occlusal relationship, overbite, overjet, occlusal plane
angulation, and transverse dimension
• Correct the inability to open or close the jaws
• Correct associated temporomandibular joint (TMJ) dys-
function, pathosis, or pain
• Correct structural abnormalities resulting from overdevel-
opment or underdevelopment
• Decrease or eliminate myofascial pain and/or headaches
• Correct abnormalities relating to respiratory compromise;
for example, sleep apnea, airway obstruction, nasal septal
deviation, snoring, choanal atresia, hypertrophied turbi-
nates, and nasal polyps
• Correct speech problems; for example, hypernasal or hypo-
nasal speech, velopharyngeal incompetence, and articulatory
speech dysfunction
• Improve stability of orthodontic and orthognathic surgery
results
• Improve dental and periodontal health
• Improve psychosocial impairments
Diagnostic factors and risk factors are conditions that may
modify the treatment planning and affect the outcome of the
surgical procedures. Awareness of potential risk factors is man-
datory for proper treatment planning and for proper preopera-
tive patient counseling. Common diagnostic and risk factors are
the following:
1049
• Type of congenital or development deformity
• Type of acquired deformity
• Type of musculoskeletal/dento-osseous deformity
• Type of malocclusion
• Respiratory problems
• Sinus or nasal airway disease and/or pathosis
• Speech problems
• TMJ dysfunction or pathosis
• Masticatory and/or swallowing difficulties
• Psychosocial impairment
• Bone and/or soft tissue pathoses
• Infection
• Bleeding dyscrasias
• Allergies or hypersensitivity to surgical or orthodontic
materials
• Abnormal osseous and/or soft tissue anatomy
• Compromised vascularity at the surgical site
• Systemic or localized diseases that may interfere with normal
healing
• Myofascial pain dysfunction
• Ocular or orbital deformity and/or impairment
• Severity of esthetic facial deformity
• Poor patient compliance
• Previous orthodontic and/or orthognathic surgery
• Neuromuscular abnormalities
Patient Evaluation
Thorough evaluation and diagnosis is one of the most impor-
tant aspects of overall patient management. Failure to recognize
major functional and esthetic problems may lead to com­
promise, complications, and unfavorable outcomes. Patient
evaluation for orthognathic surgery may be divided into five
main areas:
1. Patient concerns/chief complaints
2. Medical history
3. Clinical examination
4. Radiographic and imaging analysis
5. Dental model analysis
This diagnostic sequence may identify patients who are
candidates for orthognathic surgery and determine whether
ancillary dental, medical, or surgical procedures may be
beneficial. Such patients may require further specialist evalu-
ation for speech, audiometric, periodontal, general dental,
psychological, neurological, ophthalmological, medical, or
other concerns.
Patient Concerns
A patient’s ultimate satisfaction with treatment outcome often
depends on attention to the patient’s chief concerns.1,2 Although
a change in appearance may be an improvement in the eye of
the surgeon and may normalize a patient’s profile according
to cephalometric standards, such a change may be undesirable
to the patient. An understanding of the patient’s concerns,
motivations, and expectations helps define treatment parame-
ters and provides insight to the psychological health of the
patient. Specific questions that may help identify the patient’s
chief concerns include the following:
• What are your concerns or problems?
• Have you had previous treatment for this condition, what
was the treatment, and what was the outcome?
• Why do you want treatment?
• What do you expect from treatment?
1050 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

This assessment of patient concerns helps develop a prelimi-

nary problem list and helps identify patients with unrealistic
expectations. Patients with unrealistic expectations must be
counseled so that they understand the treatment limitations
and the likely outcomes before initiation of orthodontic or
surgical therapy. Patients who maintain unrealistic expectations
are best not treated. Patients must understand thoroughly all
the treatment options, the anticipated outcomes, and the poten-
tial risks and complications. Situations involving an uninformed
patient or a patient with unrealistic expectations often result in
dissatisfaction and may create medicolegal difficulties. Accord-
ingly, the surgeon and orthodontist must be careful not to
mislead the patient into perceiving greater expectations than A
can be provided.3-5

System-Oriented Physical Examination

Usually orthognathic surgery is performed on healthy patients.
This does not, however, diminish the significance of pre-surgical
evaluation, including medical and dental histories, physical
examination, and appropriate laboratory studies.6 Obtaining an
appropriate and current medical history may affect treatment
planning and may help the surgeon avoid potentially life-
threatening complications. Patient examination should rule out
or identify patients with difficult airways, connective tissue or
autoimmune diseases, bleeding disorders, or other pathological
conditions that may preclude or modify surgery. Perform an
appropriate systemic assessment for every patient.
Patient Preparation for Dentofacial Examination
The patient is evaluated best while sitting upright in a straight-
backed chair with the examiner seated directly opposite at eye
level. Generally, examine the patient with his or her pupillary
plane parallel to the floor. Compensatory positioning may be
appropriate for patients exhibiting orbital dystopia. The ear
lobes can be used to establish a plane parallel to the floor. Orient
the patient’s head so that the clinical Frankfort horizontal plane
(a line from the tragus of the ear to the bony infraorbital rim)
is parallel to the floor (Figure 74-1, B). This is a reproducible
position that mimics the natural head posture of most indi-
viduals with normal facial balance. This position may be used
to obtain standardized measurements throughout the treat-
ment sequence.7 Patients with dentofacial deformities often
develop alternative head postures for functional reasons or to
make the deformity less obvious. Adjustment for such compen-
satory head postures is important during clinical, radiographic,
and photographic evaluation by orienting the clinical Frankfort
horizontal plane parallel to the floor.8 Following surgical-
orthodontic correction, the natural head posture often reverts
to a more normal position because functional and esthetic com-
pensation is usually no longer necessary. Selecting a standard-
ized and reproducible head position aids in proper diagnosis
and evaluation of post-treatment results.
Once the head is oriented properly, seat the mandibular
condyles in the glenoid fossae with the teeth lightly touching
together (centric relation). Although it is important to evaluate
centric occlusion, perform the definitive clinical examination
relative to surgical-orthodontic diagnosis and treatment plan-
ning with the patient in centric relation. Failure to evaluate in
centric relation may result in a misdiagnosis or incomplete
diagnosis, inappropriate or compromised treatment plan, and
unacceptable or compromised treatment outcome. To obtain
centric relation, have the tip of the patient’s tongue positioned
B
FIG 74-1 A, Vertically, the face can be divided into equal thirds
for assessment. The lower third of the face can be divided into
thirds with the distance from subnasale to upper lip stomion
equaling one third, and lower lip stomion to soft tissue menton
equaling two thirds. This ratio provides optimal vertical facial
balance in the lower third of the face. B, In profile the face is
divided in the same manner. Head orientation is important, with
the clinical Frankfort horizontal plane oriented parallel to the
floor. Clinical Frankfort horizontal plane is a line from the tragus
of the ear to the bony infraorbitale.
at the most posterior aspect of the palate while gently closing
together. An alternate method of obtaining centric relation is to
have the patient relax the mandible and, while keeping the
condyles seated, to manipulate the mandible upward until the
first teeth touch, and ask the patient to hold that position.
For proper evaluation, the patient’s lips should be relaxed
and not forced together. This relaxed lip posture allows evalu-
ation of vertical facial height and the morphology and drape of
the soft tissues. Relaxation of the lips allows evaluation of upper
lip length; tooth-to-lip measurements; possible lip incompe-
tence; and coincidence of the facial, dental, and chin midlines.
Combined with mentalis muscle relaxation, lip relaxation also
allows evaluation of the chin position and the presence or
absence of skeletal abnormalities, such as vertical maxillary
excess or vertical maxillary deficiency. The lip posture fre-
quently is overclosed in patients with vertical maxillary
deficiency.
Facial Evaluation
For vertical facial analysis, the face is most easily divided into
equal thirds (see Figure 74-1, A). The upper facial third extends
from the hairline to the glabella. The middle third extends from
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1051

C C

FIG 74-2 The transverse facial balance includes a normal inter-
canthal distance (A) of 32 ±3 mm for whites and 35 ±3 mm for
blacks and Asians. The normal interpupillary distance (B) is 65
±3 mm. The width of the palpebral fissures (C) should equal the
intercanthal distance.
FIG 74-3 Upper lip length is measured from subnasale to upper
lip stomion. For males, the normal value is 22 ±2 mm, and for
females, it is 20 ±2 mm.

the glabella to the subnasale. The lower third extends from the
subnasale to the soft tissue menton. Orthognathic surgery most
commonly alters the lower third of the face, with some influ-
ence on the middle third. In addition to this vertical analysis,
pretreatment facial evaluation also should address the frontal
and lateral facial planes. Evaluation from the frontal view should
include the following 14 anatomical relationships:
1. Evaluate the forehead, eyes, orbits, and nose for symmetry,
size, and deformity.
2. The normal intercanthal distance is 32 ±3 mm for whites
and 35 ±3 mm for blacks and Asians (Figure 74-2).
3. The normal interpupillary distance is 65 ±3 mm (see Figure
74-2, distance B).
4. The intercanthal distance, alar base width, and palpebral
fissure width should be equal (see Figure 74-2, distances
A and C). FIG 74-4 The normal upper tooth-to-lip relationship is 2.5
5. The width of the nasal dorsum should be one-half of the ±1.5 mm.
intercanthal distance, and the width of the nasal lobule
should be two-thirds of the intercanthal distance.
6. A vertical line through the medial canthus and perpendicu- seated in centric relation. Then evaluate the true lip length
lar to the pupillary plane should fall on the alar bases and the tooth-to-lip relationship.
±2 mm (see Figure 74-2). 11. The smile is frequently one of the patient’s chief concerns.
7. The upper lip length is measured from subnasale to upper When smiling, the vermilion of the upper lip should fall at
lip stomion. The normal upper lip length is 22 ±2 mm for the cervical gingival margin with no more than 1 to 2 mm
males and 20 ±2 mm for females (Figure 74-3). of exposed gingiva. In addition to this relationship, surgical
8. A normal tooth to upper lip relationship exposes decisions also must consider the tooth-to-lip relationship
2.5 ±1.5 mm of incisal edge with the lips in repose with the lips in repose, because many factors may influence
(Figure 74-4). lip posture during animation. The amount of upper lip
9. The facial midline, nasal midline, lip midlines, dental mid- elevation during smiling may be affected by the following:
lines, and chin midline should be congruent, and the face a. Anteroposterior (AP) position of the maxilla and
should be reasonably symmetrical, vertically and trans- mandible in relation to the cranial base as well as to
versely (Figures 74-5 and 74-6). each other
10. If the patient’s lips are overclosed, rotate the jaws open until b. Amount of overjet and overbite
the lips just begin to separate. The condyles should remain c. Angulation of the anterior dentoalveolus
1052 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
FIG 74-5 The facial midlines are assessed, including the nasal,
maxillary and mandibular dental midlines, and the chin midline,
relative to the facial midline. Left-to-right facial symmetry also
is evaluated.
FIG 74-6 Transversely, the occlusal plane should parallel the
pupillary plane, providing there is no orbital dystopia.
d. Occlusal plane angulation
e. Clinical crown length
f. Neuromuscular function of the lips
g. Dental coverage of periodontium
Each of these factors may contribute to inaccuracies in the
determination of the proper maxillary vertical position
if this position is determined only by evaluation of
the tooth-to-lip position during smiling.
12. The lower eyelid should be level with or slightly above the
most inferior aspect of the iris. The sclera between the
ClFH
B
FIG 74-7 A line perpendicular to the clinical Frankfort horizontal
plane (CIFH) through subnasale (A) should be 3 ±3 mm anterior
to the chin. A line tangent to the globe, perpendicular to clinical
Frankfort horizontal plane (B) should fall on the infraorbital soft
tissues ±2 mm.
inferior aspect of the iris and the lower lid (scleral show)
may indicate infraorbital hypoplasia or exophthalmos.
13. The distance from glabella to subnasale and subnasale to
menton should be approximately a 1 : 1 ratio, providing that
the upper lip length is normal (see Figure 74-1, A).
14. The length of the upper lip should be one-third of the
length of the lower facial third; that is, lower lip stomion to
soft tissue menton should be twice the vertical dimension
of the upper lip, providing that the upper lip is normal in
length (see Figure 74-1, A).
Lateral view. Evaluation of the lateral facial view is usually
the most valuable assessment in determining vertical and AP
problems of the jaws:
1. The distance from glabella to subnasale and from subnasale
to soft tissue menton should be in a 1 : 1 ratio if the upper
lip length is normal (see Figure 74-1, B).
2. With the maxilla in the normal AP position and the upper
lip of normal thickness, the ideal chin projection is 3 ±3 mm
posterior to a line through subnasale that is perpendicular
to the clinical Frankfort horizontal plane (subnasale perpen-
dicular plane (Figure 74-7).
3. Evaluate the morphology and relationships of the nose, lips,
cheeks, and chin.
4. Evaluate the cervicomandibular angle in reference to the
chin position.
5. The length of the upper lip should be one-third of the
length of the lower facial third; that is, lower lip stomion to
soft tissue menton should be twice the vertical dimension
of the upper lip if the upper lip is normal in length (see
Figure 74-1, B).
6. The upper lip labrale superius should be 1 to 3 mm anterior
to the subnasale perpendicular plane.
7. A line perpendicular to Frankfort horizontal plane and
tangent to the globe should fall on the infraorbital soft
tissues ±2 mm (see Figure 74-7).
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
Oral examination. Oral examination helps identify func-
tional and esthetic deformities of the dento-osseous and soft
tissue structures. Thorough oral examination should address
the following issues:
• Occlusal relationship (Class I, II, or III)
• Anterior overbite or open bite
• Anterior overjet and any crossbites
• Health of the dentition
• Tooth size discrepancies
• Curve of Wilson
• Curve of Spee
• Dental crowding or spacing
• Missing, decayed, retained primary, nonsalvageable teeth
• Discrepancies between centric occlusion and centric
relation
• Periodontal evaluation
• Transverse, AP, or vertical asymmetries
• Anatomical or functional tongue abnormalities
• Any masticatory difficulties
• Any other pathological processes
Occlusal factors to be evaluated in the oral examination are
discussed in the Dental Model Analysis section.
Periodontal evaluation. There are several periodontal factors
that should be evaluated before orthodontic treatment and
orthognathic surgery. Patients with pre-existing periodontal
disease or gingivitis have an increased risk of disease exacerba-
tion during orthodontic treatment and post treatment, particu-
larly in areas where interdental osteotomies may be required.9
Factors that can affect periodontal health adversely in relation
to orthognathic surgery include smoking, excessive alcohol
or caffeine consumption, bruxism and clenching, connective
tissue/autoimmune diseases, diabetes, malnutrition, and so
on.10 Address all periodontal disease before orthodontics and
orthognathic surgery.
Inadequate attached gingiva, most frequently associated with
the mandibular anterior teeth, may contribute to the develop-
ment of periodontal problems, such as gingival retraction, tooth
sensitivity, and bone loss. In areas of inadequate attached
gingiva, consider gingival grafting. When indicated, perform
free gingival grafts or free connective tissue grafts before the
initiation of orthodontics. Gingival grafting should occur before
orthodontic treatment because orthodontic tipping and surgi-
cal incisions for genioplasty, subapical osteotomies, and vertical
interdental osteotomies may worsen periodontal problems dra-
matically. Providing adequate attached gingival tissue before
orthodontic and orthognathic surgical intervention protects
this tissue and minimizes gingival tissue retraction.
Orthognathic surgical techniques must protect the peri-
odontal tissues and minimize vascular compromise to the bone,
teeth, and soft tissues. Take care to maintain bone around the
necks of each of the teeth at the interdental osteotomy sites.
Orthodontics can facilitate interdental osteotomies by tipping
the roots of the teeth away from the osteotomy site. Several
studies demonstrate that with such orthodontic assistance and
careful surgical technique, interdental osteotomies have a
minimal effect on the periodontium.11-14 The failure to identify
risk factors, poor surgical technique, and lack of attention to
detail can result in devastating periodontal complications.
Temporomandibular joints. The TMJs provide the founda-
tion for orthognathic surgery. Pre-surgical TMJ dysfunction
or undiagnosed TMJ pathosis can result in orthognathic
surgery unfavorable outcomes, such as postoperative pain,
1053
condylar resorption, malocclusion, jaw dysfunction, and facial
deformity.15,16
Assess the TMJs before treatment and periodically through-
out treatment. Basic TMJ factors to consider include the
following:
1. The patient history may reveal headaches, ear problems,
myofascial pain, TMJ dysfunction, clicking and popping,
crepitation, limited opening, pain, difficulty chewing, pro-
gressive development of an open bite, shifting of the man-
dible and bite, neck and shoulder problems, and so on.
Document etiological factors, time of onset, signs and
symptoms, previous treatments and outcomes, symptom
frequency and duration, parafunctional habits, and other
modifying factors.
2. Identify or rule out polyarthritides or other systemic condi-
tions. These conditions may include connective tissue or
autoimmune diseases, such as rheumatoid arthritis, juvenile
idiopathic arthritis, systemic lupus erythematosus, sclero-
derma, sarcoidosis, reactive arthritis, psoriasis, psoriatic
arthritis, Sjögren disease, ankylosing spondylitis, and Reiter
syndrome.15,16
3. Clinical examination should assess pain, function, and joint
noise. Deviation of the mandible during opening, for
example, may indicate a unilateral closed lock or fibrous
ankylosis. Joint noises such as clicking and popping may
suggest articular disk displacement. Crepitation within
the joint may indicate osteoarthritis or perforation of the
retrodiscal tissues.
4. Obtain and evaluate cone beam imaging, panoramic radio-
graphs, transcranial radiographs, transpharyngeal radio-
graphs, tomograms, computed tomography (CT) scans,
magnetic resonance imaging (MRI), and other imaging
modalities as indicated.
5. Properly diagnose existing TMJ conditions and discuss them
with the patient. The surgeon should properly sequence and
plan treatment for conditions requiring correction. Inform
the patient of any abnormal TMJ findings and how such
conditions may influence the orthodontic and orthognathic
surgery outcome, even if these conditions do not require
intervention.
The nose. Take a history relative to previous nasal trauma,
nasal airway obstruction, allergies, sinus problems, predomi-
nate mouth breathing versus nasal breathing, esthetic concerns,
and previous surgery. A functional and esthetic nasal evaluation
should include thorough examination of internal and external
nasal structures. Perform esthetic evaluation of the external
nasal anatomy from frontal and profile views. Note scars,
lesions, soft tissue thickness, asymmetries, and evidence of pre-
vious surgeries. From the frontal view, the normal intercanthal
distance is 32 ±3 mm (see Figure 74-2). The normal dorsal
width is one-half of this measurement, and the normal lobule
width is two-thirds of this distance. The nasal dorsal length
should fill most of the middle third of the face. No more than
one-third of the vertical dimension of the nares should be
visible from the frontal view.
From the clinical and radiographic profile view, the nasion
should be at the same vertical level as the upper palpebral
crease. The nasal dorsum should be straight to slightly concave.
The normal nasolabial angle ranges from 90 to 105 degrees
(Figure 74-8, angle A). The normal nasal projection angle,
measured by a line tangential to the nasal dorsum relative to
a line perpendicular to the Frankfort horizontal plane (see
1054 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
B to the floor. Both hard and soft tissue structures should be
90°
A asymmetries.
FIG 74-8 The normal nasolabial angle (A) is 90 to 105 degrees.
The normal nasal projection angle with a line tangent to the
dorsum of the nose and the angle created by a line perpendicu-
lar to Frankfort horizontal plane (B) should be 36 degrees for
males and 34 degrees for females.
Figure 74-8, angle B), is 34 degrees for females and 36 degrees
for males. The columella should extend 3 to 4 mm below the
lateral alar rims. The distance ratio from the base of the nose
to the anterior extent of the nares and from the anterior aspect
of the nares to the tip of the nose should be 2 : 1. The nares
should be symmetrical. Radiographic films most helpful in
identifying nasal and paranasal sinus pathoses include cone
beam imaging, but also lateral cephalometric radiograph,
Water’s view, posteroanterior cephalometric radiograph, soft
tissue nasal radiographs, and CT scan. Perform a thorough
intranasal examination to identify any existing airway obstruc-
tion or pathosis, including nasal septal deviation, hypertrophied
turbinates, nasal polyps, or nasopharyngeal adenoid hyperplasia.
Radiographic Evaluation
Types of Imaging Techniques
Cone beam technology provides a 1 : 1 ratio of imaging with
panogram, cephalometric, and tomographic imaging, including
three-dimensional imaging, and it is currently the gold standard
for orthognathic surgery imaging. Other commonly used radio-
graphs for diagnosis of dentofacial deformities are (1) lateral
cephalometric radiograph, (2) panoramic radiograph, and (3)
periapical radiograph when indicated. Panoramic and periapi-
cal radiographs can be helpful to determine tooth alignment,
root angulation, and existing pathoses. Other imaging modali-
ties such as posteroanterior cephalograms, TMJ tomograms,
transcranial radiographs, Water’s view images, MRI, and
CT scans may be required as determined by individualized
patient needs.
Lateral cephalometric radiograph. The lateral cephalometric
radiograph is one of the most important tools in the diagnosis
of jaw deformities.16 The lateral cephalometric radiograph is
used to analyze skeletal, dentoalveolar, and soft tissue relation-
ships in the AP and vertical dimensions. For proper positioning,
pose the patient’s head so that the jaws are in centric relation
with the teeth lightly touching and the lips relaxed. Position the
head so that the clinical Frankfort horizontal plane is parallel
visible on the radiograph. If the patient’s bite is overclosed (such
as in vertical maxillary deficiency), then take a second lateral
cephalometric radiograph with the condyles still seated in
centric relation but the mouth opened until the lips just begin
to separate. This posture allows assessment of soft tissue and
bony structures without distortion of the lips. AP cephalomet-
ric radiographs may be helpful, particularly in diagnosing
and treatment planning for patients with significant transverse
Cephalometric analysis versus clinical diagnosis. Numerous
cephalometric analyses are available to evaluate lateral cephalo-
metric radiographs. Regardless of the specific analysis the clini-
cian uses, it is important to understand that there may be
significant differences between the clinical evaluation and the
values obtained from cephalometric analysis. When a signifi-
cant difference occurs, the clinical evaluation is far more impor-
tant for treatment planning.17 Cephalometric analysis is only an
aid to clinical assessment and should not be used as the sole
diagnostic tool.
Corrected Frankfort horizontal plane. In cases in which the
cephalometric values do not correlate with the clinical impres-
sion, make adjustments in the reference cranial base structures
(i.e., corrected Frankfort horizontal line). Adjust values to cor-
relate with the clinical impression for use in diagnosis and
treatment planning. The Frankfort horizontal plane may be
positioned aberrantly because of vertical malposition of porion
or orbitale and/or AP malposition of nasion. A proper Frank-
fort horizontal plane also may be difficult to locate because of
difficulty in the radiographic identification of porion or orbitale.
A corrected Frankfort horizontal plane to correlate the cepha-
lometric values for maxillary and mandibular positions with
the clinical impression provides a cephalometric analysis that
assists in diagnosis and treatment planning (Figure 74-9).
Cephalometric analysis tempered with good clinical judgment
can be a valuable tool in establishing the most appropriate
orthodontic and surgical treatment plan.
Cephalometric analysis. Many reasonable cephalometric
analyses are available for clinical decision making.17 The authors
use an analysis that evaluates 15 cephalometric relationships.
This analysis permits a rapid diagnostic assessment as follows:
1. Maxillary depth is an angular measurement formed by the
Frankfort horizontal plane and a line from nasion through
point A (NA line). The normal value is 90 ±3 degrees
(Figure 74-10, angle A).
2. Mandibular depth is the angle formed by the Frankfort
horizontal plane and a line from nasion through point B of
the mandible (NB line). The normal value is 88 ±3 degrees
(see Figure 74-10, angle B).
3. The Frankfort mandibular plane angle is the angle created
by a line from the menton through the gonion relative to
the Frankfort horizontal plane. The normal value is 25 ±5
degrees (see Figure 74-10, angle C).
4. Occlusal plane angulation is determined from a line drawn
tangent to the buccal groove of the mandibular second
molar through the cusp tips of the premolars and the angle
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A central incisors extended vertically to cross the Frankfort
B best esthetic position.
FIG 74-9 Commonly, the anatomical Frankfort horizontal plane
(A) may not correlate to the clinical impression or the patient’s
deformity. In such instances, a corrected Frankfort horizontal
plane can be constructed (B) so that the numerical cephalomet-
ric values correlate to the clinical diagnosis of the patient.
A
B
E
D D
C
FIG 74-10 A normal maxillary depth (A) is 90 ±3 degrees. The
normal mandibular depth (B) is 88 ±3 degrees. The normal
mandibular plane angle to Frankfort horizontal plane (C) is 25
±5 degrees. The normal occlusal plane angle (D) is 8 ±4 degrees.
The normal esthetic line (red line designated E) is 90 ±2 degrees.
1055
of this line relative to the Frankfort horizontal plane.
The normal value is 8 ±4 degrees. The occlusal plane has
significant influence on function and esthetics, particularly
when double jaw surgery is performed (see Figure 74-10,
angle D).
5. The esthetic line (see Figure 74-10, red line labeled E)
relates a line tangent to the labial surface of the maxillary
horizontal plane and should form a 90-degree angle when
ideally aligned. This places the central incisor crown in the
6. Upper incisor angulation relates the long axis of the maxil-
lary incisor to the NA line and is normally 22 ±2 degrees.
The labial surface of the incisor tip should be 4 ±2 mm
anterior to the NA line. Upper incisor angulation is impor-
tant in establishing the pre-surgical orthodontic goals
(Figure 74-11, angles A and B).
7. The lower incisor angulation relates the long axis of the
mandibular incisor to the NB line and is normally 20
±2 degrees. The labial surface of the incisor tip should
be 4 ±2 mm anterior to the NB line. Assessment of the
lower incisor angulation is important in determining the
pre-surgical orthodontic goals (see Figure 74-11, angles
C and D).
B
C
E
FIG 74-11 The long axis from the upper incisor to the NA line
(A) has a normal value of 22 ±2 degrees. The labial surface of
the upper incisor (B) should be 4 ±2 mm anterior to the NA line.
The long axis of the lower incisor to the NB line (C) has a normal
value of 20 ±2 degrees. The labial surface of the mandibular
central incisors (D) should be 4 ±2 mm anterior to the NB line.
Hard tissue pogonion (E) should be 4 ±2 mm anterior to the NB
line with a 1 : 1 ratio, with the position of the labial surface of
the mandibular central incisors anterior to the NB line.
1056 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
8. The pogonion projection is measured from the most pro-
trusive point of bony pogonion to the NB line with a
normal relationship of 4 ±2 mm. Optimal mandibular den-
toskeletal balance is achieved when the labial surface of the
lower incisors and pogonion are in a 1 : 1 ratio anterior to
the NB line (see Figure 74-11, distance E).
9. The upper lip length is measured from the base of the nose
(subnasale) to the inferior part of the upper lip (upper lip
stomion). The normal length of an adult male lip is 22
±2 mm. For a female, it is 20 ±2 mm. Upper lip length is
the basis for establishing vertical facial dimensions in the
lower third of the face because the upper lip length usually
is not altered easily. This measurement is the basis for estab-
lishing the vertical length of the lower two thirds of the
lower third of the face (Figure 74-12, distance A).
10. The upper tooth-to-lip relationship is measured from the
relaxed upper lip stomion to the incisal edge of the upper
incisor. The normal value is 2.5 ±1.5 mm. This evaluation
is important in establishing the vertical dimensions of the
face, particularly when there are vertical dysplasias present
in the maxilla (see Figure 74-12, distance B).
11. The lower anterior dental height is measured from the
lower incisor tip to hard tissue menton. The average lower
A bilizing the maxilla. After mounting the dental models on a
D semiadjustable articulator using an occlusal plane indicator or
B a face-bow transfer and centric bite registration, carefully trim
D the models.19 Trim the mandibular model with its base flat on
C D
E
FIG 74-12 Normal upper lip length (A) for a male is 22 ±2 mm
and for females is 20 ±2 mm. Normal tooth-to-lip relationship
(B) is 2.5 ±1.5 mm. The lower anterior dental height (C) is mea-
sured from the mandibular central incisor tips to hard tissue
menton. It has a normal value of 44 ±2 mm in males and 40 ±2
mm in females. An important interrelationship is two times the
upper lip length should equal the lower anterior dental height.
The soft tissue thickness of the upper lip, lower lip, and chin
area (D) usually ranges from 11 to 14 mm but more importantly
should be a 1 : 1 : 1 ratio. The soft tissue thickness in the menton
area (E) is normally 7 ±2 mm.
anterior dental height for a male is 44 ±2 mm, and for a
female it is 40 ±2 mm. For optimal balance in the lower
third of the face, the lower anterior dental height should be
approximately twice the upper lip length. If the upper lip is
longer than normal, then the lower anterior dental height
should be longer than normal so that the facial dimensions
will be balanced in the lower facial third (see Figure 74-12,
distance C).
12. The soft tissue thickness of the upper lip, lower lip, and chin
area normally ranges from 11 to 14 mm. More importantly,
there should be a 1 : 1 : 1 ratio. Variations in this ratio may
influence treatment planning decisions regarding the lips
and chin (see Figure 74-12, distance D).
13. The soft tissue thickness of the menton is measured per-
pendicular to Frankfort horizontal plane from hard tissue
menton to soft tissue menton. The normal dimension is 7
±2 mm. Excessive thickness or thinness of this area may
influence alterations in the height of the anterior mandible
(see Figure 74-12, distance E).
14. The nasal projection angle is a line tangent to the soft
tissue of the nasal dorsum and a line perpendicular to
Frankfort horizontal plane through soft tissue nasion.
Normal is 34 degrees for females and 36 degrees for males
(see Figure 74-8, angle B).
15. The nasolabial angle is a line tangent to the columella
through the subnasale and a line tangent to the upper lip.
The normal range is 90 to 105 degrees (see Figure 74-8,
angle A).
Dental Model Surgery
Many techniques for model surgery have been proposed. In
two-jaw surgery, most surgeons advocate positioning the
maxilla first and fabricating an intermediate splint with the
intact mandible and the repositioned maxilla. An alternative
technique, however, may provide improved surgical accuracy by
avoiding intraoperative maxillary shifting during the placement
of intermaxillary fixation caused by excessively thin maxillary
walls or by intermaxillary instability during large mandibular
advancements.18
This alternative technique involves repositioning the man-
dible first, rigidly stabilizing it, and then repositioning and sta-
the anterior aspect. Then trim the base of the mandibular
model to form a rectangular column of plaster beneath the
model, using the initial anterior surface as the starting reference
plane (Figure 74-13). Next, trim the maxillary model and the
base flat from the canine to molar region bilaterally, with these
cuts parallel to the dentition. Then trim the anterior and pos-
terior aspects of the maxillary model and base flat, parallel to
each other and perpendicular to the base and the AP midline
(Figure 74-14). Draw three horizontal reference lines 5 mm
apart around each of the models. Then place three to five verti-
cal lines on each side of the models. The reference lines quantify
AP, vertical, and transverse movements of the mandible relative
to the maxillary teeth and articulator base.
Take measurements from the surgical treatment objective
(STO; or prediction tracing) to determine the position of
the mandible for model surgery. Superimpose the STO over
the original cephalometric analysis. A pencil point held at the
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1057

LM
pre-op
predicted mand.

FIG 74-13 The base of the mandibular model is trimmed to

form a rectangular column of plaster beneath the model. Place-
ment of the reference lines allows better control of mandibular
orientation when moving it anteroposteriorly or transversely.

FIG 74-15 To determine the anteroposterior (AP) position of

the mandible in relation to the unoperated maxilla, a pencil point
is held in the midpoint of the condylar head. The prediction
tracing is rotated so that the mandible on the surgical treatment
objective (STO) articulates with the maxilla on the cephalomet-
ric tracing where initial tooth contact is projected to occur. This
relates the AP position of the mandible in relation to the unoper-
ated maxilla. This relationship then should be reproduced in the
model surgery.

FIG 74-14 The maxillary model is trimmed so that the plaster

walls are trimmed parallel in relation to the buccal aspects of
the posterior teeth.

condylar area allows rotation of the STO, in relation to the

underlying cephalometric tracing, until the first dental contact
occurs between the mandible on the STO and the maxilla on
the original cephalometric tracing (Figure 74-15). This spatially
gives the AP vertical and occlusal plane orientation of the repo-
sitioned mandible relative to the uncut maxilla. Then cut the
mandibular plaster model free of its base and reposition it into
its new position as predetermined by the STO and cephalomet-
ric tracings (Figure 74-16). The incisal pin is not altered verti-
cally at all. Remove any interferences on the plaster base from
the inferior base attached to the mounting ring or the under-
surface of the resected mandibular model. Then secure the
mandible in its new position with sticky wax or glue. Fabricate
an intermediate splint to aid in positioning the mandible at the FIG 74-16 The mounted mandibular model is repositioned on
time of surgery. the articulator to correlate to the anteroposterior (AP) move-
Then cut the maxillary model off its base at the approximate ments achieved on the surgical treatment objective (STO). The
level of the anticipated Le Fort osteotomy. The maxilla may be resultant interdental relationship can be duplicated in surgery
sectioned to obtain the best functional and occlusal relation- with the use of an intermediate splint made on the models in
ship. Trim interferences, and interdigitate the maxillary occlu- this position. The incisal pin is not altered in length. The man-
sion to the best possible dental relationship and fix it to the dibular model is repositioned by removing plaster from the
maxillary base (Figure 74-17). To maximize accuracy, remove bottom of the cast. The intermediate splint is constructed.
1058 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
FIG 74-17 The maxilla then is mobilized and sectioned, if indi-
cated, and placed into occlusion to maximize the dental inter-
cuspation and final splint constructed. The incisal pin can remain
in the original to accurately reposition the maxilla relative to the
base, or as seen in this figure, the pin was lowered decreasing
the amount of “fill” required between the maxillary model and
the base.
FIG 74-18 Transverse stability of the segmentalized maxilla can
be achieved using a palatal splint. The soft tissues on the palate
must be waxed out, providing approximately 2 mm of wax relief
so that there is no impingement on the palatal soft tissues that
could compromise blood supply to the maxilla. This splint does
not cover the occlusal surface of the teeth. The transverse
palatal stability is achieved by contact of the splint against the
palatal aspects of the maxillary teeth.
the plaster or add wax between the mobilized segments and the
stable base to simulate vertical changes. In cases in which the
maxilla is to be surgically expanded or spaces created in
the interdental cut area, a palatal splint is constructed to provide
transverse stabilization (Figure 74-18). This splint creates trans-
verse stability by interdigitating along the palatal surfaces of
the dentition. The palatal splint is designed without occlusal
coverage. We prefer to section the maxilla into three pieces
between the lateral incisors and canines. Once the segments are
positioned properly and stabilized, wax out the palate with a 1
FIG 74-19 The maxillary splint is seated and secured. Light-
gauge wires usually engage the first molars and first premolars
bilaterally. The anterior teeth are not ligated into the splint.
to 2 mm thickness of wax so that the palatal mucosa is not
impinged, because this could cause vascular compromise to the
maxillary segments (see Figure 74-18).
This splint design provides transverse stability of the maxil-
lary arch yet allows a maximal occlusal inter-relationship. These
splints can be wired in place for 1 to 2 months and then con-
tinued for an additional 2 to 3 months as a removable appliance
to maximize the transverse stability. Place interdental holes in
the splint so that it can be ligated to the teeth, maxillary
first molars and the first premolars. The anterior teeth are not
ligated into the splint, but the interdigitation of the splint to
those teeth can help maintain the AP position (Figure 74-19).
The palatal splint is preferred to an occlusal covering splint,
because it significantly decreases occlusal discrepancies and
allows maximal interdigitation of the maxillary and mandibular
teeth at surgery, thus decreasing potential post-surgical occlusal
problems. Shifting between the reference lines on the mobilized
portion of the models and the stable bases is useful at the time
of surgery to help correlate the same movements. Accurate pre-
diction tracings, model surgery, and splint fabrication greatly
simplify the surgery. When the mandible is positioned first, the
only measurement required during surgery is the vertical posi-
tion of the maxillary central incisors. Proper use of the man-
dibular inferior border reciprocating saw blade reduces the risk
of a bad splint and facilitates predictable mandibular first surgi-
cal sequencing.20
Maxillary surgery can be performed first, but segmental
surgery requires the construction of intermediate and final
splints. With a final splint that covers the occlusal surfaces of
the maxillary teeth, the intermediate splint must join the man-
dibular teeth and the undersurface of the final splint. Surgical
stability may be compromised if the maxilla is repositioned first
and large mandibular advancements are required. Mandibular
advancement may stress the maxillary bone plates to the degree
that the maxillomandibular complex can rotate backward
before rigid fixation is applied to the mandible. This may result
in a functional and esthetic compromise.
Orthodontics Without Prior Surgical Consideration
Occasionally, orthodontic treatment is initiated before the
need for surgery is recognized. When this situation arises, the
orthodontist and surgeon should compare the pretreatment
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1059

records with records that show the patient’s present condition.

They must assess the stability of the orthodontic mechanics. If
concerns arise about instability of the dental alignment within
the arches, then the arch wires can be sectioned to allow vertical
and transverse relapse while maintaining the correction of any
rotations. Allow the teeth to settle for 4 to 6 months if signifi-
cant unstable movements have been performed, such as rapid
palatal expansion, orthodontic expansion, orthodontic closing
of open bites, or dental extrusion or intrusion. Reevaluate the
patient with new records after stabilization to establish the
proper diagnosis and treatment goals.

Diagnostic List
Before developing a treatment plan, establish a list of all existing
problems evident from clinical, radiographic, dental model, and
other indicated evaluations. This problem list should include
skeletal imbalances, occlusal problems, esthetic concerns,
temporomandibular dysfunction, myofascial pain, missing
teeth, crowns, bridges, endodontically treated teeth, dental
implants, periodontal problems, or other functional disorders.
The diagnostic list includes all functional, esthetic, and dental
problems, as well as any other medical factors that may affect
treatment outcomes. Formulate the treatment plan from the
problem list.
Initial Surgical Treatment Objective
The STO, or prediction tracing, is a two-dimensional projection
of the osseous, dental, and soft tissue changes resulting from
surgical orthodontic correction of orthodontic and orthopedic
deformities.21 The purpose of the STO is threefold: (1) to estab-
lish orthodontic goals, (2) to develop surgical objectives, and
(3) to create the predicted facial profile that can be used as a
visual aid in patient consultation. The STO has significant
importance in two phases of treatment planning. The initial
STO is prepared before treatment to determine orthodontic and
surgical goals. The final STO is prepared after active orthodon-
tic treatment and before surgery to determine the exact vertical
and AP changes to be achieved. The STO is important in estab-
lishing treatment objectives and projected results as a diagnostic
aid and a treatment planning blueprint.
Double Jaw Surgery
After the cephalometric tracing is complete, draw the surgical
reference lines on it to mimic the actual position of the surgical
sites (Figure 74-20). Three critical decisions to make when plan-
ning double jaw surgery are the following:
1. The vertical position of the maxillary incisor
2. The AP position of the maxillary incisor
3. The occlusal plane angulation
Draw these lines on the STO after tracing all stable land-
marks (Figure 74-21, A). Position the anterior maxillary segment
on the cephalometric tracing on the STO by placing point A on
the normal NA line and placing the incisor tip on the vertical
and AP reference lines (90 degrees to Frankfort horizontal
plane) and tracing it onto the STO (see Figure 74-21, B). With
the mandible positioned onto the STO in relation to the maxil-
lary incisors and the occlusal plane angulation (Figure 74-22),
trace the distal mandibular segment onto the STO. Then align
the proximal mandibular segment onto the STO with the distal
segment and trace it (Figure 74-23). Position the posterior
segment of the maxilla onto the STO to interdigitate best with
the mandibular dentition (Figure 74-24). Trace the surgical
FIG 74-20 In double jaw surgery, the surgical reference lines
are drawn on the cephalometric tracing to mimic the actual
position of the surgical cuts. Note the vertically directed line
between the maxillary lateral incisor and cuspid, representing
the interdental osteotomy.
reference lines onto the STO with each segment. Once the
maxilla and mandible are positioned onto the STO, then deter-
mine the chin position. The NB line provides a convenient
reference for determination of the AP position of bony pogo-
nion. The ratio between the distances from the labial surface of
the mandibular central incisors to the NB line and from the
pogonion to the NB line should be 1 : 1 (Figure 74-25). Measure
the vertical dimension of the anterior mandible from the tip of
the mandibular central incisors to hard tissue menton. For
optimal esthetics, this dimension should equal twice the upper
lip length. Trace appropriate alteration of the bony chin onto
the STO. Then add the soft tissues to complete the STO.
Compare skeletal, dental, and soft tissue changes on the STO
with the original cephalometric tracing. Record these changes
on the STO. The STO now provides the blueprint for dental
model surgery and the actual surgical procedures.
Soft Tissue Changes
The soft tissue changes discussed assume that an alar base cinch
suture and an intraoral V-Y closure are used to close the maxil-
lary incision. The upper lip labrale superius advances approxi-
mately 80% the amount of maxillary advancement (Figure
74-26, A). In maxillary setbacks, the upper lip moves posteriorly
about 50% the amount of AP movement of the maxilla (see
Figure 74-26, B). Superior repositioning of the maxilla shortens
the upper lip 10% of the amount of the vertical movement (see
Figure 74-26, C), and down-grafting the maxilla lengthens the
upper lip about 50% the amount of downward movement of
the maxilla (see Figure 74-26, D). Mandibular advancement
advances the soft tissue pogonion approximately 100%. With
mandibular advancement, the lower lip labrale inferius advances
approximately 85% (see Figure 74-26, E). As the mandible is
1060 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

FIG 74-22 The mandible is positioned into the best fit in refer-
ence to the maxillary incisors and the occlusal plane angle refer-
ence line. The distal mandibular dental segment and surgical
reference lines then are traced.

FIG 74-21 A, The vertical position of the maxillary central inci-

sors is selected, and a horizontal line is drawn to mark that
position. The anteroposterior (AP) position of the labial surfaces
of the maxillary central incisors is determined by placing a short
vertical line 4 mm anterior to the normal maxillary depth. The
occlusal plane angle (normal 8 ±4 degrees) is selected based
on functional and esthetic goals. B, The anterior maxillary
segment is aligned and positioned by placing the incisal tips of
the maxillary central incisors on the horizontal reference line.
The vertical surface should be placed against the anterior refer-
ence line and point A on the normal maxillary depth line. The
anterior maxilla and the surgical reference lines then are traced.

moved posteriorly, the soft tissue pogonion moves backward

approximately 90% of the amount of bony movement (see
Figure 74-26, F). For chin augmentations, osseous or alloplastic,
soft tissues advance approximately 80% to 85% the amount of
AP hard tissue augmentation (see Figure 74-26, G). The vertical
lengthening of the chin causes about 100% of soft tissue vertical
change at the menton. Posterior movement of the chin results
in about 90% posterior movement of the soft tissues (see
Figure 74-26, H). Vertical reduction of the chin with a wedge
ostectomy and moving the inferior border of the mandible
superiorly results in about a 90% vertical soft tissue change (see
Figure 74-26, I).
FIG 74-23 The proximal segment is rotated until the buccal
horizontal surgical reference lines contact each other. The proxi-
mal segment and surgical reference lines then are traced.
and immediately before surgery. Use the same basic approach
to STO construction as described for the initial STO. Correla-
tion of the model surgery to the final STO prediction tracing
should provide an accurate surgical guide.

Final Surgical Treatment Objective Definitive Treatment Plan

Perform the final STO on a lateral cephalometric tracing after Formulate the definitive treatment plan based on the patient’s
active pre-surgical orthodontic treatment has been completed concerns, clinical evaluation, radiographic analysis, dental
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1061

FIG 74-24 The posterior segment of the maxilla is positioned

and integrated with the best fit into the mandible. The surgical
reference lines are traced appropriately.

model evaluation, initial STO, and other relevant studies. The

general sequencing of treatment is described next.

Dental and Periodontal Treatment

Perform any indicated periodontal or general dental mainte-
nance, prevention, or restoration before orthodontic and surgi-
cal intervention. The dental objective is to maintain as many 5 6
teeth as possible and to stabilize the periodontium. Place tem- 3
porary crowns and bridges where necessary for the orthodontic 5
and surgical phases of treatment. Fabricate definitive restora- 3 6
tions and deliver them after surgery and orthodontics are 3
4
completed. Periodontal management may include scaling and
curettage, as well as gingival grafting, to provide adequate
attached gingiva. Gingival grafting most commonly is needed
in the anterior mandible. Adequate attached gingiva and good
9 5
periodontal health are most important when orthodontic
mechanics will tip the mandibular anterior teeth forward and 6
when anterior vestibular incisions are necessary to perform B 21
genioplasty, subapical osteotomies, or anterior body osteoto-
mies. Inadequate attached gingiva likely will result in periodon-
tal stripping and loss of supportive bone. FIG 74-25 A, The NB line is drawn to determine the anteropos-
terior (AP) position of the chin. An ideal relationship is when the
Extractions labial surfaces of the mandibular central incisors and the chin
Extractions are sometimes necessary to correct for arch length are 4 ±2 mm anterior to the NB line. The vertical height of the
and dental width discrepancies. Premolars are the most common mandible, as measured from the mandibular central incisor tips
teeth extracted, usually related to excessive crowding or overan- to hard tissue menton, should equal twice the upper lip length
gulated incisors. Ideally, third molars should be removed at least for optimal facial balance. B, Indicated chin alterations are
9 to 12 months before mandibular osteotomies, particularly made, the soft tissues are drawn, and dento-osseous changes
when traditional sagittal split surgical techniques are planned. are recorded.
Early removal allows the extraction sites to heal properly and
provides stable bony interfaces for the osteotomized bony
margins. The presence of the third molars significantly weakens
proximal and distal segments and may increase the risk of unfa-
vorable splits or mandibular fractures with the traditional sag-
gital split design. Use of the inferior border osteotomy technique
1062 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B

35%

80% 50%

FIG 74-26 A, The upper lip moves forward approximately 80%

to 100% the amount of maxillary advancement, depending on C D
the soft tissue management, such as using the alar base cinch
suture and V-Y closure to increase the post-surgery thickness
of the upper lip, and the nasal tip elevates approximately 35%.
B, When the maxilla is moved posteriorly, the upper lip retracts
about 50% of the maxillary movement. C, With superior repo- 20%
sitioning of the maxilla, the upper lip shortens vertically 10% to 20%
40% the amount of vertical movement, depending on soft
tissue management. D, The upper lip lengthens approximately 30%
50% the amount of downward movement of the maxilla.
E, With mandibular advancement, the soft tissue pogonion 10% - 40% 50%
advances approximately the same distance as the anteroposte-
rior (AP) bony movement. The lower lip advances about 85%.
F, As the mandible is moved posteriorly, the soft tissue pogo- E F G
nion moves posteriorly approximately 90% the amount of bony
movement. The upper lip moves posteriorly approximately 20% 80%

the amount of mandibular posterior movement. G, Osseous or

alloplastic chin augmentation produces approximately an 80% 20%
to 85% soft tissue advancement. H, As the chin is set posteri-
orly, the soft tissues change about 90% the amount of AP 85% 90%
movement. I, As the osseous chin is moved superiorly, the soft 100% 90%
tissue change is about 90% of the vertical bony movement. 100% 90% 80%

H I

90%

90%

allows safe removal of the mandibular third molars at the time
of sagittal split osteotomy.20 Maxillary third molars also may be
removed at the same time as the maxillary osteotomies. If
removing maxillary third molars during orthognathic proce-
dures, preferably remove them after mobilization of the maxilla
to minimize the risk of unfavorable fracture in the tuberosity
region. If the maxillary third molars are removed before orthog-
nathic surgery, remove them 9 to 12 months before to allow
adequate healing and to optimize the vertical bony support in
this region.
Virtual Surgical Planning
VSP uses computer technology to simulate the planned surgical
procedures. Over the past decade, computer-aided surgical
simulation (CASS) technology has been integrated to many
maxillofacial surgical applications, including dentofacial
deformities, congenital deformities, defects after tumor abla-
tion, posttraumatic defects, reconstruction of cranial defects,
and reconstruction of the TMJ.22-26 CASS technology applied to
orthognathic surgery can improve surgical accuracy, provide
intermediate and final surgical splints, and decrease the sur-
geon’s time input for pre-surgical preparation compared with
traditional methods of case preparation. Data for VSP in
orthognathic surgery cases can be obtained from high quality
cone beam scans, but better quality simulation and accuracy
can be acquired from medical grade CT scans of the jaws with
1-mm overlapping cuts.
For orthognathic surgery cases, the original cephalometric
tracing, clinical evaluation, and prediction tracing are used in
conjunction with computer-generated skeletal, occlusion, and
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1063

soft tissue simulation of the patient’s structures to configure the
surgical movements. Dental models can be scanned and incor-
porated into the computer model to accurately duplicate the
dental anatomy (see Dental Model Preparation later in this
chapter). Working with a computer engineer at one of the VSP
companies (Figure 74-27, A), the mandible and maxilla on the
computer model are placed into the final predetermined posi-
tion using the planned measurements for correction of the
maxillary and mandibular AP and vertical positions, occlusal
plane angulation, pitch, yaw, and roll based on the clinical eval-
uation, prediction tracing, and computer model (see Figure
74-27, B). Computer simulation eliminates errors that can be

C
FIG 74-27 A, Virtual surgical planning (VSP) set-up on the computer with maxilla and mandible
in the original position and dental models scanned and incorporated into the computer model.
B, Maxilla and mandible in final post-surgical position. C, Because mandibular surgery will be
done first in this case, the mandible is retained in its final position, the maxilla is placed into its
original position, and the intermediate splint is constructed. If the surgeon prefers to operate on
the maxilla first, then the maxilla is maintained in the final position and the mandible is placed
back into its original position for intermediate splint construction.
1064 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A B
FIG 74-28 A and B, The intermediate splint is constructed from the virtual surgical planning (VSP)
model. The final palatal splint is also constructed from the VSP model with the same design as
seen in Figures 75-18 and 75-19.
created with the traditional model surgery techniques for repo-
sitioning the maxilla and mandible on articulator-mounted
models that rely on the operator’s manual dexterity and three-
dimensional perspective that play a critical role in setting the
mandible and maxilla into their proper and final position. This
operator factor can predispose the planning process to signifi-
cant error.
Once the final position of the maxilla and mandible are
established, the intermediate splint can be constructed by one
of the following methods:
1. Many patients requiring orthognathic surgery will benefit
from counterclockwise rotation of the maxillomandibular
complex, which requires the development of posterior open
bites on the model for construction of the intermediate
splint when the mandible is repositioned first. In this situa-
tion, the maxilla is returned to its original position while the
mandible is maintained in its final position (see Figure
74-27, C), and the computer-generated intermediate splint
is printed out. The final splint (a palatal splint is used by the
authors) is printed out with the maxilla and mandible in
their final position.
2. When it is preferred to reposition the maxilla first, the man-
dible is returned to its original position while the maxilla is
maintained in its final position and the palatal splint, if the
maxilla is segmented, and the intermediate splint are printed
out. The final splint is generated with the maxilla and man-
dible in the final position. The splints are produced by the
VSP company.
Dental Model Preparation
Approximately 2 weeks before surgery, the final dental models
are produced, including two maxillary models if the maxilla is
to be segmented or dental equilibration is required. One of the
maxillary models is segmented if indicated, dental equilibration
is performed, and the segments are placed in the best occlusion
fit with the mandibular dentition and maxillary segments fixed
to each other. The dental models do not require mounting on
an articulator. The three or four models (two maxillary and one
mandibular, or two mandibular models if dental equilibrations
are done) are sent to the VSP company for scanning and simula-
tion into the computer model. Because the authors routinely
perform the mandibular osteotomies first, the unsegmented
maxillary model is simulated into the original maxillary posi-
tion and the mandible model is simulated into its final position.
The intermediate splint is constructed (Figure 74-28). Then the
segmented maxillary model is simulated into the computer
model with the maxilla in its final position, the maxilla and
mandible are placed into the best occlusal fit, and the palatal
splint is fabricated, or an occlusal splint if the surgeon prefers.
The dental models, splints, and images of the computer-
simulated surgery are sent to the surgeon for implementation
during the actual surgery.
Combined Temporomandibular Joint Total Joint Replacement
With Concomitant Orthognathic Surgery
TMJ disorders or pathology and dentofacial deformities com-
monly coexist. The TMJ pathology may be the causative factor
of the jaw deformity, develop as a result of the jaw deformity,
or the two entities may develop independently of each other.
The most common TMJ pathologies that can adversely affect
jaw position, occlusion, and orthognathic surgical outcomes
include (1) articular disc dislocation, (2) adolescent internal
condylar resorption (AICR), (3) reactive arthritis, (4) condylar
hyperplasia, (5) ankylosis, (6) congenital deformation or
absence of the TMJ, (7) connective tissue and autoimmune
diseases, (8) trauma, and (9) other end-stage TMJ pathologies.
These TMJ conditions are often associated with dentofacial
deformities, malocclusion, TMJ pain, headaches, myofascial
pain, TMJ and jaw functional impairment, ear symptoms,
sleep apnea, and so on. Patients with these conditions may
benefit from corrective surgical intervention, including TMJ
and orthognathic surgery. Some of the aforementioned TMJ
pathologies may have the best outcome prognosis using
patient-fitted (custom-made) total joint prostheses for TMJ
reconstruction.25,26
Many clinicians choose to ignore the TMJ pathology and
perform only orthognathic surgery for these types of cases,
but this treatment philosophy can result in continuation or
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
BOX 74-1 Protocol for Traditional
Concomitant Orthognathic Surgery
1. Computed tomography (CT) scan including the entire mandible,
maxilla, and temporomandibular joints (TMJs)
2. Fabrication of stereolithic model with the mandible separated
3. Surgeon positions the mandible in its final position and fixates it
4. Remove condyles and recontour the lateral aspect of the rami and
fossae if indicated
5. Model sent to TMJ Concepts for prostheses design, blueprint, and
wax-up
6. Approval of total joint prostheses blueprint and wax-up by the surgeon
7. Manufacture of custom-fitted total joint prostheses
8. Prostheses sent to hospital for surgical implantation
exacerbation of the pre-surgery TMJ pathology and reproduce
the original deformity with worsening occlusion, jaw dysfunc-
tion, facial imbalance, and pain. Clinicians who address the
dentofacial deformities and TMJ pathologies that require total
joint prostheses can perform the surgery in one stage or two
separate stages. The two-stage approach requires the patient to
undergo two separate operations and anesthesia, significantly
prolonging the overall treatment. However, performing con-
comitant TMJ and orthognathic surgery (concomitant orthog-
nathic surgery [CTOS]) in these cases significantly decreases
treatment time and provides better outcomes, but it requires
careful treatment planning and surgical proficiency in the two
surgical areas. Using traditional model surgery and treatment
planning techniques exposes the outcome to its own subset of
error margin. As a result, CTOS can provide improved accuracy
and saves considerable preparation time, but it requires experi-
ence and expertise in orthognathic and TMJ surgery.
VSP is a significant improvement for the construction of
total joint prostheses that also required CTOS. Treatment plan-
ning for CTOS cases is based on cephalometric analysis, predic-
tion tracing, clinical evaluation, and dental models, which
provide the template for movements of the upper and lower
jaws to establish optimal treatment outcome in relation to
function, facial harmony, occlusion, and oropharyngeal airway
dimensions. For patients who require total joint prostheses, a
medical grade CT scan with 1-mm overlapping cuts is acquired
of the maxillofacial region that includes the TMJs, maxilla, and
mandible. The surgeon has two options for model preparation
to aid in the construction of patient-fitted total joint prostheses
using the TMJ Concepts system (Ventura, CA).
Protocol for Traditional Concomitant
Orthognathic Surgery
Treatment planning for CTOS cases is based on prediction
tracing, clinical evaluation, and dental models, which provide
the template for movements of the upper and lower jaws to
establish optimal treatment outcome in relation to function,
facial harmony, occlusion, and oropharyngeal airway dimen-
sions (Boxes 74-1 and 74-2). For patients who require total joint
prostheses, a CT scan is acquired of the maxillofacial region that
includes the TMJs, maxilla, and mandible with 1-mm overlap-
ping cuts. Using these CT scan data, a stereolithic model is
fabricated, with the mandible as a separate piece. Using the
original cephalometric tracing and prediction tracing (Figure
74-29, A), the mandible on the stereolithic model is placed into
its future predetermined position using the planned measure-
ments for correction of mandibular AP and vertical positions,
1065
BOX 74-2 Steps in Traditional
Orthognathic Surgery, Intermediate, and
Palatal Splint Fabrication for Concomitant
Orthognathic Surgery
1. Acquisition of dental models
2. Mounting maxillary and mandibular dental models on an articulator
3. Reposition the mandibular dental model, duplicating the positional
changes acquired on the stereolithic model
4. Fabrication of intermediate splint
5. Reposition maxillary dental model with segmentation if indicated
6. Construction of palatal splint
7. Ready for surgery
occlusal plane alteration, pitch, yaw, and roll (see Figure 74-29,
B). The mandible is stabilized to the maxilla with quick-cure
acrylic. Many patients with TMJ pathology requiring CTOS will
benefit from counterclockwise rotation of the maxillomandibu-
lar complex. Repositioning the mandible into its final position
requires the development of posterior open bites on the model
(see Figure 74-29, B). Because the mandibular position on the
stereolithic models is established using hands-on measure-
ments, the operator’s manual dexterity and three-dimensional
perspective play a critical role in setting the mandible in its
proper and final position. This step can predispose the planning
process to a certain margin of error.
The next step requires condylectomies as well as preparation
of the lateral aspect of the rami and fossae (Figure 74-30, A and
B) for fabrication of the patient-fitted total joint prostheses. The
goal of this step is to recontour the lateral ramus to a relatively
flat surface in the area where the mandibular component will
be placed. The fossa requires recontouring only if heterotopic
bone or unusual anatomy is present. The recontouring areas are
marked in red for duplication of bone removal at surgery.
Because most patients with TMJ problems requiring CTOS can
benefit from counterclockwise rotation of the maxillomandibu-
lar complex, the stereolithic model will likely be set with poste-
rior open bites, because the maxilla is maintained in its original
position.
Once the stereolithic model is finalized, the model is sent to
TMJ Concepts to perform the design, blueprint, and wax-up of
the custom-fitted total joint prostheses (see Figure 74-30, C),
with the design and wax-up sent to the surgeon for approval
before manufacture of the prostheses. The period from CT
acquisition to the manufacturer’s completion of the patient-
fitted prostheses is approximately 8 weeks. Prior to surgery, the
surgical procedures are performed on articulator-mounted
dental models. The mandible is repositioned on the articulator,
duplicating the movements performed on the stereolithic
model, and the intermediate splint is constructed. The maxil-
lary model is repositioned, segmented if indicated, and placed
into the maximal occlusal fit. Then, the palatal splint is con-
structed (see Figures 74-18 and 74-19).
Protocol for Concomitant Orthognathic Surgery Using
Computer-Aided Surgical Simulation
For CTOS cases, the orthognathic surgery is planned using
CASS technology and moving the maxilla and mandible into
their final position in a computer-simulated environment
(Figure 74-31, A and C). Using the computer simulation, the
AP and vertical positions, occlusal plane alteration, pitch, yaw,
1066 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B
FIG 74-29 A, Measurement of the cephalometric prediction tracing for the amount of open
bite produced at the second molar after counterclockwise rotation of the mandible into its final
position. B, Duplication of the measurement obtained from the prediction tracing to the final
mandibular position on the stereolithic model and fixating the mandible to the maxilla with meth-
ylmethacrylate. (From Movahed R, Teschke M, Wolford LM: Protocol for concomitant temporo-
mandibular joint custom-fitted total joint reconstruction and orthognathic surgery utilizing
computer-assisted surgical simulation. J Oral Maxillofac Surg 71(12):2123-2129, 2013.)

A B C
FIG 74-30 A, Marking the condylectomy osteotomy and the irregularities of the fossa. B, The
stereolithic model after condylectomy and recontouring of the fossae and rami (marked in red).
C, Stereolithic model with prostheses wax-up for approval by the surgeon. (From Movahed R,
Teschke M, Wolford LM: Protocol for concomitant temporomandibular joint custom-fitted total
joint reconstruction and orthognathic surgery utilizing computer-assisted surgical simulation.
J Oral Maxillofac Surg 71(12):2123-2129, 2013.)

and roll are accurately finalized for the maxilla and mandible
based on clinical evaluation, dental models, prediction tracing,
and computer-simulation analysis. Segmentation of the maxilla
can be simulated (Box 74-3).
Using Digital Imaging and Communications in Medicine
(DICOM) data, the stereolithic model is produced with the
maxilla and mandible in the final position and provided to
the surgeon for removal of the condyle and recontouring of
the lateral rami and fossae if indicated (Figure 74-32, A). The
stereolithic model is sent to TMJ Concepts for the design,
blueprint, and wax-up of the prostheses. Using the Internet, the
design is sent to the surgeon for approval. Then, the custom-
fitted total joint prostheses are manufactured (see Figure 74-32,
B). It takes approximately 8 weeks to manufacture the total joint
patient-fitted prostheses.
Approximately 2 weeks before surgery, final dental models
are acquired including two maxillary models if the maxilla is to
be segmented or dental equilibration is required. One of the
maxillary models is segmented if indicated, dental equilibration
is performed, and the segments are placed in the best occlusion
fit with the mandibular dentition and maxillary segments fixed
to each other. The dental models do not require mounting on
an articulator. The three or four models (two maxillary and one
mandibular, or two mandibular models if equilibrations are
done) are physically sent to the VSP company for scanning and
simulation into the computer model. Alternatively, with an
i-CAT machine, the models can be scanned and digitally sent
to the VSP company. Because the authors routinely perform the
TMJ reconstruction and mandibular advancement with the
TMJ Concepts total joint prosthesis first, the unsegmented
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1067

C
FIG 74-31 Staged computer-aided surgical simulation surgical report. A, Simulated preoperative
position of the maxilla and mandible. B, The maxilla and mandible in the simulated intermediate
position, with the maxilla in its original position, but mandible in its final position with the
mandibular surgery performed first for fabrication of the intermediate splint. C, The final
position of maxilla and mandible, after advancement of mandible and segmental osteotomy of
the maxilla, for the production of a palatal splint. (From Movahed R, Teschke M, Wolford LM:
Protocol for concomitant temporomandibular joint custom-fitted total joint reconstruction and
orthognathic surgery utilizing computer-assisted surgical simulation. J Oral Maxillofac Surg
71(12):2123-2129, 2013.)
1068 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B
FIG 74-32 A, Stereolithic model fabricated after simulated maxillary and mandibular advance-
ment to the final position. Condylectomy and recontouring of the lateral rami and fossae were
performed and sent to TMJ Concepts for construction of the prostheses. B, Constructed patient-
fitted temporomandibular joint (TMJ) prosthesis using the computer-aided surgical simulation
fabricated stereolithic model. (From Movahed R, Teschke M, Wolford LM: Protocol for concomi-
tant temporomandibular joint custom-fitted total joint reconstruction and orthognathic surgery
utilizing computer-assisted surgical simulation. J Oral Maxillofac Surg 71(12):2123-2129, 2013.)

BOX 74-3 Protocol of Concomitant
Orthognathic Surgery Using Computer-Aided
Surgical Simulation
1. Computed tomography (CT) scan of entire mandible, maxilla, and
temporomandibular joints (TMJs) (1-mm overlapping cuts)
2. Processing of Digital Imaging and Communications in Medicine
(DICOM) data to create a computer model in computer-aided
surgical simulation (CASS) environment
3. Correction of dentofacial deformity, including final positioning of the
maxilla and mandible, with computer-simulated surgery
4. Stereolithic model constructed with jaws in final position and sent
to surgeon for condylectomy and rami and fossae recontouring if
indicated
5. Model sent to TMJ Concepts for prostheses design, blueprint, and
wax-up
6. Surgeon evaluation and design approval using the Internet
7. TMJ prostheses manufactured and sent to hospital for surgical
implantation
8. Two weeks before surgery, acquisition of final dental models (two
maxillary, one or two mandibular models if dental equilibrations are
required); one maxillary model is segmented and models equili-
brated if indicated to maximize the occlusal fit; models sent to the
virtual surgical planning (VSP) company
9. Models incorporated into computer-simulated surgery for construc-
tion of intermediate and final palatal splints
10. Models, splints, and printouts of computer-simulated surgery sent
to surgeon
maxillary model is simulated into the original maxillary posi-
tion and the mandible is maintained in the final position. The
intermediate splint is constructed (see Figures 74-28 and 74-
31). Then the segmented maxillary model is simulated into the
computer model in its final position, with the best occlusal fit
with the mandibular occlusion, and the palatal splint is fabri-
cated or an occlusal splint is made if the surgeon prefers. The
dental models, splints, and images of the computer-simulated
surgery are sent to the surgeon for implementation during
surgery.
Using CASS technology for CTOS cases eliminates the ‘‘tra-
ditional’’ steps requiring the surgeon to manually set the man-
dible into its new final position on the stereolithic model, thus
saving time and improving surgical accuracy. Although dental
model surgery is necessary only if the maxilla requires segmen-
tation, the models do not require mounting on an articulator.
This saves considerable time by eliminating the time required
to mount the models, prepare the model bases for model
surgery, reposition the mandible, construct the intermediate
occlusal splint, and make the final palatal splint. With CASS
technology, the splints are manufactured by the VSP company.
Surgery
The surgical procedures used to correct existing musculoskel-
etal deformities should provide optimal functional and esthetic
results with good stability. Take new records before surgery, and
reevaluate the patient to determine the progress and readiness
for surgery. Perform a new STO to determine the final position
of the jaws and to predict the resultant profile. Use VSP or
traditional pre-surgical preparation.25,26 For traditional prepa-
ration in double jaw surgery, perform simulated surgery on
the articulator–mounted dental models to duplicate the dento-
osseous movements determined from the STO and make the
intermediate and final splints. Alternatively, use the CASS tech-
nology for surgical preparation.
The following is the preferred surgical sequencing:
1. TMJ surgery if indicated
2. Mandibular ramus sagittal split osteotomies
3. Removal of mandibular third molars
4. Subapical and/or body osteotomies
5. Application of rigid fixation to mandible
6. Maxillary osteotomies and mobilization
7. Removal of maxillary third molars
8. Turbinectomies/nasal septoplasties
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
9. Maxillary segmentation, application of rigid fixation, and
appropriate bone grafting
10. Adjunctive procedures; genioplasty, facial augmentation,
rhinoplasty, and so on
This sequencing helps achieve optimal outcomes, whether
performed in one or more operations. With the use of rigid
fixation, maxillomandibular fixation is rarely needed.
Definitive Periodontal and General Dental Management
Definitive periodontal treatment, such as esthetic periodontal
surgery and mucoperiosteal flap procedures, may be performed
at this time. Lastly, definitive restorations and prosthetic tooth
replacement complete the treatment.
Surgical Procedures
Many surgical procedures are available to correct dentofacial
deformities. Oral and maxillofacial surgeons should have expe-
rience with these procedures and a thorough understanding of
reasonable treatment goals in order to develop a plan that pro-
vides optimal functional and esthetic results. The surgeon must
be aware of the potential risks and complications that can occur
with each of these procedures. This knowledge enables the
surgeon to develop an optimal treatment plan and alternative
treatments according to his or her skill level. The surgeon should
communicate to the patient the existing problems, the magni-
tude of these problems, the recommended treatment, alternative
treatment options, and the potential risks and complications.
Genioplasty procedures. Genioplasty procedures can alter
the position of the chin in all three planes of space. Chin posi-
tion most commonly is changed by use of a sliding osteotomy
or by the addition of an alloplastic implant.
Osseous procedures. When the bony chin is to be reposi-
tioned, a soft tissue pedicle must be maintained to ensure viabil-
ity to the osteotomized segment. The traditional horizontal
osteotomy (Figure 74-33, A) or the tenon and mortise tech-
nique can be used. Stabilization can be achieved by wiring, bone
screws, and/or bone plates.
Anteroposterior augmentation. The usual limiting factor
for chin advancement is the AP dimension of the symphysis,
unless the osteotomized segment is tiered surgically. If the chin
is narrow transversely, advancement tends to make the face
appear more tapered. Soft tissue change is approximately 80%
A B
FIG 74-33 A, An osseous genioplasty can be used to augment
the chin, move it posteriorly, alter its vertical position, or change
the transverse position of the chin. B, Alloplastic implants can
be used to augment the chin anteriorly. They are less effective
for vertical augmentation.
1069
to 85% of the amount of bony augmentation (see Figure 74-26,
G). Over time, anterior bone resorption can occur with an
osseous result of 80% compared with the original amount of
advancement. Soft tissue also may regress posteriorly.
Anteroposterior reduction. Optimal soft tissue change is
achieved by performing a horizontal sliding osteotomy and
moving the chin and attached soft tissues posteriorly. The chin
usually appears wider after this procedure, and the labiomental
fold decreases. Soft tissue change, if soft tissue remains attached
to the anterior and inferior aspect of the chin, is usually 90%
of the AP bony reduction. Shaving of the anterior aspect of the
bony chin may result in only 20% to 30% posterior movement
of the soft tissue in relation to the amount of bone removed.
Take care to ensure the soft tissues “follow” the hard tissue. Not
infrequently, failure to do so leaves a mobile soft tissue mass
that may be pulled inferiorly by the mentalis to produce an
unattractive ptosis of the lower lip and chin.
Vertical augmentation (down graft). Vertical augmenta-
tion is accomplished best with a horizontal osteotomy and infe-
rior repositioning of the chin segment. This technique usually
requires bone or synthetic bone grafting. Soft tissue change is
approximately 100% of the osseous change.
Vertical reduction. The most predictable vertical reduction
is with a wedge resection and rotation of the inferior chin
segment superiorly. When soft tissue remains attached to the
inferior border, the soft tissue change is approximately 90% of
the vertical osseous change. If the inferior border is resected and
removed, then the vertical soft tissue change is only 25% to 30%
of the amount of bone removed.
Transverse repositioning. Transverse repositioning is used
to correct chin asymmetry. A horizontal osteotomy is per-
formed, and the chin is shifted to the determined position and
stabilized.
Lateral augmentation. By splitting the chin segment in the
midline, the segments can be expanded and stabilized. If a large
expansion is planned, the midline defect may require bone or
synthetic bone grafting. Narrowing of the chin can be accom-
plished by rotating the segments medially, but the effectiveness
of this technique is limited.
Age for osseous genioplasty. Perform osseous genioplasty
after 12 years of age to allow for eruption of the permanent
mandibular canines and premolars.
Alloplastic augmentations. Various synthetic materials have
been used to augment the chin (see Figure 74-33, B).27 Rigid
stabilization of implants is critical, because mobility may result
in malposition, bone resorption, and infection. Most infections
of chin implants occur when there is improper fixation or inad-
equate soft tissue closure. The following recommended tech-
nique is safe and provides good long-term stability:
1. Perform the chin implant as the last step, after all other
orthognathic procedures are completed and the associated
incisions are closed.
2. After exposure and preparation of the implant area, thor-
oughly irrigate with sterile saline.
3. Change gloves and wash off glove powder before handling
the implant.
4. Stabilize the implant to the mandible to eliminate mobility
and migration by using bone screws, plates, or intraosseous
wiring.
5. Irrigate the surgical area thoroughly and close the incision
in two layers with reapproximation of the mentalis muscle
layer and tight mucosal closure.
1070 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

Although many alloplastic materials have been used for chin

augmentation, only one is currently recommended: Medpor
(Porex, Newnan, GA) is a porous polyethylene preformed
implant with a selection of sizes and designs.
Alloplastic augmentation genioplasty may be performed
after eruption of the mandibular anterior teeth.
Complications. Several potential complications are associ-
ated with osseous and alloplastic augmentation:
• Loss of osteotomized bone segment
• Bone resorption
• Infection
• Displacement/malalignment
• Paresthesia/anesthesia of lower lip and chin
• Lower lip ptosis
• Mentalis muscle dysfunction
• Unsatisfactory esthetic outcome A
Loss of the osteotomized bone segment may occur following
avascular necrosis. Avascular necrosis usually occurs because of
loss of tissue attachment or infection. Loss of the segment may
require further alloplastic or bone graft reconstruction. A large
amount of bone resorption can be expected if a free bone graft
is used to augment the chin or if the soft tissue pedicle to the
mobilized chin segment is stripped excessively. Pedicled osseous
genioplasties usually undergo anterior bone resorption of about
10% to 20%. Infection most commonly is caused by avascular
necrosis, contamination, and wound breakdown. Displacement
of the alloplast may occur following trauma or inadequate sta-
bilization. This may require additional surgery to restabilize the
implant. Lower lip ptosis may be caused by inadequate posi-
tioning, resuspension, or stabilization of the mentalis muscle
and associated soft tissues. Normally, when relaxed, the lower
lip should be level with the lower incisor edges. Correction of B
lower lip ptosis requires repositioning and resuspension of the FIG 74-34 A and B, Vertical interdental osteotomies are per-
mentalis muscles. Anesthesia or paresthesia of the lower lip and formed with a connecting horizontal osteotomy. The horizontal
chin may result from trauma to the inferior alveolar and/or osteotomy should be positioned at least 5 mm below the apices
mental nerve branches from incision design, dissection, retrac- of the teeth to minimize the risk of dental devitalization.
tion, or direct injury when performing osteotomies. Nerve
injury may be avoided by careful incision placement, careful
dissection, minimal nerve retraction, and carefully planned
bone cuts. If nerve transection is directly visualized, immediate
repair is indicated. A relative contraindication is the necessity for multiple single-
Mandibular subapical procedures. These procedures are or two-tooth segments because of a high incidence of tooth and
designed to alter portions of the mandibular dental alveolus and bone loss.
can be divided into three types: anterior, posterior, and total If a tenon and mortise technique is used and the segment is
subapical osteotomies. to be moved posteriorly, base the tenon on the mobilized
Anterior mandibular subapical osteotomy. Osteotomy segment.28 When the segment is being moved forward, base
design involves vertical interdental osteotomies joined by a the tenon on the proximal mandibular segment. Bone screws,
horizontal osteotomy at least 5 mm below the apices of the interosseous wiring, or bone plates can be used to stabilize the
associated teeth (Figure 74-34). A horizontal vestibular incision bone segments. Soft tissue closure is achieved by suturing the
is used for access. The vascularity to the mobilized segment is muscle layer first to resuspend the lower lip and then a tight
maintained by the lingual soft tissue pedicle. Indications for mucosal closure.
anterior mandibular subapical osteotomy include leveling the Posterior mandibular subapical osteotomy. Posterior
occlusal plane, changing the AP position of the mandibular mandibular subapical osteotomy is a difficult procedure that
anterior teeth, correcting asymmetries, and changing the axial may result in a tenuous blood supply to the mobilized segment.
angulation of the mandibular anterior teeth. Usually the inferior alveolar neurovascular bundle is detached
Identify contraindications to these procedures before pre- from the segment so that the vascular supply is primarily from
surgical orthodontic treatment. Tooth roots too close together lingual periosteum and muscle. Morbidity to the inferior alveo-
at the interdental osteotomy site may cause root amputation, lar nerve is high. The procedure is technically more difficult in
ankylosis, periodontal defects, or loss of teeth and bone. Severe patients with high mandibular plane angles and decreased pos-
periodontal problems also may result from excessive removal of terior vertical mandibular height.
interdental bone. Major changes in vertical position may worsen Total mandibular subapical osteotomy. Total mandibular
pre-existing periodontal problems in area of vertical osteotomy. subapical osteotomy is also a technically difficult procedure, but
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
if performed below the inferior alveolar bundle, the mobilized
segment maintains a good blood supply. This procedure is com-
plicated by the fact that it most often is indicated in patients
with a low mandibular plane angle. The neurovascular bundle
sometimes must be dissected free of the mandible before per-
forming the osteotomy. The risk of inferior alveolar nerve
injury is high. Indications include a retruded dentoalveolus
with a strong chin and transverse discrepancies with an accen-
tuated curve of occlusion. Although few absolute contraindica-
tions exist, there are several relative contraindications and
precautions for this difficult procedure. Decreased anterior and
posterior mandibular height, for example, increases the techni-
cal difficulty of performing the osteotomy. When the dentoal-
veolus needs to be advanced considerably beyond the stable
chin point, there may be better treatment alternatives.
Age for surgery. Although no studies refer to the vertical
growth effects of interdental osteotomies, it is recommended
that surgery be performed in females after the age of 14 and
males after the age of 16.
Possible complications. Possible complications include the
loss of teeth and bone, periodontal defects, lower lip paresthesia/
anesthesia, and pathological fracture. Anesthesia or paresthesia
of the lip, teeth, and gingiva may result from trauma of the
inferior alveolar or mental neurovascular bundle. This usually
resolves in a few weeks to several months. If the neurological
deficit lasts longer than 1 year, the prognosis for recovery is
poor. If the nerve is severed, primary repair gives the best result.
Teeth and gingiva in subapical segments commonly exhibit an
extended period of anesthesia or paresthesia.
Mandibular ramus surgery. Mandibular sagittal split ramus
osteotomy is the most common mandibular orthognathic
procedure. This osteotomy technique originally was described
by Trauner and Obwegeser in 1957.29 The bilateral sagittal
split ramus osteotomy (BSSRO) can be used for mandibular
advancement or setback, control of the occlusion, and posi-
tion of the condyle. The technique has undergone numerous
modifications. The most recent modification maximizes bony
interface by splitting the mandible at the inferior border, pro-
viding controlled positioning of the proximal segment (Figure
74-35).20 Even with large advancements, bone grafting rarely
is required. Indications for sagittal split ramus osteotomies
include mandibular advancement, setback (Figures 74-36 and
74-37), and correction of mandibular asymmetries. Progna-
thic mandibular setback requires removal of bone from both
the proximal and distal segments, but is the authors’ preferred
choice of procedure. Contraindications include severe decreased
posterior mandibular body height, extremely thin medial-
lateral width of ramus, severe ramus hypoplasia, and severe
asymmetries.
The advantages are as follows:
• Healing is enhanced because of a good bony interface.
• The surgery can advance or set back the mandible, correct
most asymmetries, and alter the occlusal plane.
• Rigid fixation can be used, eliminating the need for maxil-
lomandibular fixation. Rigid fixation, when properly applied,
significantly improves the stability and predictability of
results. Bone plates with monocortical screws (see Figure
74-45) or bicortical bone screws can provide good stability.
• Modifications can maintain the angle of the mandible in the
original spatial position, even in large advancements.
• Major muscles of mastication remain in the original spatial
position.
1071
The disadvantages are as follows:
• The incidence of nerve damage is increased, although this is
usually temporary.
• Unfavorable splits may occur.
• Surgery must create a fracture on the lingual aspect of the
ramus.
• Severe asymmetries are difficult to correct.
Vertical oblique osteotomy (subcondylar osteotomy). Extra-
oral or intraoral approaches can be used for vertical oblique
osteotomy (Figure 74-38).
Indications. The following are indications for vertical
oblique osteotomy:
• Mandibular setback
• Small movements (unless temporalis, medial pterygoid, and
masseter muscles are detached from the distal segment)
• Asymmetries of mandible requiring setback
• Large movements that may require coronoidectomies
Stabilize segments with intraosseous wiring or rigid fixation
for the most predictable results. This procedure is designed to
allow the condyle and posterior border of the mandible to
remain essentially in their original positions (although there is
some rotation and torquing of the condylar head), while the
mandibular ramus and body are moved posteriorly. This pro-
cedure involves making a vertical cut from the sigmoid notch
to the angle of the mandible.
The contraindications are:
• Large setbacks (unless temporalis, medial pterygoid, and
masseter muscles are detached from the distal segment)
• Large advancements
• Lengthening of the ramus (unless temporalis, medial ptery-
goid, and masseter muscles are detached from the distal
segment)
The advantages are:
• Technically easy
• Correction of mandibular prognathism or asymmetries
The disadvantages are as follows:
• Unless segments are wired or rigidly stabilized, it may be
difficult to control the position of the condyle. Condylar sag
may result in anterior open bite postoperatively.
• Healing time may be increased because of poor bony inter-
face between segments.
• Rigid skeletal fixation (i.e., bone screws) is difficult to use
through an intraoral approach, so the procedure usually
requires 4 to 8 weeks of maxillomandibular fixation.
• The procedure may require relatively long-term interarch
elastics to control occlusion following removal of maxillo-
mandibular fixation because of increased healing time and
lack of condyle positional control.
Mandibular ramus inverted L osteotomy. Extraoral and
intraoral approaches are acceptable procedures for mandibu-
lar setbacks (Figure 74-39). Indications include small or large
setbacks, asymmetries, mandibular advancements, ramus
lengthening, presence of a thin ramus mediolaterally, and
severe decrease in posterior mandibular body height. Con-
traindications include abnormal posterior location of the
mandibular foramina and mandibular advancements without
grafting.
The advantages are as follows:
• Correct mandibular prognathism or asymmetries.
• Coronoid process and temporalis muscle remain in original
position.
• Mandible can be set back a great distance.
1072 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

D
FIG 74-35 A and B, Mandibular ramus sagittal split osteotomy is the most common technique
used for mandibular advancement. C, Rigid fixation significantly improves the stability and pre-
dictability of this technique. D, Demonstrated here is the Z-plate that can be used for mandibular
advancements and setbacks for reliable stability.

• Lengthens ramus or advances the mandible when used with
bone or synthetic bone grafting.
• Rigid skeletal fixation can be used.
The disadvantages are as follows:
• Requires bone or synthetic bone grafting for significant
ramus lengthening or mandibular advancement.
• Healing time may be increased compared with other tech-
niques because of poor approximation of the segments when
grafts are not used.
Effects on growth. Ramus procedures have no significant
effect on rate of growth, but alteration of the position and ori-
entation of the proximal segment can alter the vector of subse-
quent mandibular growth.
Age at surgery. Surgery can be performed predictably from
the age of 12 years and older. With the sagittal split osteotomy,
it is best to use the procedure after the second molars are
erupted so that they are not injured before eruption.
Mandibular Body Surgery
Mandibular body surgery can be divided into anterior body and
posterior body surgery. Anterior body surgery refers to osteoto-
mies anterior to the mental foramen, including the symphysis
area. Posterior body surgery involves osteotomies around and
adjacent to the mental foramen area or further posterior in the
body (Figure 74-40). Posterior body surgery requires specific
management of the inferior alveolar neurovascular bundle for
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A Medial Side
C
FIG 74-36 A, For mandibular prognathism, the sagittal split is
completed in a similar fashion as for mandibular advancements.
B, Bone from the proximal segment must be removed from the
anterior and superior aspects. C, The segments can be inter-
digitated and rigid fixation used to stabilize the segments.
its preservation. The basic indications for mandibular body
osteotomies are (1) occlusal plane leveling, (2) mandibular
setback, (3) removal of edentulous space or teeth and associated
bone, (4) narrowing or widening of the mandible, (5) lengthen-
ing of the mandible, and (6) distraction osteogenesis. Contra-
indications include adjacent roots that are too close together
and vascular compromise to adjacent soft tissue and bone.
Perform the osteotomies so that there will be maximum bony
interface following the repositioning of the segments. Signifi-
cant bony gaps may interfere with healing. Precise treatment
planning in the model surgery and the prediction tracing is
paramount for success in body osteotomies. Rigid fixation is
preferred for stabilization of the segments.
Effects on growth. Interdental osteotomies should not affect
vertical alveolar growth, unless a tooth root is injured, resulting
1073
Bone removed
Osteotomy
FIG 74-37 For mandibular prognathic patients, using the sagit-
tal split ramus technique, where it moves posteriorly along the
occlusal plane angle, the posterosuperior aspect of the distal
segment is moved superiorly and posteriorly creating bony
interference. This requires removal of bone above the medial
cut, and along the posterior aspect of the proximal segment,
posterior to where the vertical fracture occurs.
in dental ankylosis, which could result in deficient vertical
growth.
Age for surgery. This surgery is recommended after the age
of 14 in females and after age 16 in males.
Potential complications for mandibular body surgery
Nonunion or malunion. Nonunion or malunion usually
results from a poor bony interface, inaccurate position of the
bony segments, or inadequate stabilization of the segments.
Nonunion or malunion may necessitate additional surgery to
reposition and stabilize the segments with or without bone
grafting.
Loss of teeth and bone. The loss of teeth and bone may
occur because of vascular compromise, resulting in infection,
osteomyelitis, or avascular necrosis. Vascular insufficiency can
be devastating and may require hyperbaric oxygen treatment
and secondary procedures that restabilize or reconstruct the
bone segments.
Infections. Infection or osteomyelitis may require antibiot-
ics and débridement. Infection is rare unless there is major
damage done to the bone, teeth, and soft tissues during surgery.
Hyperbaric oxygen therapy may be required as well as second-
ary reconstruction.
Periodontal defects. Periodontal defects may occur as a
result of vascular compromise, inadvertent removal of the cer-
vical interdental bone, or major damage to the periodontal
tissues. Defects also may occur by creating tears or vertical inci-
sions in the osteotomy area.
Nerve damage. Anesthesia or paresthesia of the lower lip,
chin, and gums are the most common complications of man-
dibular body surgery. Generally, neurosensory deficit is tempo-
rary but can be permanent. Nerve damage usually is caused by
edema and manipulation of the neurovascular bundle. In an
anterior body ostectomy, where the anterior branch of the infe-
rior alveolar nerve is sacrificed, the anterior teeth and gingiva
may be numb for many months or permanently. If a major
inferior alveolar or mental nerve injury is encountered during
the surgery, immediate repair is indicated for the most predict-
able outcome.30-32
1074 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A A
B
FIG 74-38 A and B, The vertical oblique osteotomy of the
mandibular ramus can be used to set the mandible
posteriorly.
Simultaneous mandibular ramus and body procedures. Simul-
taneous ipsilateral mandibular body and ramus procedures can
be accomplished providing that the soft tissues are managed
appropriately. Maintaining the integrity of the inferior alveolar
neurovascular bundle, particularly in posterior segments, is
important. Careful management and protection of the lingual
tissues is also vital. When mandibular sagittal split ramus oste-
otomies are performed concomitant with mandibular body
procedures, it is generally recommended to complete the sagit-
tal split procedure before the body osteotomies. If the body
osteotomies are performed first, even with rigid fixation, the
prying forces necessary to complete the sagittal split may dis-
place the body segments. If vertical oblique or inverted L oste-
otomies are performed along with body osteotomies, either
procedure may be completed first. Once the ramus and body
osteotomies are completed, the occlusal splint can be used to
B
FIG 74-39 A and B, The inverted L osteotomy can be used to
set the mandible posteriorly. A greater distance can be achieved
than by the vertical oblique osteotomy. It also allows vertical
lengthening or shortening of the ramus without affecting the
major muscles of mastication.
align the segments appropriately for stabilization, preferably by
rigid fixation. The body osteotomies are stabilized with rigid
fixation first followed by the ramus rigid fixation.
Maxillary Procedures
Maxillary deformities can occur in all three planes of space
(AP, vertical, and transverse). Surgical procedures are custom
designed for each patient. The maxilla can be repositioned
superiorly, inferiorly, anteriorly, posteriorly, or transversely and
in one or more segments, depending on the nature of the defor-
mity. Segmentalization of the maxilla permits the arch to be
widened, narrowed, leveled, or the arch symmetry improved.
Basic maxillary Le Fort I surgical designs. There are four
basic maxillary Le Fort I surgical designs available. The oste-
otomies can be completed with a tapered fissure bur or a
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A
B B
FIG 74-40 A and B, Mandibular body osteotomies can be per-
formed in any area of the mandible to move the anterior
segment of the mandible posteriorly or to alter the vertical and
transverse position. Combining body osteotomies and sagittal
splits of the ramus allows flexibility and movement of the pos-
terior and anterior segments independent of each other. Rigid
fixation improves the stability and facilitates healing.
reciprocating saw. Preservation of the descending palatine
vessels is important because approximately 80% of blood flow
to the maxilla normally comes from these vessels.33-36 Some
surgeons, however, routinely place a vascular clip on the vessels
or coagulate these vessels. Some studies have shown that pulpal
blood flow is not altered compared with preservation of the
vessels. Circumvestibular incision is usually adequate, even with
segmentalization. However, pedicle flaps may be necessary in
patients with compromised vascularity to the maxilla (i.e.,
reoperated maxilla, cleft deformity, or small dento-osseous
segments). The basic maxillary osteotomy procedures are
detailed next.
Traditional Le Fort I osteotomy. The traditional Le Fort I
osteotomy is made with a straight-line cut from the piriform
rim area (4 to 5 mm above apices of teeth) to the pterygoid plate
area. Surgical separation is completed at the pterygoid plate/
tuberosity area, lateral nasal walls, and septum/vomer area. Be
aware of the ramping effect of this osteotomy design, particu-
larly with maxillary advancement or setback. The ramping
effect occurs because of the horizontal osteotomy is not parallel
to the Frankfort horizontal plane (Figure 74-41).
Maxillary step osteotomy. Make horizontal cuts parallel to
the Frankfort horizontal plane (4 to 5 mm above the canine
1075
A
45
41
FIG 74-41 A and B, A retruded maxilla undergoing a Le Fort I
osteotomy for advancement. The traditional Le Fort I gener-
ally angles the osteotomy from a higher position anteriorly
to a lower point posteriorly in the zygomatic buttress area.
This creates a slope along the lateral maxillary wall. As the
maxilla is advanced forward, it also moves superiorly along the
bony ramp.
apex) from piriform rim to zygomatic buttress. In the buttress
region, make a vertical step (usually 5 to 8 mm in length) and
continue the horizontal osteotomy posteriorly at a lower level
to the pterygoid plates, usually parallel to the Frankfort hori-
zontal plane.29 This design permits straight forward or back-
ward movement of the maxilla and eliminates the ramping
effect. The maxillary step provides an additional area for graft-
ing with bone or synthetic bone if indicated. The maxillary step
provides an AP reference point to help facilitate repositioning
of the maxilla (Figure 74-42).
High Le Fort I osteotomy. Anterior maxillary osteotomies
are made close to the infraorbital rim, carefully preserving the
infraorbital nerve. Direct this osteotomy posteriorly at the but-
tress area at a lower level. Complete the osteotomy as described
for the traditional Le Fort I osteotomy.
Maxillary horseshoe osteotomy. The maxillary horseshoe
osteotomy is designed to keep the horizontal palatal shelf
attached to the nasal septum and lateral nasal walls while mobi-
lizing the maxillary dentoalveolus (Figure 74-43).36 For superior
movements, telescope the dentoalveolus over the stable palatal
bone, maintaining the nasal airway dimensions. This technique
may be used in select cases of vertical maxillary excess. Because
the vomer and septum remain attached to the palate, this
technique may enable maxillary osteotomies to be performed
1076 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
B dentoalveolus.
FIG 74-42 A, The maxillary step osteotomy allows straightfor-
ward or posterior movement of the maxilla. The horizontal cuts
are made parallel to the Frankfort horizontal plane. B, If the
maxilla is advanced significantly, then it is necessary to graft
with bone or synthetic bone along the horizontal osteotomy, at
the maxillary step, and in larger advancements between the
tuberosity and the pterygoid plates.
without an adverse effect on maxillary growth, unlike the other
osteotomy designs.
Segmentalization of the maxilla. Segmentalization of the
maxilla has several advantages over one-piece Le Fort I
osteotomies:
• Correction of transverse excesses or deficiencies
• Correction of asymmetry (i.e., one cuspid is more anterior
than the opposite cuspid and is corrected by advancing one
side more than the other side)
• Correction of transverse vertical deformities
A B
C D
FIG 74-43 A to D, The maxillary horseshoe technique maintains
the attachment of the palatal bone to the septum and
lateral nasal walls but mobilizes the remaining maxillary
• Correction of accentuated or reverse curves of occlusion
• Elimination or creation of spacing within the arch
Segmentalization of the maxilla includes one or more inter-
dental osteotomies coupled with midline or parasagittal oste-
otomies of the palate to permit repositioning of the maxilla in
two or more segments. Orthodontic preparation should diverge
the roots adjacent to the predetermined interdental osteotomy
sites. Careful interdental vertical cuts should correlate with the
model surgery and STO. One can make palatal cuts with a bur,
saw, or osteotome, being careful to protect the integrity of the
palatal mucosa. With a circumvestibular incision, the blood
flow to the anterior maxillary segment is primarily from the
palatal mucosa. Tears or injuries to the palatal mucoperiosteum
may lead to oronasal fistula, periodontal defects, or avascular
necrosis of the anterior segments. Preserve interdental bone
around the necks of teeth and over roots. Some surgeons prefer
a four-piece maxilla where parasagittal osteotomies are made
on the palate where the palate becomes a separate, fourth maxil-
lary segment. For three-piece or four-piece maxillary surgery,
interdental cuts between the lateral incisor and canine fre-
quently are more advantageous than cuts between the canine
and first premolar, because they allow for the following:
• Control of incisor angulation
• Ability to level the occlusion
• Expansion or constriction of the posterior maxilla from the
canines through the molars
• Adjustment for tooth size discrepancies in the anterior
arch by creating space between the lateral incisors and
canines (Elimination of this spacing may require dental
restorations.)
Stabilization
Rigid fixation. Rigid fixation for maxillary surgery implies
the use of bone plates. Ideally, one should use a minimum of
four bone plates. Each side should have a plate in the piriform
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
rim area and one plate in the zygomatic buttress area. For
each plate, place a minimum of two bone screws above the
osteotomy and two screws below it. The bone plates must be
adapted so that they are positioned passively against the bone
so that when the bone screws are inserted and tightened, the
maxilla will not be displaced. Surgery must be more precise and
exacting with use of rigid fixation than with other fixation
techniques. Rigid fixation offers more stability and enhanced
healing compared to interosseous wiring or suspension wiring
techniques.37
Surgical stabilizing appliance (splint). Surgical stabilizing
appliances may assist in repositioning and stabilizing the jaws
or segments thereof. Use an intermediate splint to reposition
and rigidly stabilize one of the jaws so that it then can be used
as a reference to reposition the other jaw (Figure 74-44). A final
splint ensures proper repositioning of the jaws or segments in
relation to each other. The final splint also may prevent trans-
verse maxillary relapse. Construct an occlusal splint on properly
positioned dental models to fit between the occlusal surfaces of
the upper and lower teeth. The splint may be secured to either
jaw by wire fixation. Design a palatal splint (see Figures 74-18
and 74-19) to help stabilize maxillary segments, and fit it along
the palatal aspects of the crowns, but do not cover the occlusal
surfaces. Relieve the palatal soft tissues in the splint construc-
tion so that no impingement occurs on the palatal tissues that
A
B
FIG 74-44 A and B, An intermediate splint is made on dental
models and is used to reposition one jaw into a predetermined
position in relation to the stable jaw. Demonstrated here is the
intermediate splint used to reposition the mandible, which will
be rigidly stabilized and followed by maxillary repositioning.
1077
could compromise the blood flow to the maxillary segments.
Design a lingual splint similarly to stabilize a segmented
mandible.
Bone or synthetic bone grafting. Bone or synthetic bone
grafting frequently is required to fill bony defects, improve sur-
gical stability, and enhance healing, especially with large move-
ment (above 5 mm).
Autogenous bone. Local autogenous bone for grafting is
commonly available from the mandible. In double jaw surgery,
following the sagittal split osteotomy, bone is usually available
on the medial side of the mandibular angle where the medial
fracture occurs. There is usually lingual cortex available that can
be cautiously cut with a thin reciprocating saw blade, being
careful not to cut the angle off, just the lingual cortex. In addi-
tion, in concomitant total joint prostheses, the excised condylar
head and neck can be used to graft the maxillary defects as well
as harvested cornoid processes. Distant harvest sites including
iliac crest, tibia, fibula, cranial bone, rib, and so on, can provide
good quality bone for grafting. These grafts obviously require
a second surgery site. The healing process may be longer for
autogenous bone grafts than for porous block hydroxyapatite.
Autogenous grafts are preferred by the authors, but they are
more difficult to contour than porous block hydroxyapatite.
Porous block hydroxyapatite. Porous block hydroxyapatite
is a bone graft substitute used in orthognathic surgery (Figure
74-45).38-42 With this material, bone and soft tissue growth
occurs through the pores and is complete by 3 to 4 months, with
bone maturation occurring after that (Figure 74-46). Porous
block hydroxyapatite is easier to work with and stabilize than
bone, but it is brittle and must be stress shielded (it requires
four bone plates for maxillary stabilization) during its initial
healing phase. This material causes no adjacent bone resorption
and rarely becomes infected, even when exposed to the maxil-
lary sinus. The material does not resorb. If exposed to the oral
or nasal cavity, porous block hydroxyapatite most likely will
become infected and require removal. However, with careful
management of the soft tissues, this risk is minimal.
Effects on growth. Le Fort I osteotomies for the normal
growing maxilla or the deficient growing maxilla effectively
eliminates further AP growth, although vertical alveolar growth
remains essentially unchanged.43-47 With a normal, growing
FIG 74-45 Porous block hydroxyapatite is a bone graft substi-
tute with pores ranging from 190 to 230 µm. It is composed of
pure hydroxyapatite.
1078 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
FIG 74-46 Histological assessment of a porous block hydroxy-
apatite graft 8 months after surgery demonstrates good bony
ingrowth without evidence of inflammation.
mandible, a Class III occlusion may develop. Although patients
with vertical maxillary hyperplasia also have the AP component
of growth affected, the vertical alveolar growth continues at the
same excessive growth rate as pre-surgery, thus usually main-
taining a stable occlusal relationship, but with a downward and
backward jaw growth vector. Patients with cleft palates includ-
ing alveolar clefts may have deficient growth effects in all three
planes of space.
The maxillary horseshoe technique (see Figure 74-43), or
maxillary dentoalveolar osteotomy, keeps the palatal bone
attached to the septum and lateral nasal walls. This technique
demonstrates good maxillary growth post-surgically in patients
with vertical maxillary hyperplasia.44 AP growth and horizontal
and vertical growth may be maintained.
Age for surgery. Patients with normal or deficient growth of
the maxilla should be deferred for surgery until maxillary
growth is essentially complete, which is generally 15 years old
for females and 17 to 18 years old for males. Operating before
completion of growth may result in the development of a
Class III occlusal tendency. Patients with vertical maxillary
hyperplasia can be operated on earlier, around 13 years for
females and 14 to 15 years for males, with the understanding
that subsequent growth will be downward and backward
because the vertical alveolar bone growth will continue at the
pre-surgical rate.43-47
Ancillary procedures in maxillary surgery. A number of addi-
tional procedures can be carried out to enhance the quality
of results with maxillary surgery. These procedures can have
esthetic and functional effects.
Alar base cinch suture. The intra-alar base width almost
always increases when maxillary surgery is performed (Figure
74-47). The reasons for this are as follows:
• The soft tissues, particularly the periosteum and muscula-
ture, are detached from the lateral walls of the maxilla in the
perinasal area.
• Superior or anterior movements of the osseous structures in
the piriform area cause widening of the alar base because
of the increased prominence of the supportive skeletal
structures.
• The tissue edema that normally occurs with maxillary
surgery causes the alar base width to increase.
A B
FIG 74-47 The alar base cinch suture is placed intraorally
through the fibroadipose tissue of the alar base on one side (A),
in a figure-eight fashion through the opposite side (B), and is
secured. This controls the transverse width of the alar bases.
Therefore, an alar base cinch suture usually is indicated in
maxillary surgery to help ensure a more refined and esthetic
result. The use of the alar base cinch suture significantly
improves the controllability of the width of the alar bases.48
Perform the alar base cinch suture following maxillary stabiliza-
tion and before closure of the incision. Place the suture intra-
orally with a large curved needle. Pass the needle through
adjacent soft tissue of the alar base and direct it upward to
catch the fibroadipose tissue at the alar base. Pass the needle
from the lateral to the medial direction. Perform the procedure
on the opposite alar base, again approaching from a lateral to
medial direction, resulting in a figure-eight pattern. Then
tighten the suture until the desired width of the alar base is
achieved. The suture material of choice is 2-0 polydioxanone
sutures. The alar base cinch suture controls the alar base width,
improves nasal tip projection, decreases nasolabial angle promi-
nence, decreases lip shortening, and helps maintain the AP
thickness of the upper lip, particularly at the superior portion
of the upper lip.
V-Y closure. A V-Y closure of the circumvestibular incision
also can assist in the esthetic improvement of the upper lip
(Figure 74-48). Perform a predetermined amount of vertical
closure before closing the horizontal aspect of the incision. A
4-0 chromic suture usually is preferred for this closure. The alar
base cinch suture and V-Y closure help to minimize lip shorten-
ing, maintain lip thickness, improve the amount of vermilion
exposed, and support the upper lip tubercle.
Septoplasty. Once the maxilla has been mobilized and
down-fractured, direct access to the nasal septum is obtained
easily. One can approach the entire septum, including the car-
tilaginous portion, vomer, and perpendicular plate of the
ethmoid bone. Carefully dissect the perichondrium and perios-
teum off the septum to expose the underlying septal bone and
cartilage (Figure 74-49). Treat the septum by removing, cutting,
or repositioning the involved bone and cartilage. Low-tension
transseptal suturing may reapproximate the septal mucosa and
help avoid the development of a septal hematoma. Indications
for septoplasty include (1) correction of nasal airway obstruc-
tion created by a deviated nasal septum, (2) correction of a
deviated septum that is causing an esthetic concern, (3) removal
of bone spurs, or (4) prevention of post-surgical deviation of
the septum when the maxilla is being advanced or moved
superiorly.
Inferior turbinoplasty or turbinectomy. Nasal airway
obstruction is common in patients with maxillary deformities,
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
FIG 74-48 V-Y closure of the maxillary vestibular incision helps
to maintain the thickness and length of the upper lip and the
amount of vermilion exposed.
FIG 74-49 The mucoperiosteum and perichondrium have been
reflected from the nasal septum, revealing a large septal spur
on the left side. This structure can be removed and any septal
deviations corrected by incising, excising, and/or removing por-
tions of the septal bone and cartilage.
particularly those with high occlusal plane facial morphology
with retruded maxilla and mandible. The nasal airway obstruc-
tion may be due to large inferior turbinates. Approximately 80%
of functional nasal airway occurs from the top of the inferior
turbinate to the nasal floor. Enlargement of the turbinates can
be absolute or relative. Absolute enlargement means that the
1079
FIG 74-50 An incision is made through the mucoperiosteum of
the nasal floor to expose the turbinate from the anterior aspect
to its posterior extent. This approach is performed unilaterally
or bilaterally, depending on where the nasal airway obstruction
is occurring in reference to the turbinates.
bone or soft tissue of the turbinates is larger than normal,
causing an obstruction. Relative enlargement means that
normal-sized turbinates cause obstruction because of the
decreased transverse width of the nasal cavity. This is more
evident in patients with high occlusal plane facial morphology
in which the transverse width of the functional nasal cavity is
frequently less than normal.49 In addition, patients requiring
maxillary superior repositioning procedures have a further
decreased functional airway available as the nasal floor is moved
upward and the inferior turbinates may create a physical obsta-
cle preventing the maxilla from being moved upward, thus
increasing the need for turbinectomies in order to maintain a
functional nasal airway and allow upward repositioning of the
maxilla. Indications for removing a portion of the inferior tur-
binates include nasal airway obstruction created by the turbi-
nates, hypertrophy of the bone or soft tissue components of the
turbinates, and superior repositioning of the maxilla such that
additional space is required to move the maxilla upward or to
maintain a good functional nasal airway.
Approach the turbinates following down-fracture of the
maxilla. Make an incision through the mucoperiosteum of the
nasal floor, exposing the turbinate from its anterior aspect to its
posterior extent (Figure 74-50). Perform a partial turbinectomy
by direct excision of bone and mucosa (Figure 74-51). Hemo-
stasis is achieved by electrocautery. Then close the nasal floor
mucoperiosteum with 4-0 chromic suture. Perform the same
procedure bilaterally.
Third molar removal. Removal of third molars may be
indicated in orthognathic cases for any of the following reasons:
• Impacted tooth
• Inadequate space within the arch for the tooth to erupt and
be a functional tooth
• Malalignment of the third molar creating lack of function
• Associated pathological condition with the tooth
• Recurrent pericoronitis
• Location within the osteotomy site that may render struc-
tural weakness within the jaw component
The timing for removal of third molars in relation to orthog-
nathic surgery may be important. Maxillary third molars,
1080 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
FIG 74-51 Partial turbinectomies are performed, removing the
inferior portion.
whether they are impacted or erupted, can be taken out at the
same time as the orthognathic surgery or be removed a
minimum of 9 months to 1 year before the surgery. If removed
before surgery, it will take 9 to 12 months for the socket area to
heal adequately. Orthognathic surgery within 6 months of
extraction may result in an unfavorable fracture through the
tuberosity, resulting in mobilization of the anterior aspect of
the maxilla but with the posterior tuberosity area remaining
attached to the pterygoid plates and to the palatine bone. This
may cause extreme difficulty in mobilizing and repositioning
the maxilla. When removed at the time of surgery, the third
molars are extracted most easily following the down-fracture
and mobilization of the maxilla. This helps prevent aberrant
fracturing through the tuberosity area.
Special Considerations
To obtain the optimal functional and esthetic results, it is fre-
quently necessary to perform double jaw surgery. Appropriate
treatment planning and sequencing of the various procedures
are necessary to achieve optimal outcomes. The options in
sequencing of double jaw surgery are repositioning the maxilla
first or the mandible first.
Repositioning the Mandible First
Repositioning the mandible first in most cases provides overall
improved predictability of the final esthetic outcome.18 The
sequencing when the mandible is repositioned first is as follows:
1. Completion of mandibular sagittal split osteotomies, repo-
sitioning with intermediate splint, application of intermaxil-
lary fixation, and application of rigid fixation
2. Completion of maxillary osteotomies and mobilization
3. Intranasal procedures, such as turbinectomies and nasal
septoplasty
4. Application of the final splint, maxillomandibular fixation,
rigid fixation to the maxilla, and appropriate bone grafting,
if indicated, with bone or porous block hydroxyapatite;
release maxillomandibular fixation and check occlusion
5. Other procedures (i.e., genioplasty, facial augmentation, or
rhinoplasty)
This sequencing technique works particularly well when the
occlusal plane angle is to be decreased and the mandible is to
be rotated in a counterclockwise direction. An intermediate
splint is necessary and is made from the models where the
mandible has been repositioned accurately with the maxilla
remaining in its original place. The AP and vertical position of
the mandible being repositioned in the model surgery is deter-
mined from the prediction tracing and clinical assessment.
Complete the mandibular surgery using an intermediate splint
for repositioning and then apply rigid fixation. Then reposition
the maxillary model to occlude and function with the mandible.
Apply the final palatal splint. Place the maxilla into the best
functional occlusal relationship with the mandible and apply
intermaxillary fixation along with rigid fixation and bone graft-
ing if indicated. A palatal splint is the authors’ preferred method
of stabilizing an expanded maxilla because the splint can be
kept in position for several months if necessary to maximize the
transverse stability.
Repositioning the Maxilla First
When the maxilla is repositioned first, consider the forces that
may be placed on the repositioned maxilla by whatever indi-
cated procedures are necessary in the mandible. The recom-
mended treatment sequence is as follows:
1. Perform mandibular ramus sagittal split osteotomies but do
not complete the splits.
2. Perform maxillary osteotomies, segment if indicated, and
mobilize.
3. Complete intranasal procedures if indicated (e.g., turbinec-
tomies and nasal septoplasty).
4. Apply maxillary splint, maxillomandibular fixation, rigid
fixation, and grafting as necessary with bone or porous block
hydroxyapatite.
5. Complete mandibular sagittal split osteotomies, place into a
maximal occlusal fit (use a final splint if surgeon prefers),
and apply maxillomandibular fixation and rigid fixation.
Release maxillomandibular fixation and check occlusion.
6. Perform other indicated procedures (i.e., genioplasties, facial
augmentation, rhinoplasty).
In performing the sagittal split osteotomies on the mandible,
a bite block is generally necessary in order to perform the
medial osteotomy cuts, and much of the prying and forces may
have to be placed on the mandible to separate the segments.
During instrumentation, forces can be placed inadvertently on
the maxilla, displacing it from its original position. Usually the
best procedure is to perform all of the surgical cuts for the
mandibular ramus sagittal split osteotomy except for the final
splitting of the mandible. This way, most of the force that may
displace the maxilla is completed and the mandible can be used
as a reference to reposition the maxilla.
If appropriate and accurate model surgery is performed, the
maxilla can be repositioned anteroposteriorly, transversely, and
vertically using the mandible as the base reference. Use bone
plates in double jaw surgery because of increased stability
requirements. If a one-piece maxilla is planned, then construct
a monoblock type of splint from the model surgery to position
the maxilla at surgery. If segmentalization of the maxilla is
planned, make a final splint along with an intermediate splint
to articulate with the lower teeth and undersurface of the final
splint. Reposition the mandible into its final position to con-
struct the final splint. Then using a second mounted mandibu-
lar model, make an intermediate splint to interdigitate between
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
the lower teeth and the lower occlusal imprint of the final splint.
Following repositioning of the maxilla, complete the sagittal
splits and set the mandible into its final position and apply
appropriate stabilization. Mandibular segmental or body oste-
otomies, if indicated, generally are performed after the sagittal
splits are complete. Then the chin and other procedures can be
performed.
Occlusal Plane Alteration
The correction of dentofacial deformities often requires double
jaw surgery to achieve a quality functional and esthetic result.
An often ignored but important cephalometric and clinical
interrelationship in the diagnosis and treatment planning for
the correction of dentofacial deformities is the occlusal plane
angulation.50-54 The occlusal plane angle is formed by the Frank-
fort horizontal plane 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 degrees. An increased (high)
occlusal plane angle usually is reflected in an increased man-
dibular plane angle (dolichocephaly), and a decreased (low)
occlusal plane angle usually correlates with a decreased man-
dibular plane angle (brachycephaly).
Traditional management in double jaw surgery, regardless of
the steepness of the pre-surgical occlusal plane, manages the
occlusal plane angle in one of the following manners: (1) main-
tains the pre-surgical occlusal plane angulation, (2) establishes
the occlusal plane angle by autorotation of the mandible
(usually in an upward and forward direction), or (3) selectively
increases the occlusal plane relative to Frankfort horizontal
plane to “improve stability.” Although these methods may
achieve an acceptable relationship of the teeth in centric rela-
tion, they commonly do not provide the optimal functional and
esthetic relationship of the musculoskeletal structures and the
dentition. As the occlusal plane angle increases in steepness
(high occlusal plane angle) and begins to approach the slope of
the TMJ articular eminence, certain functional problems can
develop, including the following:
• Loss of canine rise occlusion
• Loss of incisal guidance
• Development of working and nonworking posterior dental
functional interferences
If the clinician believes in the protected occlusion philoso-
phy, there may be concern over the application of the traditional
treatment modalities of increasing the angulation of the occlu-
sal plane in certain types of cases.
Morphological facial types. Two facial types that may
benefit for occlusal plane alteration are the low occlusal plane
brachycephalic type and the high occlusal plane dolichoce-
phalic type.
Low occlusal plane facial type. The patient with a low occlu-
sal plane facial type may require an increase in occlusal plane
angulation. Some of the basic clinical and radiographic charac-
teristics of the low occlusal plane facial type include the
following:
• Decreased occlusal plane angulation (occlusal plane less than
4 degrees)
• Low mandibular plane angulation
• Prominent mandibular gonial angles
• Strong chin in relation to the mandibular alveolus (AP
macrogenia)
• Most often Class II malocclusion, although Class I or Class
III also occur
1081
8°
0°
FIG 74-52 Surgical increase of the occlusal plane rotates the
chin posteriorly in relation to the incisor tips, the perinasal areas
advance, the posterior facial height decreases, the maxillary
incisor angulation decreases, and the mandibular incisor angula-
tion increases.
• Often an accentuated curve of Spee in the mandibular arch
and sometimes a reversed curve in the maxillary arch
• Anterior deep bite
• Decreased angulation of the maxillary incisors as in the Class
II, division 2 malocclusion, but overangulated incisors also
are possible
• Decreased angulation of the mandibular incisors
Surgical increase of the occlusal plane. Patients demonstrat-
ing the low occlusal plane facial type may benefit functionally
and esthetically by increasing the occlusal plane angle with a
clockwise rotation of the maxillomandibular complex to fall
within the normal range (8 ±4 degrees). To illustrate the specific
changes associated with a clockwise rotation of the jaws, a case
with a Class I occlusion is used, and the maxillary central incisor
edge functions as the center of rotation (Figure 74-52). The
following changes occur:
• Occlusal plane angle increases.
• Mandibular plane angle increases.
• Chin rotates posteriorly.
• Posterior facial height decreases.
• Perinasal bone structures advance.
• Maxillary incisor angulation decreases.
• Mandibular incisor angulation increases.
Clockwise rotations have become one of the most acceptable
methods for treating patients and should provide adequate sta-
bility because all of the muscles of mastication remain basically
the same length or shortened. The center of rotation of the
maxillomandibular complex effects the esthetic change. If the
point of rotation is at the incisor tips, then the perinasal area
advances and the chin rotates posteriorly. If the point of rota-
tion is at point A, then the perinasal area is not affected as
significantly, but the upper incisor edge and the inferior aspect
of the upper lip rotate posteriorly and the chin rotates even
further posteriorly. Pure vertical or AP movements (without
rotation) do not affect the occlusal plane angulation or incisor
1082 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
angulation. These movements, however, have an influence on
lip function and esthetics.
The surgical approach to increase the occlusal plane com-
pared with decreasing the occlusal plane may vary in sequenc-
ing of maxillary and mandibular osteotomies during surgery.
Accurate pre-surgical prediction tracings and accurate model
surgery simplify the surgery and enhance the accuracy and sta-
bility of the treatment outcome. With the low occlusal plane
facial type, most surgeons may find it easier to reposition the
maxilla first with rigid fixation, creating a posterior open bite
that can be set up with an intermediate splint (made from
accurate model surgery). The mandible then is moved into
proper alignment with the maxilla by using ramus osteotomies
(preferably sagittal split osteotomies). Usually, bone must be
removed from the medial aspect of the proximal segment,
directly above the level of the medial horizontal cut. This bone
is consistently an area of interference if it is not removed. The
use of rigid fixation eliminates the need for intermaxillary fixa-
tion after surgery and is most helpful in achieving a predictable
outcome when properly applied. One must take care not to
overload the TMJs.
High occlusal plane facial type. The characteristics of the
high occlusal plane facial type generally include the following:
• Increased occlusal plane angulation (occlusal plane greater
than 12 degrees)
• Increased mandibular plane angulation
• Anterior vertical maxillary hyperplasia and/or posterior ver-
tical maxillary hypoplasia
• Increased vertical height of the anterior mandible and/or
decreased vertical height of the posterior mandible
• Decreased projection of the chin (AP microgenia)
• AP and vertical posterior mandibular and maxillary
hypoplasia
• Decreased angulation of maxillary incisors, although overan-
gulation can occur
• Increased angulation of mandibular incisors
• Class II malocclusion is common, although Class I and Class
III malocclusions also can occur
• An anterior open bite may be accompanied by an accentu-
ated curve of Spee in the upper arch
• In more pronounced cases in which the occlusal plane
approaches the slope of the articular eminence, the following
may occur: loss of incisal guidance, loss of canine rise occlu-
sion, and the presence of working and nonworking dental
interferences in the molar areas
• The more severe cases may demonstrate moderate to severe
sleep apnea symptoms as a result of the tongue base dis-
placed posteriorly and constricting the oropharyngeal airway
(normal oropharyngeal airway space is 11 ±2 mm)
Surgical decrease of the occlusal plane. In the high occlusal
plane facial type, the indicated surgical correction may include
a counterclockwise rotation of the maxillomandibular complex.
In open bite cases or deep bite cases, the maxillary occlusal
plane and the mandibular occlusal plane may be different and
each should be evaluated independently. For illustrative pur-
poses, a Class I case is used with the maxillary incisor edge as
the center of rotation (Figure 74-53). The anatomical changes
that occur include the following:
• Occlusal plane angle decreases.
• Mandibular plane angle decreases.
• Maxillary incisor angulation increases (the same amount
that the maxillary occlusal plane decreases).
16°
8°
FIG 74-53 Surgical decrease of the occlusal plane rotates the
chin forward, decreases prominence of the perinasal areas,
maxillary incisor angulation increases, mandibular incisor angu-
lation decreases, and the oropharyngeal airway increases.
• Mandibular incisor angulation decreases (the same amount
that the mandibular occlusal plane decreases).
• Projection of the chin increases relative to the lower incisor
edges.
• Posterior facial height may increase.
• Prominence of the mandibular angles may increase.
• Perinasal area moves posteriorly in relation to the maxillary
incisor edges.
• Incisal guidance and canine rise occlusion improves, and
posterior working and nonworking interferences are
eliminated.
• Oropharyngeal airway increases.
The center of rotation affects the esthetic relationship of the
jaws with the other facial structures. If the center of rotation is
at the maxillary incisor edge, as in Figure 74-54, the perinasal
area, subnasale area, and the nasal tip move posteriorly and the
chin comes forward. If rotation is around point A or higher,
then the perinasal area and the nose are less affected, but the
maxillary incisor edges come forward, increasing the AP support
to the upper lip. The chin also comes further forward. When
decreasing the occlusal plane angle and advancing the mandi-
ble, the oropharyngeal airway increases approximately 50% of
the advancement measured at the genial tubercles. Figure 74-54
demonstrates the significant esthetic difference that the altera-
tion of the occlusal plane can make.50-54 Evaluation of the status
of the TMJ before surgery is important, particularly when one
is decreasing the occlusal plane angulation. The movement
associated with decrease of the occlusal plane increases pressure
in the joints until the muscles, soft tissues, and dento-osseous
structures have a chance to equilibrate. If the joints are healthy
and stable, they should be able to withstand the increased
loading through the adaptation phase. Conversely, carefully
assess and appropriately manage patients with pre-existing TMJ
disorder so that the joints will be stable when the surgery is
performed.
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
16°
8°
0°
FIG 74-54 With the fulcrum of rotation located at the incision
tips, the changes created by increasing the occlusal plane or
decreasing the occlusal plane can be appreciated. Of course,
anteroposterior (AP), vertical, and transverse movements are
also usually involved to obtain the ideal functional and esthetic
outcomes.
When the occlusal plane angle is decreased, it is usually easier
first to set the mandible into its new position, creating a poste-
rior open bite. An intermediate splint helps align the mandible
in its new position, and then rigid fixation is applied to the
mandible. Usually a four- or six-hole Z-plate with 2-mm–
diameter monocortical screws provides adequate stability for
mandibular setbacks and for most mandibular advancements
(see Figure 74-35). However, for large advancements, one or
two bone screws can be placed in the ascending ramus for
additional stability. This makes the maxillary surgery much
easier to perform with better positional accuracy. Stabilization
of the maxilla is achieved with four bone plates and bone or
porous block hydroxyapatite grafting to fill any osseous defects.
In some cases, the vertical height of the ramus may be increased.
However, because most of the cases requiring this type of move-
ment are skeletal and occlusal Class II malocclusions, the distal
segment moves inferiorly but anteriorly to the pterygoid-
masseteric sling. In Class III skeletal and occlusal relations
because the ramus portion of the distal segment must move
down through the sling (which can occur in Class III facial types
with high occlusal and mandibular angles), the pterygoid-
masseteric sling can be split to allow the posteroinferior aspect
of the distal segment to rotate down through the sling. The bone
eventually remodels back up to the height of the sling. Rigid
fixation eliminates the requirement for post-surgery maxillo-
mandibular fixation, and usually light guiding elastics are all
that are necessary to control the occlusion after surgery.
Tongue Assessment
An enlarged tongue can cause dentoskeletal deformities and
instability of orthodontics and orthognathic surgical treatment
and can create masticatory, speech, and airway management
problems. Understanding the signs and symptoms of macro-
glossia helps identify those patients who can benefit from
1083
A B
C
FIG 74-55 The keyhole procedure is the most common tech-
nique used for reduction glossectomy. A, Midline elliptical
and anterior wedge resection outlined. B, Tissue removed.
C, Midline closure.
reduction glossectomy (surgical reduction of the tongue size)
to improve function, esthetics, and treatment stability. A
number of congenital and acquired causes of true macroglossia
exist, including the following:
• Muscular hypertrophy
• Glandular hyperplasia
• Hemangioma
• Lymphangioma
Macroglossia occurs commonly in conditions such as
Down syndrome and Beckwith-Wiedemann syndrome.
Acquired factors may include acromegalia, myxedema, amyloi-
dosis, tertiary syphilis, cysts or tumors, and neurological injury.55
Specific clinical and cephalometric features may help the clini-
cian identify the presence or absence of macroglossia. Not all
these features are always present, and their existence is not
necessarily pathognomonic for the diagnosis of macroglossia.
The clinical features and the radiographic features are listed at
the end of the section. Most open bites are not related to mac-
roglossia. In fact, it has been established that closing open bites
with orthognathic surgery allows a normal tongue, which is an
adaptable organ, to readjust to the altered volume of the oral
cavity, with little tendency toward relapse.56,57
If true macroglossia is present with the open bite, then
instability of the orthodontics and orthognathic surgery are
likely to occur, with a tendency for the open bite to return.
Pseudo macroglossia is a condition in which the tongue may
be normal in size, but it appears large in relation to its ana-
tomical interrelationships, such as maxillary and mandibular
hypoplasia.
Patients with true macroglossia may be candidates for reduc-
tion glossectomy. The most common technique used is the
keyhole or midline elliptical excision and anterior wedge resec-
tion. The tongue flaps then are sutured back together in a
straight line (Figure 74-55). In the presence of musculoskeletal
1084 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
deformity with a malocclusion and true macroglossia, there are
basically three choices on surgical sequencing:
• Stage 1: Reduction glossectomy; stage 2: Orthognathic
surgery
• Stage 1: Orthognathic surgery; stage 2: Reduction
glossectomy
• Perform the orthognathic surgery and reduction glossec-
tomy in one surgical stage
The option of performing the reduction glossectomy first as
an isolated procedure and the orthognathic surgery second has
the following advantages compared with the combined proce-
dure: (1) less airway concern, (2) no intermaxillary fixation
required, and (3) pre-surgical orthodontics when performed
after the reduction glossectomy that are more stable and predict-
able. Performing the reduction glossectomy as the primary stage
is indicated when extensive orthodontics are necessary before
the orthognathic surgery and the size of the tongue impedes
the required orthodontic movements. Reducing the size of the
tongue in these cases is indicated to facilitate the stability of the
pre-surgical orthodontics. The second sequencing option would
be indicated if occlusal instability developed after orthodontics
and orthognathic surgery as a result of an enlarged tongue. The
development of dentoskeletal changes directly related to tongue
size, such as an anterior open bite or a Class III occlusal ten-
dency, would indicate that reduction glossectomy may be ben-
eficial. In performing the treatment simultaneously with rigid
fixation, it is usually helpful to complete the orthognathic
surgery first. Once the orthognathic surgery is rigidly stabilized,
one can perform a reduction glossectomy. Because a reduction
glossectomy generally causes a transient but significant increase
in the size of the tongue because of edema, performing the
tongue procedure last may allow the occlusion to be established
better before the onset of edema. However, if the tongue is
extremely large, the reduction glossectomy may need to be
sequenced first to allow the proper occlusion to be established
when the orthognathic surgery is performed. With the surgical
procedures, one must use care not to injure the lingual, hypo-
glossal, and glossopharyngeal nerves. Although the indications
for reduction glossectomy are few, when the procedures are
indicated, the following conclusions can be drawn:
• Reduction glossectomy can improve functional and esthetic
outcomes significantly.
• The anterior resection combined with the midline keyhole
type procedure is the best technique.
• Improved function relative to airway, speech, and mastica-
tion can be anticipated.
• If the excessively large tongue is causing significantly unfa-
vorable mandibular growth, reduction of the tongue may
help control the problem.55
Temporomandibular Joint Management
The TMJs are the foundation for jaw position, facial growth and
development, function, occlusion, facial balance, and comfort.
If the TMJs are not stable and healthy (non-pathological),
patients requiring orthognathic surgery may have unsatisfac-
tory outcomes relative to function, esthetics, occlusal and
skeletal stability, and pain.
TMJ disorders/pathology and dentofacial deformities com-
monly coexist. The TMJ pathology may be the causative factor
of the jaw deformity, develop as a result of the jaw deformity,
or the two entities develop independent of each other. The
most common TMJ pathologies that can adversely affect jaw
position, occlusion, and orthognathic surgical outcomes
include: (1) articular disc dislocation, (2) AICR, (3) reactive
arthritis, (4) condylar hyperplasia, (5) ankylosis, (6) congenital
deformation or absence of the TMJ, (7) connective tissue
and autoimmune diseases, and (8) other end-stage TMJ pathol-
ogies. These TMJ conditions are often associated with dentofa-
cial deformities, malocclusion, TMJ pain, headaches, myofascial
pain, TMJ and jaw functional impairment, ear symptoms, sleep
apnea, and so on.16,58 Patients with these conditions may benefit
from corrective surgical intervention including TMJ and
orthognathic surgery. Many clinicians may have difficulty iden-
tifying the presence of a TMJ condition, diagnosing the specific
TMJ pathology, and selecting the proper treatment for that
condition. This section should improve the clinician’s diagnos-
tic and treatment planning skills.
Although most TMJ patients have associated symptoms,
approximately 25% of patients with TMJ pathology/disorders
will be asymptomatic. Accurate diagnosis and proper surgical
intervention for the specific TMJ pathologies that may be
present in orthognathic surgery patients will provide highly
predictable and stable results.15,16,58
When coexisting conditions do exist, separate or simul-
taneous management of the TMJ pathology and dentofacial
deformity may be indicated. In most cases, correct TMJ prob-
lems first.
Surgical TMJ treatment modalities are determined from
patient history, clinical assessment, imaging (tomography,
MRI), cause, time since onset, TMJ anatomy, duration of symp-
toms, type of previous treatment, number of previous surgeries,
and presence of systemic or other local conditions. A brief
description of the types of TMJ problems and treatment recom-
mendations follow.
Articular disk displacement. In patients with TMJ articular
disk displacement with or without reduction, carefully evaluate
the health of the disk and surrounding joint structures. With a
salvageable disk and healthy condylar and fossa elements, target
treatment at stabilizing the disk by repositioning and ligament
repair. Articular disk repositioning and ligament repair with a
Mitek suture anchor and artificial ligaments will provide
improved stability over other traditional techniques (Figure
74-56).59-66 The success rate is high if this surgery is performed
within the first 4 years of the onset of symptoms and there is
no presence of reactive arthritis, polyarthritic, or other systemic
and localized diseases. After 4 years, the success rate decreases
as the disc becomes more degenerated and deformed.
Adolescent internal condylar resorption. AICR is a poorly
understood but well documented condition that can affect the
TMJs. This condition is predominately in teenage females (8 : 1
female-male ratio) and is initiated as they progress through
their pubertal growth spurt (onset between 11 to 15 years old),
with anterior displaced articular discs and progressive condylar
resorption (Figure 74-57). It can proceed until remission, or
result in complete loss of the condylar head. AICR may be
hormonally mediated and is seen predominantly in high occlu-
sal plane/high mandibular plane angle facial types. In this pro-
gressive disease process, the articular disks are always anteriorly
dislocated. If the disk is salvageable, repositioning it, removing
the hypertrophied synovial and bilaminar tissues, and stabiliz-
ing the disk with a Mitek anchor has been proved by Wolford
and colleagues to be a stable and predictable approach to treat
this condition.59,64,66-68 Orthognathic surgery can be done in the
same operation or performed in a second operation. If the TMJs
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1085

A B

M L

Mitek 0-Ethibond
suture

C D
FIG 74-56 A, The Mitek mini anchor measures 1.5 mm x 5 mm and has an eyelet to support
two 0-Ethibond sutures. B, The excess bilaminar tissue surrounding the condyle is excised and
the disc mobilized to sit passively over the condyle. C, Posterior view shows placing the anchor
8 mm below the top of the condylar head and lateral to the mid-sagittal plane. Three throws
from each of the two sutures are placed through the posterior band of the disc. D, The disc is
held in position with the Mitek anchor and supportive artificial ligaments.

A B

FIG 74-57 A, Adolescent internal condylar resorption (AICR) is a condition resulting in anterior
disc dislocation (red arrow) and progressive condylar resorption. B, The discs (red arrow) com-
monly become nonreducing on opening early in the pathological progression.
1086 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

are not addressed, orthognathic surgery procedures will pre-

dictably cause further resorption of the condyles, resulting in a
Class II anterior open bite skeletal and dental relationship, as
well as increased pain.
Articular disk dislocated, nonsalvageable; condyle and fossa
in good condition. When the articular disk is dislocated and
nonsalvageable without perforation but the condyle and fossa
are in good condition, there are three basic surgical approaches
for TMJ management:
1. Arthroscopy can be a consideration, particularly if no
orthognathic surgery is required. Arthroscopy is not recom-
mended for the Class II patient requiring mandibular
advancement or any procedure in which increased TMJ
loading occurs as a result of the orthognathic surgery.
2. If the disk requires replacement, consider one of the follow-
ing techniques, in order of preference: (1) sternoclavicular
disk graft, (2) temporal fascia graft, (3) dermal graft, and (4)
auricular cartilage graft. The sternoclavicular joint is the
most similar joint in the body to the TMJ functionally, struc-
turally, and histologically. The articular disk is similar to the
TMJ articular disk. A split-thickness or full-thickness disk
graft can be harvested and stabilized to the condyle with a
Mitek anchor and also to the medial capsule, lateral ptery-
goid muscle, bilaminar tissue, and lateral capsule. Although
a relatively new technique, initial results are favorable. Tem-
poral fascial, dermal, and auricular cartilage grafts, thin with
loading, may perforate, and may result in further degenera-
tive changes of the disk replacement tissue, fossa, and condyle
(including condylar resorption) in a large percentage of
patients with a significant risk of requiring further surgery.69,70
3. Total joint prostheses are the most predictable method of
treatment for this specific situation because they eliminate
the risks of using autogenous tissues.71-74
Articular disk and condyle nonsalvageable (end-stage). When
the articular disk and condyle are not salvageable, the following
treatment options are available: (1) sternoclavicular graft
including the articular disk, (2) costochondral graft, or (3) total
joint prostheses. The preferred autogenous tissue is the sterno-
clavicular graft because of its strength, available length, good
medullary bone, articular disk, and similarity to the TMJ. The
costochondral graft lacks strength and can warp under loading,
resulting in difficulty in controlling the occlusion after surgery,
and there is no disk. However, if there is the presence of reactive
arthritis, polyarthritis conditions, systemic or local diseases,
two or more previous TMJ surgeries, or significantly altered
joint anatomy, then using autogenous tissues may have a high
failure rate.
The total joint prosthesis is the method of choice, is highly
predictable, and is the best treatment option for end-stage TMJ
pathology.71-74 A number of degenerative joint conditions pre-
clude the use of autogenous tissues for a predictable outcome.
These conditions include the following:
• Degenerative changes resulting in a nonsalvageable disk and
condyle, with degenerative changes also in the fossa
• Reactive arthritis
• Failed TMJ autogenous grafts or alloplastic devices
• Two or more previous surgical procedures to the TMJ
• The presence of connective tissue/autoimmune disease
affecting the joint, such as juvenile idiopathic arthritis (JIA;
Figure 74-58), psoriatic arthritis, psoriasis, lupus, sclero-
derma, Sjögren syndrome, ankylosis spondylitis, and rheu-
matoid arthritis
FIG 74-58 Connective tissue/autoimmune diseases affecting
the temporomandibular joints (TMJs) can commonly cause
major condylar resorption, although the disc may remain in
reasonably good position, but may be surrounded by a reactive
pannus as seen in this case of juvenile idiopathic arthritis (JIA).
The structures are outlined in orange.
These conditions are treated best by condylectomy, diskec-
tomy, joint débridement, and reconstruction with an FDA-
approved total joint prosthesis (preferably patient-fitted), as
well as fat grafts to the TMJ area generally harvested from the
abdomen or buttock. Wolford and Karras have demonstrated
that fat grafts packed around the prosthesis significantly reduce
fibrosis and heterotopic bone formation around joints, improv-
ing treatment outcomes and significantly decreasing the risk of
further surgery being required for removal of these unfavorable
tissues.75-78 With the use of patient-fitted total joint prostheses,
the significant mandibular deformities can be corrected by
repositioning the mandible on a reproduced three-dimensional
model of the patient’s TMJ and jaw anatomy. A patient-fitted
joint prosthesis is designed and constructed to fit the TMJ
anatomy and the new position of the mandible (see Figure
74-32). With total joint prostheses, the TMJ is reconstructed
and the mandible repositioned into its most ideal position.
Maxillary surgery and other procedures can be performed
concomitantly.
Condylar hyperplasia type 1. Condylar hyperplasia type 1
causes increased size of the condyle(s) and mandible with onset
usually occurring during puberty with an accelerated and pro-
longed growth aberration of the “normal” condylar growth
mechanism causing condylar and mandibular elongation
(prognathism) (Figure 74-59, D-F). Growth is self-limiting
usually ending by the early to middle 20s, and can occur bilater-
ally (condylar hyperplasia type 1A) or unilaterally (condylar
hyperplasia type 1B). Patients may begin with a Class I occlusal
and skeletal relationship as they enter their pubertal growth
phase and grow into a Class III skeletal and occlusal relationship
or begin as a Class III and develop into a worse Class III
 A B C

D E F

G H I

J K L

M N O
FIG 74-59 Cone beam computed tomography (CT) of temporomandibular joints (TMJs). A to
C, Normal TMJ with balanced joint spaces. D to F, Condylar hyperplasia type 1 with relatively
normal condylar shape, elongated condylar head and neck, and narrow joint space related to thin
articular disc or displaced disc. In the coronal view the condylar head is more rounded. G to
I, Condylar hyperplasia type 2A is an osteochondroma with a vertical growth vector without
significant horizontal condylar enlargement or exophytic growth. This is a “young” osteochon-
droma with only about 3 years of growth. J to L, Condylar hyperplasia type 2A, with a larger and
wider condylar head and neck that may be in a transitional phase progressing toward condylar
hyperplasia type 2B. M to O, Condylar hyperplasia type 2B with horizontal (as well as vertical)
enlargement of the condyle and exophytic outgrowth of the tumor. This tumor has been present
for 6 years. Notice the significant increased vertical height of the mandibular body, ramus and
condylar head and neck.
1088 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
relationship. Growth is usually in a horizontal vector or uncom-
monly a vertical vector.
Active condylar hyperplasia can be treated predictably in the
mid-teen years with high condylectomies, including removal
of the medial and lateral condylar poles, recontouring of the
remaining condylar head to conform to the fossa, and reposi-
tioning of the articular disk over the remaining head of the
condyle, usually with a Mitek anchor. This predictably elimi-
nates any further growth of the mandible, and simultaneous
orthognathic surgery can be carried out to correct the associ-
ated jaw deformities. With this technique, post-surgical jaw
function is typically very good.79-82
Condylar hyperplasia type 2 (osteochondroma of the condyle).
Condylar hyperplasia type 2 is a relatively rare unilateral TMJ
condition but is the most common neoplastic condition that
can occur in the TMJ. Growth is usually in a vertical vector
creating a unilateral elongation of the face and jaws. This condi-
tion can occur at any age but most commonly develops in the
teenage years. The abnormal condylar growth may be slow or
rapid, and the presenting symptoms may include facial asym-
metry, malocclusion, ipsilateral lateral open bite, and 75% of
the time, a contralateral TMJ disk displacement occurs with the
development of TMJ symptoms. The condyle can grow pre-
dominantly vertical (condylar hyperplasia type 2A) (see Figure
74-59, G-I), without or with increase in AP width (Figure
74-59, J-L), or develop exophilic outgrowth from the condylar
head (condylar hyperplasia type 2B) (see Figure 74-59, M-O)
that can occur vertically, medially, anteriorly, laterally, posteri-
orly, and usually can be identified by radiographic, CT, or MRI
imaging. Two basic approaches can be used to correct this path-
ological condition. First, perform a low condylectomy with
recontouring of the lower portion of the condylar neck to func-
tion as a new condyle and reposition the articular disk over the
“new” head and stabilize it. Then perform the indicated orthog-
nathic procedures (usually double jaw to get the best outcome
functionally and esthetically) in the same operation. The second
option includes performing a low condylectomy with recon-
struction of the condyle using a sternoclavicular graft, costo-
chondral graft, or a total joint prosthesis. Perform other required
orthognathic procedures in the same operation or in a later
operation. The contralateral TMJ may require a disk reposition-
ing procedure at the same time if the disk is displaced.80,82,83
Simultaneous Orthognathic Surgery and Rhinoplasty
Nasal airway difficulties usually can be corrected at the time of
the orthognathic surgery, while the maxilla is mobilized and
rotated inferiorly. This gives good access to perform nasal sep-
toplasty, partial turbinectomy, removal of nasal polyps, or other
indicated procedures. External nasal deformities can be cor-
rected at the same time as the orthognathic surgery or at a
secondary procedure. For some patients, it may be more con-
venient and practical to carry out the rhinoplasty procedures at
the same time as the orthognathic surgery.84,85 The use of rigid
fixation for the orthognathic surgery is paramount because of
the necessity to maintain a good oral airway, because the nasal
airway often is obstructed with mucous, packing, edema, and
blood clots, rendering it ineffective as an airway immediately
after surgery and for a few more days. Surgical sequencing
includes performing all of the orthognathic surgery with appli-
cation of rigid fixation first using a nasal endotracheal tube.
Two basic approaches to airway management are available when
performing the required change from the nasoendotracheal
tube to the oral endotracheal tube. Following completion of the
orthognathic portion and release of intermaxillary fixation, one
option is to remove the nasal endotracheal tube and insert an
oral endotracheal tube. The second technique involves stabiliz-
ing the tube intraorally with a clamp and then pulling the nasal
portion of the tube out through the mouth, thus eliminating
the need to change out the tube and eliminating the use of the
laryngoscope. Each of these techniques provides complete and
unobstructed access to the nasal structures since the endotra-
cheal tube has been transitioned to an oral tube. The anesthetist
must take extreme care during oral intubation not to place
excessive pressure on the maxilla or mandible that could dis-
place the dento-osseous segments. The alternative to simultane-
ous surgery is to perform the orthognathic surgery first and
then to perform the rhinoplasty. The rhinoplasty should not be
carried out as the first surgical stage. Performing rhinoplasty at
the same time as orthognathic surgery is challenging. Because
of the edema present from just performing the orthognathic
aspect and because of any spatial changes of the underlying
dento-osseous structures, significant alteration and distortion
of the soft tissues in and around the nose, cheeks, and upper lip
occurs. Careful planning before the surgery to incorporate the
expected final soft tissue changes from just the orthognathic
surgery and then plan and execute the rhinoplasty procedures
at the same time as the orthognathic surgery. The nasal dorsum
will appear more retruded than it actually will be after the facial
edema has resolved.
OUTCOME STABILITY IN ORTHOGNATHIC
SURGERY
Excellent stability following orthognathic surgery is of para-
mount importance for patient satisfaction and successful clini-
cal practice. This goal can be achieved by involving accurate
diagnosis including TMJ pathology assessment, predictable
treatment planning, stable pre-surgical orthodontics mechan-
ics, precise surgical techniques, and appropriate post-surgical
management and retention.
Bailey and colleagues state one of the main problems with
the literature on orthognathic surgery stability86: “The vast
majority of studies use statistics based on normal distribution
to describe post treatment changes. With a normal distribution,
the mean is the most likely indicator of what a patient would
experience, and the clinician tends to think of it in just that
way. But if essentially no change occurred in three-fourths of
the patients who experienced change, the mean is highly mis-
leading as an expectation of treatment response.” Although
many good papers on orthognathic surgery are available today,
readers must be careful of the methods and statistics used to
guide conclusions. Because the clinician should know from
experience, in the patient’s mind, his or her success or failure
means 100% and not an isolated event. A case series or even a
clinical trial might mislead to conclude for stability of the
average sample, whereas a few patients experience dramatic
instability.
Mandibular Advancement
The stability of mandibular advancement has been studied with
two-dimensional lateral cephalometric analysis, and three-
dimensional surface analysis for several years now.86-96 There is
no doubt that the BSSRO is the technique of choice for man-
dibular advancement because it does not require bone grafts
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
and allows for internal rigid fixation (IRF) in several distinct
intraoral and extraoral protocols. There is some controversy
between the use of bicortical screws or bone plates and mono-
cortical screws as the best method of fixation.97-99 Although
both methods can accomplish the goal, the inclusion of bicorti-
cal screws can increase effectiveness of IRF mechanical proper-
ties and decrease the possibility of pseudarthrosis and earlier
release of intermaxillary elastics.99 The negative factors of its use
are the extraoral approach for posterior drilling and screw
insertion through a transcutaneous trocar, possible condylar
torque, and increased risk of damage to the inferior alveolar
nerve. Condylar torque is probably the major concern of the
use of bicortical screws following BSSRO and related to the
higher rates of long-term instability compared with miniplate
methods. This observation is probably influenced by the
fact that larger mandibular advancement is more frequently
reported with bicortical screws and by the greater number of
clinical trials compared with miniplate fixation methods.97
It is well known that increased loading is potentially harmful
for any body joint mainly with previous pathologies associated.
Condylar torque can be minimized with careful surgery in
experienced hands, use of osteotomy design that improves
precise bone contact and visualization of bone interferences,
removal of all bone interferences, use of positional bicortical
screws after appropriate tapping, use of passive method/device
to hold proximal and distal segments in place without compres-
sion, and use of bone plate fixed with monocortical screws
inserted prior to bicortical screws insertion.100,101 Although
experience and proper technique can make a difference, some
condylar torque will occur after large mandibular advance-
ments and counterclockwise rotation of the occlusal plane angle
regardless of the technique used.92,94,96,102 This is a matter of
physics principles that states: Two solid objects cannot be in the
same place at the same time. Due to the anatomy of the man-
dible in a parabolic format with the larger width at the posterior
region, it is obvious that large mandibular advancement might
promote some condylar torque despite the use of bicortical
screws or not. We have shown that although condylar torque is
harmful to TMJs, post-surgical condylar resorption is mostly
related to previous TMJ pathologies instead.91,96,103 A recent
clinical case presentation has shown a patient with greater
amount of TMJ condylar resorption on the side where less
condylar torque was observed and more aggressive TMJ pathol-
ogy was present prior to surgery.103
Other factors influencing relapse following mandibular
advancement include the amount of advancement, type and
material of fixation, low and high mandibular plane angle,
spatial control of proximal segment, soft tissue and muscle
activity, remaining growth and remodeling, preoperative age,
and surgeon skills.97,104,105 Mandibular advancement has been
considered a stable procedure on the hierarchy of stability
studies.86,87,90 However, such stability was related to single jaw
surgery, mandibular advancement smaller than 10 mm, and for
patients with short or normal face height only. A recent study
that addressed the stability of mandibular advancement with
and without advancement genioplasty concluded that both pro-
cedures are clinically stable and emphasized lack of suprahyoid
musculature influence.106 The conclusions of this study seem to
be beyond the scope of its methods and study design because
the sample selection and surgical changes were very specific
(not very common) and of low risk of relapse. They did not
determine hyoid bone position and excluded patients with
1089
previous TMJ pathology and mandibular advancements larger
than 7 mm.
The largest group of Class II patients to seek orthognathic
surgery have a high occlusal plane angle facial profile and
most frequently they require double jaw surgery including
counterclockwise rotation of the occlusal plane and signifi-
cantly larger mandibular advancement than 10 mm in order to
achieve appropriate function and esthetics.54,107 It is well docu-
mented that these patients are much more susceptible to TMJ
internal derangements and instability after maxillomandibular
osteotomies being considered as problematic in the stability
studies.86,87,90,108-116
High occlusal plane angle facial profile patients commonly
have mouth breathing with nasal obstruction due to enlarged
turbinates, decreased oropharyngeal airway space, severe
retruded mandible, and increased anterior facial height. Wolford
and other groups have shown that maxillomandibular counter-
clockwise rotation with mandibular advancement stability will
be dramatically affected by untreated pre-existing TMJ pathol-
ogy, including AICR, reactive arthritis, autoimmune and
connective tissue diseases, condylar hyperplasia, and so on.*
Identification and appropriate treatment of the TMJ pathology
is paramount for predictable treatment outcomes for orthog-
nathic surgery.
A patient that has previous TMJ pathology and refuses to
have TMJ surgery prior to or concomitant with orthognathic
surgery increases significantly the risk of condylar resorption
following maxillomandibular counterclockwise rotation and
mandibular advancement. In this situation, condylar resorption
that can originate from different etiologies will lead to orthog-
nathic surgery relapse. Figures 74-60 through 74-75 show a
16-year-old female patient with AICR that was submitted to
maxillomandibular counterclockwise rotation and mandibular
advancement and no TMJ surgery. In preparation for surgery
(Figures 74-60 through 74-62), the patient was directed to avoid
parafunctional habits and nutritional supplementation was
prescribed (vitamin C, D, and E; calcium; and omega-3 fatty
acid).120 Cone beam CT surface model superimposition dem-
onstrates the surgical movements involving counterclockwise
rotation of the maxillofacial complex and the immediate effect
on the condyles (Figures 74-63 through 74-65). One year fol-
lowing surgery, she presented with acceptable dental, skeletal,
and facial profile stability (Figure 74-66), although condylar
resorption was occurring (Figures 74-67 and 74-68), creating
skeletal relapse as seen with the cone beam CT superimposition
on the immediate post-surgery and 1-year follow-up imaging
(Figures 74-69 through 74-71). Further instability occurred at
the second year of follow-up due to continued condylar resorp-
tion and consequent clockwise rotation of the maxilloman-
dibular complex (Figures 74-72 through 74-75).
Mandibular advancement or maxillomandibular advance-
ment (MMA) stability is achieved with detailed diagnosis,
careful orthodontics and surgical plan, precise execution, and
long-term retention. Appropriate TMJ diagnosis and treatment
should be done before or simultaneous with orthognathic
surgery in order to offer predictable results. A successful treat-
ment plan, precise execution, and solid stability are presented
for this 16-year-old female with AICR, but the TMJ pathology
Text continued on p. 1095
*References: 15, 91, 105, 107, 117-119.
1090 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B

C D E
FIG 74-60 A to E, A 16-year-old female with adolescent internal condylar resorption (AICR)
submitted to maxillomandibular counterclockwise rotation and mandibular advancement, but
with no temporomandibular joint (TMJ) surgery.

FIG 74-61 Magnetic resonance imaging (MRI) of right temporo-

mandibular joint (TMJ) of 16-year-old patient with adolescent FIG 74-62 Magnetic resonance imaging (MRI) of left temporo-
internal condylar resorption (AICR). mandibular joint (TMJ) of 16-year-old patient with adolescent
internal condylar resorption (AICR).
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1091

A B C
FIG 74-63 A to C, Pre-surgery (white) and immediate post-surgery (red) cone beam computed
tomography (CT) surface models with voxel-wise cranial bone superimposition showing the
maxillomandibular surgical movements.

FIG 74-64 Right condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of pre-surgery (white) and immedi-
ate post-surgery (red). Vector maps (bottom figures) show
the direction and amplitude of displacement/remodeling in
millimeters.
FIG 74-65 Left condyle cone beam computed tomography
(CT) surface models (front, top and back views) with voxel-
wise cranial base superimposition of pre-surgery (white) and
immediate post-surgery (red). Vector maps (bottom figures)
show the direction and amplitude of displacement/remodeling
in millimeters.
1092 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B

C D E
FIG 74-66 A to E, The patient is seen 1-year post-surgery showing the achievement of accept-
able facial balance and occlusion.

FIG 74-67 Magnetic resonance imaging (MRI) of right temporo-

mandibular joint (TMJ) shows the progression of resorption of FIG 74-68 Magnetic resonance imaging (MRI) shows the pro-
the right condyle. gressive condylar resorption of the left condyle.
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1093

A B C
FIG 74-69 A to C, Immediate post-surgery (red) and 1-year follow-up (light blue) cone beam
computed tomography (CT) surface models with voxel-wise cranial base superimposition. Note
slight maxillomandibular counterclockwise rotation.

FIG 74-70 Right condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of immediate post-surgery (red)
and 1-year follow-up (light blue). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.
FIG 74-71 Left condyle cone beam computed tomography (CT)
surface models (front, top, and back views) with voxel-wise
cranial base superimposition of immediate post-surgery (red)
and 1-year follow-up (light blue). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.
1094 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B

C D E
FIG 74-72 A to E, The patient is seen 2 years post-surgery with significant change in facial profile
with the mandible becoming significantly more retruded. Occlusion has remained reasonably
stable, although there is a slight tendency for the bite to open.

A B C
FIG 74-73 A to C, Immediate post-surgery (red) and 25-month follow-up (blue) cone beam com-
puted tomography (CT) surface models with voxel-wise cranial base superimposition. Note sig-
nificant maxillomandibular clockwise rotation.
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
FIG 74-74 Right condylar cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of immediate post-surgery (red)
and 25-month follow-up (blue). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.
FIG 74-75 Left condyle cone beam computed tomography (CT)
surface models (front, top and back views) with voxel-wise
cranial base superimposition of immediate post-surgery (red)
and 25-month follow-up (blue). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.
was addressed at surgery by concomitant TMJ articular disc
repositioning with the Mitek anchor technique (see Figure
74-56) and double jaw orthognathic surgery with counterclock-
wise rotation of the maxillomandibular complex and genio-
plasty (Figures 74-76 through 74-83).
This next section presents the common TMJ pathologies that
affect orthognathic surgical outcomes, clinical and radiographic
1095
characteristics, as well as the proven treatment protocols that
will provide predictable and stable results.
Common Temporomandibular Joint Pathologies that
Adversely Affect Orthognathic Surgical Outcomes
Magnetic Resonance Imaging Evaluation
MRI is one of the most important diagnostic tools that we have
in evaluation and diagnoses of TMJ pathology. In general, T1
MRIs are helpful in identifying disc position, the presence of
alteration in bone and soft tissue structures structure, and inter-
relationships of the bony and soft tissue anatomy. T2 MRIs are
more helpful in identifying inflammatory responses in the TMJ.
The importance of disc position cannot be overemphasized.
In our study, we evaluated three different patient groups
that required counterclockwise rotation and advancement of
the maxillomandibular complex.11 The three groups were well
matched relative to the amount of advancement at menton of
approximately 13 mm in a counterclockwise direction. Group
1 had healthy TMJ joints with the articular discs in position and
had only orthognathic surgery performed. Group 2 had anteri-
orly displaced articular discs, and at surgery these discs were
repositioned into a normal relationship with the Mitek anchor
technique and CTOS performed. Group 3 had anteriorly dis-
placed discs but only had orthognathic surgery performed. At
longest follow-up with an average of 31 months, the average
relapse at menton for Group 1 with the healthy joints was 5%,
or 0.5 mm for every 10 mm of maxillomandibular counter-
clockwise advancement. Group 2, who had displaced discs
repositioned with the Mitek anchor technique and orthogna-
thic surgery had an average relapse of 1%, or 0.1 mm per 10
mm of counterclockwise mandibular advancement. In Group
3, who had displaced discs where only orthognathic surgery was
performed, the average AP relapse was 28% of the amount of
advancement or almost 3 mm for every 10 mm of mandibular
advancement, indicating post-surgical condylar resorption
occurring in this group of patients. This study conclusively
shows the importance of having the articular discs in position
for stability in orthognathic surgery, particularly in patients
who require mandibular advancement and specifically for those
that require counterclockwise rotation of the maxillomandibu-
lar complex. The counterclockwise rotation of the maxillo-
mandibular complex is a very stable procedure if the discs are
healthy and/or placed into proper anatomical position.
In a previous study, we evaluated 25 patients who had bilat-
eral TMJ displaced articular discs and underwent double jaw
MMA surgery with an average advancement of 9 mm at point
B, but the TMJs were not addressed, so the articular discs
remained anteriorly displaced.15 At pre-surgery, 36% of the
patients had pain or discomfort involving the TMJ, head, and
jaw area. At an average of 2.2 years post-surgery, 84% of the
patients had pain. The average pain at longest follow-up
increased 70% in intensity over the pre-surgical pain level. In
addition, 30% of the patients developed significant mandibular
AP relapse and developed open bites. This study also demon-
strates the adverse effect of performing orthognathic surgery on
patients with displaced TMJ articular discs.
For MRI evaluation of the TMJs, the basic views that are
most helpful in diagnoses include:
• Sagittal views in centric relation as well as in maximum
opening
• Coronal views in centric relation
• Dynamic views, if available
 A B

C D E
FIG 74-76 A to E, This 16-year-old female presented with bilateral temporomandibular joint (TMJ)
adolescent internal condylar resorption (AICR) with progressive condylar resorption, retrusion of
the mandible, and development of an anterior open bite. The patient was treated with bilateral
TMJ articular disc repositioning with Mitek anchor, counterclockwise rotation of the maxilloman-
dibular complex with maxillary osteotomies and bilateral sagittal split osteotomies, genioplasty,
and nasal turbinectomies.

A B
FIG 74-77 A, Magnetic resonance imaging (MRI) of right temporomandibular joint (TMJ)
shows an anteriorly displaced disc and a condyle that is undergoing some resorption. B, MRI
of left TMJ showing anteriorly displaced discs and presence of adolescent internal condylar
resorption (AICR).
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1097

A B C
FIG 74-78 A to C, Pre-surgery (white) and post-surgery (red) cone beam computed tomography
(CT) surface models with voxel-wise cranial base superimposition (T2 minus T1).

FIG 74-79 Right condylar cone beam computed tomography

(CT) surface models (front, top, and back views) with voxel-
wise cranial base superimposition of pre-surgery (white) and
immediate post-surgery (red)—T2 minus T1. Vector maps
(bottom figures) show direction and amplitude of displacement/
remodeling in millimeters.
With a normal healthy condyle (Figure 74-84), the condyle
should have a uniform shape and consistent thickness of cortical
bone. The condyle should be positioned in the fossa with equal
joint space between the condyle and fossa posteriorly, superiorly,
and anteriorly. The articular disc should sit on top of the condyle
with the posterior band being about the 12 o’clock position. The
disc should have a bowtie shape with increased thickness of
the posterior band and anterior band and a thinner area for the
intermediate zone. The articular eminence should have a mod-
erate inclination, although the articular eminence may be quite
variable in its steepness, which in some cases can contribute or
predispose to certain TMJ conditions. The MRI imaging can be
correlated to cone beam imaging of the TMJs for joint space and
greater interpretation of bony pathology.
FIG 74-80 Left condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-
wise cranial base superimposition of pre-surgery (white)
and immediate post-surgery (red)—T2 minus T1. Vector maps
(bottom figures) show direction and amplitude of displacement/
remodeling in millimeters.
Figure 74-84 demonstrates the sagittal view of a normal and
healthy TMJ. On opening, there should be good translation of
the condyle and the articular disc forward and positioned
beneath the articular eminence. The most common direction of
disc displacement is anterior and anteromedial. Upon opening,
a click or pop may be heard at the TMJ as the condyle reduces
over the posterior band and onto the disc (Figure 74-85).
Silent Temporomandibular Joint With Disc Displacement
There are a number of TMJ pathological processes where the
disc is displaced, but yet the disc is silent with function. These
1098 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B

C D E
FIG 74-81 A to E, At 2 years post-surgery, the patient maintains good facial balance and a good
stable occlusion.

A B C
FIG 74-82 A to C, Immediate post-surgery (red) and 1-year follow-up (light blue) cone beam
computed tomography (CT) surface models with voxel-wise cranial base superimposition (T3
minus T2).

situations include a steep articular eminence where the articular
disc is anteriorly displaced but in a vertical orientation so that
upon opening there is an immediate reduction of the disc
because it is in a “pre-click” position. Medial and lateral dis-
placements of the disc may create pain and dysfunction, but the
joints may be silent because there is no reduction over the pos-
terior band (Figure 74-86). This also goes along with posterior
displaced discs where the TMJs may make no noise but could
contribute to pain and discomfort (Figure 74-87).
Certain pathological conditions such as AICR where there
may be thickening of the bilaminar tissues so that there is a
smooth transition from the thickened bilaminar tissue onto the
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
disc, thus no noise is made. Also in patients who have anteriorly
displaced discs without reduction may have no noises (Figure
74-88). Patients who have been in long-term splint therapy with
downward and forward posturing of the mandible may create
thickening of the bilaminar tissues so that there is a smooth
transition onto the disc. Any Class II mechanics may artificially
pull the condyle down and forward onto the disc, but this may
be an unstable position that the surgeon must be aware of
and understand that orthognathic surgeries performed with
advancement of the mandible will likely position the condyle
into a centric relation post-surgery and the disc will again be
anteriorly displaced.
FIG 74-83 Right condyle and left condyle cone beam computed
tomography (CT) surface models (front, top, and back views)
and voxel-wise cranial base superimposition on immediate
post-surgery (red) and 1 year follow-up (light blue)—T3 minus
T2. Vector maps (bottom figures) show direction and amplitude
of displacement/remodeling in millimeters.
Articular disc
A B
FIG 74-84 A, Normal temporomandibular joint (TMJ) with posterior band of disc at 12 o’clock.
B, On opening, the condyle and disc translate down and forward beneath the articular
eminence.
1099
Adolescent Internal Condylar Resorption
AICR has a relatively classic presentation. This condition
develops usually between 11 to 15 years old, predominantly in
females (ratio 8 : 1 females to males). Clinically, the mandible
will be noted to slowly retrude into a Class II occlusal and skel-
etal relationship with a tendency toward anterior open bite (see
Figures 74-60 and 74-76). These patients all have high occlusal
plane angle facial morphological profiles. However, on the MRI
(see Figure 74-61 and 74-62), these cases present with a condyle
that may be slowly becoming smaller in size in all three planes
of space. In some cases, there is significant thinning of the corti-
cal bone on top of the condyle contributing to the inward col-
lapse of the condylar head in this pathological process. The
articular discs are anteriorly displaced and may or may not
reduce on opening. Non-reducing discs will degenerate and
deform at a more rapid rate as compared to a disc that reduces.
Our studies demonstrate that AICR is arrested if the articular
discs are put back into position on top of the condyle and sta-
bilized with the Mitek anchor technique.121-123 A post-surgical
view of a repositioned disc with a Mitek anchor is seen in
(Figure 74-89). There is some distortion of the MRI imaging
because of the metal anchor in the head of the condyle, but the
reduced position of the disc is noted. Results are best for AICR
if the TMJ surgery is performed within 4 years of the onset of
the pathology. After 4 years, the discs may not be salvageable
and the indicated treatment may then be custom-fitted total
joint prostheses to repair the TMJs and advance the mandible.
Osteochondroma (Condylar Hyperplasia Type 2)
Osteochondroma (condylar hyperplasia type 2) will commonly
present as an enlarged condyle with either extended exophytic
growth off the condylar head (Figure 74-90) versus increased
vertical dimension of the condylar head (see Figure 74-59, J-O).
This condition is a unilateral TMJ pathological process, and the
articular disc is commonly in position, even in the presence
of large exophytic pathological growth processes. However,
importantly, in cases with condylar hyperplasia type 2, often
the contralateral “normal” joint may be overloaded, developing
an anteriorly displaced disc and subsequently arthritic
Articular disc
1100 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

Articular disc Articular disc

Articular disc, Articular disc,

Anteriorly reduced during
displaced in jaw opening
centric relation

A B
FIG 74-85 A, In closed position, the condyle is positioned posterior in the fossa and the disc is
anteriorly displaced. B, On opening, the disc reduces into a normal position.

Lateral disc
Anterior disc displacement
displacement
Medially
displaced
disc
A B C
FIG 74-86 A, Sagittal view of anteriorly displaced discs. B, In this coronal view, the articular disc
is medially displaced. C, In this coronal view, the disc is laterally displaced.

Non-salvageable
Anteriorly displaced
Posterior disc articular disc
displacement

FIG 74-87 In this case of condylar hyperplasia type 1, the

condyle is growing vertically at an accelerated rate that is faster FIG 74-88 The articular disc is anteriorly displaced and signifi-
than the posterior ligament attachment can migrate upward, cantly deformed, degenerated, and nonreducing, rendering it
thus pulling the disc posterior to the condyle. nonsalvageable.
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
Articular disc,
repositioned
with Mitek
anchor
technique
Mitek anchor
FIG 74-89 Magnetic resonance imaging (MRI) demonstrates a
repositioned articular disc using the Mitek anchor technique
with the disc in a normal position.
Articular disc in
favorable position
and condition
Right condylar
osteochondroma
FIG 74-90 Magnetic resonance imaging (MRI) scan of right
temporomandibular joint (TMJ) shows an osteochondroma with
large exophytic growth of the anterior aspect of the condyle
(condylar hyperplasia type 2B). The articular disc is in favorable
position and salvageable.
changes, which occurs in about 75% of the cases with a unilat-
eral condylar hyperplasia type 2. The indicated treatment
includes a low condylectomy for removal of the tumor, recon-
touring of the condylar neck to form a new condyle, and repo-
sitioning of the articular disc, as long as the disc is salvageable,
with a Mitek anchor technique, and the recontoured ipsilateral
condylar neck will then function as a new condyle. The required
orthognathic surgery procedure can be done concomitantly.
Reactive Arthritis
Reactive arthritis may show a localized area of inflammation
with erosion of the condyle and/or fossa. It also can present as
1101
FIG 74-91 T2 magnetic resonance imaging (MRI) scan of right
temporomandibular joint (TMJ) with reactive arthritis and con-
dylar resorption. The inflammatory process is noted to occupy
a significant volume between the fossa and condyle. The disc
is not identifiable.
Bone to bone contact
of condyle and fossa
Articular disc Condyle
with perforated
lateral
attachment
FIG 74-92 Magnetic resonance imaging (MRI) of left condyle
with perforation of the bilaminar tissue posterior to the articular
disc. Bone-to-bone contact of condyle and fossa is observed
with crepitation on jaw function.
a more profuse inflammatory process through the bilaminar
tissues, capsule (Figure 74-91), and so on. Surgical indication
may be to go in and remove the nidus of inflammation versus
extensive destruction of the joint that may require a total joint
prosthesis.
Perforations
Perforations can occur in the TMJ area resulting in bone-on-
bone contact. For perforations, the discs are usually displaced.
Almost always, these perforations are posterior to the posterior
band of the articular disc or lateral to the disc; rarely do perfora-
tions occur through the disc itself (Figure 74-92). Relative to
1102 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
Reactive pannus
FIG 74-93 Common temporomandibular joint (TMJ) changes in
connective tissue/autoimmune disease. The disc is in position,
but with a reactive pannus (gray tissue) surrounding the disc
that destroys the disc, condyle, and articular eminence.
the condyle, perforations can occur in the middle, medially, or
laterally. Clinically, crepitation will usually be present; and on
the MRI, there will be evidence of bone-on-bone contact and
usually arthritic evidence on the condylar head and/or fossa.
Connective Tissue/Autoimmune Diseases
The MRI presentation of connective tissue/autoimmune dis-
eases is fairly pathognomonic. In these conditions, the articular
disc oftentimes is in the normal position, but there is progres-
sive condylar resorption and often resorption of the articular
eminence with slow but progressive destruction of the articular
disc that is surrounded by a reactive pannus (Figure 74-93).
This presentation almost always indicates the requirement of a
total joint prosthesis for jaw reconstruction to eliminate the
pathologic process in the joint. Use of autogenous tissues in this
scenario could result in the disease process attacking autoge-
nous tissues placed into the joint with subsequent failure.
Nonsurgical and Closed Treatment Considerations
Nonsurgical TMJ treatments (e.g., splints, physical therapy, chi-
ropractic treatment, orthodontics, biofeedback, acupuncture,
and medications) may help the TMJ symptoms but do not
stabilize and eliminate TMJ disorders (e.g., disc dislocation,
arthritis, condylar resorption, or condylar hyperplasia) to with-
stand the increased TMJ loading that usually accompanies
orthognathic surgery. Arthrocentesis and arthroscopy are con-
traindicated in patients with TMJ disorders requiring orthog-
nathic surgery, because these techniques do not reposition and
stabilize the articular disc in a normal position but may convert
a reducing disc into a nonreducing disc that will yield a more
rapid deformation and degeneration process of the disc, subse-
quently rendering it nonsalvageable.
Temporomandibular Joint and Facial Asymmetry
Facial asymmetries are commonly caused by TMJ pathology
and can create a progressive worsening of the facial deformity
and malocclusion.124 For example, a unilateral condylar patho-
logical over-development of the condyle can cause facial asym-
metry and affect the contralateral “normal” TMJ by creating
articular disc dislocation and arthritis from the increased func-
tional loading on that joint related to the over-development of
the ipsilateral side. Unilateral condylar under-development or
resorption can cause the mandible and face to be smaller on
one side and the jaws to shift toward the involved side. Perform-
ing orthognathic surgery only in facial asymmetry cases and
ignoring the TMJs during treatment or failure to render proper
TMJ management can result in the dentofacial asymmetry and
malocclusion redeveloping with worsening TMJ-associated
symptoms including jaw dysfunction and pain.
Age for Surgical Intervention
Although there are individual variations, females usually have
the majority of their facial growth (98%) complete by 15 years
old and males by 17 to 18 years old.125 Predictability of results
and limiting correction of the jaw and TMJ pathology–related
deformities to one major operation can best be achieved by
waiting until growth is relatively complete. However, there are
definite indications for performing surgery during the growing
years, such as progressive TMJ deterioration, ankylosis, require-
ments for growth center transplants (i.e., rib or sternoclavicular
grafts), masticatory dysfunction, tumor removal, pain, sleep
apnea, and so on. Performing surgery during growth may result
in the need for additional surgery at a later time to correct a
resultant deformity and malocclusion that may develop during
the completion of growth. In addition, some orthognathic sur-
gical procedures have a profound effect on subsequent facial
growth and development, including maxillary Le Fort I osteoto-
mies. We have previously published on maxillary and mandibu-
lar surgery and the effects on growth with guidelines for age
considerations for surgical intervention, as well as TMJ surgery
effects on facial growth.44-46,126
Adolescent Internal Condylar Resorption
Etiology. AICR, formerly referred to in the generic terminol-
ogy as idiopathic condylar resorption, is one of the most common
TMJ conditions affecting teenage females.117,121-123 AICR is also
known as cheerleader syndrome, idiopathic condylysis, condylar
atrophy, and progressive condylar resorption. AICR is a well-
documented disease process occurring with an 8 : 1 female to
male ratio, onset between 11 to 15 years old during pubertal
growth and development, and is rarely initiated before 11 years
old or after 15 years old.117,121-123 There are other local and sys-
temic pathologies or diseases that can cause condylar resorp-
tion, but AICR is a specific disease entity different from all of
the other disease processes and can create occlusal and muscu-
loskeletal instability resulting in the development of a dentofa-
cial deformity, TMJ dysfunction, and pain.
Although the specific cause of AICR has not been clearly
identified, its strong predilection for teenage females in their
pubertal growth phase supports a theory of hormonal media-
tion. Estrogen receptors have been identified in the TMJs of
female primates, human TMJ tissues, and in arthritic knee
joints.127-129 Estrogen is known to mediate cartilage and bone
metabolism in the female TMJ.130,131 An increase in receptors
may predispose an exaggerated response to joint loading from
parafunctional activity, trauma, orthodontics, or orthognathic
surgery.
The authors’ hypothesis for this TMJ pathology is that
female hormones mediate biochemical changes within the TMJ,
causing hyperplasia of the synovial tissues that stimulate the
production of destructive substrates that initiate breakdown of
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
the ligamentous structures that normally support and stabilize
the articular disc to the condyle. This allows the disc to become
anteriorly displaced. The hyperplastic synovial tissue then
surrounds the head of the condyle. The substrates penetrate
through the outer surface of the condyle and causes thinning
of the cortical bone and breakdown of the subcortical bone. The
condyle slowly collapses, shrinking in size in all three planes as
a result of internal condylar bone resorption without clinically
apparent destruction of the fibrocartilage on the condylar head
and roof of the fossa; unlike the other arthritic conditions,
where the fibrocartilage and cortical bone are destroyed by
an inflammatory, connective tissue, or autoimmune disease
process. AICR can progress for a while and then go into remis-
sion or proceed on until the entire condylar head has resorbed.
In cases where it goes into remission, excessive joint loading
(i.e., parafunctional habits, trauma, orthodontics, orthognathic
surgery, and so on) can reinitiate the resorption process. AICR
usually occurs bilaterally with symmetrical condylar resorption,
but facial asymmetry can occur if one side resorbs faster than
the other or with only unilateral TMJ involvement.
Clinical features. AICR has classic clinical features that
include the following:
• Initiated during pubertal growth (11 to 15 years old) pre-
dominately in teenage females (8 : 1 female to male ratio)
• Progressive worsening skeletal and occlusal deformity
although occurring at a slow rate (average rate of condylar
resorption is 1.5 mm per year)117,121
• High occlusal plane angle facial morphology, Class II occlu-
sion with or without an anterior open bite
• May be associated with TMJ symptoms, such as clicking,
TMJ pain, headaches, myofascial pain, earaches, tinnitus,
vertigo, and so on; however, 25% of patients with AICR have
no overt symptoms
• Jaw and jaw joint dysfunction
• No other joint or systemic involvement (see Figures 74-60
and 74-76)117,121
Because AICR is normally initiated during pubertal growth,
condylar resorption that originates prior to 11 years old or after
15 years old is usually not AICR but a different TMJ pathology
and may need a different treatment protocol. AICR rarely
occurs in low occlusal plane angle (brachiocephalic) facial types
or in Class III skeletal relationships. All cases are isolated occur-
rences with no genetic correlation.
Imaging. Radiographic features include the following:
• Progressive decrease of condylar size and volume
• Some cases have thinning cortex on top of the condyle
• Can present with increased, normal, or decreased superior
joint space
• Decreased vertical height of the ramus and condyle
• High occlusal plane angle facial morphology
• Skeletal and occlusal Class II relationship (see Figure
74-3, A)
A normal MRI is seen in Figure 74-84. An MRI of AICR (see
Figures 74-60 and 74-61) will show the following:
• The articular disc is anteriorly displaced and commonly
becomes nonreducing relatively early in the pathological
process (nonreducing discs have an accelerated rate of defor-
mation and degeneration compared to discs that reduce)
• Condyle gets progressively smaller in three dimensions
• Amorphous-appearing tissue may surround the condyle,
with or without an increased joint space
• No inflammatory process seen
1103
Treatment options. When the discs are still salvageable, our
treatment protocol has proven to eliminate this TMJ pathology
and allow optimal correction of the associated dentofacial
deformity at the same operation. The protocol includes the
following62,117,121,123,132-135:
1. Remove the bilaminar tissue surrounding the condyle.
2. Mobilize, reposition, and stabilize the disc to the condyle with
a Mitek anchor and artificial ligaments (see Figure 74-56).
3. Perform the indicated orthognathic surgery (usually double
jaw) with counterclockwise rotation of the maxillo-
mandibular complex.
4. Other adjunctive procedures that are indicated (see Figures
74-76 through 74-83).
Because this high occlusal plane angle facial morphology
is commonly associated with decreased oropharyngeal airway
space and sleep apnea, the counterclockwise rotation of the
maxillomandibular complex will also maximize the AP dimen-
sion of the oropharyngeal airway, eliminating sleep apnea
symptoms. In growing patients, this approach not only stops
the condylar resorption, but mandibular condylar growth will
begin again.117,121 Results are best for AICR if the TMJ surgery
is performed within 4 years of the onset of the pathology.
After 4 years, the discs may become significantly deformed
and degenerated so as not to be salvageable; then the indicated
treatment would be patient-fitted total joint prostheses (TMJ
Concepts) to repair the TMJs and advance the mandible.
Although this AICR surgical protocol has been successful for
more than 20 years, some controversy still remains in the litera-
ture, specifically in regard to the possible side-effects related to
open joint surgery and condylar changes afterwards.136-138 In an
ongoing study, we are assessing three-dimensional condylar
changes occurring 1 year after surgery in two patient groups:
Group 1 consists of young adult patients with normal TMJs
that had MMA only, and group 2 consists of young adult
AICR patients with MMA and articular disc repositioning
(MMA-Drep). For each patient, cone beam CTs were seg-
mented in a semi-automatic protocol and registered in a
rigid, voxel-wise automatic algorithm over the cranial base.139-141
Three distinct methods were used to assess the condyles
three-dimensionally:
1. Surface shape correspondence using the SPHARM-PDM
package142,143
2. Subjective analysis of semi transparency overlays91,141,144,145
3. Condylar volume estimation using ITK-Snap software90,91
The values for the voxels in each tomographic image were
obtained in Hounsfield units, representing the opacity of
the x-rays.
Our preliminary results showed that at 1 year following
surgery AICR patients (MMA-Drep) had increased condylar
volume compared to patients with healthy TMJs with
MMA only that experienced a reduction of condylar volume
(p <0.01).96
Reactive (Inflammatory) Arthritis
Etiology. Reactive arthritis (also called seronegative spondy-
loarthropathy) is an inflammatory process in joints commonly
related to bacterial or viral factors. This condition reportedly
occurs during the third to fourth decade of life, but it can
develop at any age. In the TMJ, it more commonly develops in
the late teens through the fourth decade. Commonly, reactive
arthritis is seen in conjunction with a displaced TMJ articular
disc, but it also can develop with the disc in position.
1104 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
Henry and colleagues demonstrated that 73% of patients
with TMJ articular disc displacements have bacteria in the
bilaminar tissues.146,147 The bacterial species that we have
identified in the TMJ include Chlamydia trachomatis and
Chlamydophila psittaci, as well as Mycoplasma genitalium and
Mycoplasma fermentans.146-149 Other bacteria that have been
found in other joints but also may infect the TMJ include Bor-
relia burgdorferi (Lyme’s disease), Salmonella species, Shigella
species, Yersinia enterocolitica, and Campylobacter jejuni. We
suspect that other bacterial/viral species may cause reactive
arthritis in joints, including Chlamydia pneumoniae, Myco-
plasma pneumoniae, Ureaplasma urealyticum, herpes virus,
Epstein-Barr virus, cytomegalovirus, Varicella zoster virus, and
so on. Kim and colleagues analyzed TMJ synovial fluids for
specific bacteria and found M. genitalium and M. fermentans/
orale, as well as Staphylococcus aureus, Actinobacillus actinomy-
cetemcomitans, and Streptococcus mitis present in 86%, 51%,
37%, 26%, and 7% of samples respectively.150 They did not test
for the Chlamydia species.
Chlamydia and Mycoplasma bacterium species live and
function like viruses; and therefore, antibiotics may not be
effective in eliminating these bacteria from joints and the
body. Antibiotics may affect the extracellular organisms but will
not affect the intracellular bacteria, although the microbes may
be placed into a dormant state. These bacteria are known to
stimulate the production of Substance P, cytokines, and tissue
necrosis factor, which are all pain modulating factors and con-
tribute to the destruction of the bone and cartilage of the
joint.146-149 In addition, these bacterial species have been associ-
ated with Reiter’s syndrome and dysfunction of the immune
system.
We also have identified specific genetic factors, human leu-
kocyte antigen (HLA) markers that occur at a significantly
greater incidence in TMJ patients than the normal popula-
tion.149 These same markers also may indicate an immune dys-
functional problem for these bacterial species, allowing the
bacteria to have a greater effect on patients with these markers
compared to people without these same markers.
Patients with localized TMJ reactive arthritis may have dis-
placed discs, pain, TMJ and jaw dysfunction, headaches, and ear
symptoms. As the disease progresses, condylar resorption and/
or bony deposition can occur, causing changes in the jaw and
occlusal relationships. Patients with moderate to severe reactive
arthritis may have other body systems involvement, including
the genitourinary, gastrointestinal, reproductive, respiratory,
cardiopulmonary, ocular, neurological, vascular, hemopoietic,
and immune systems, as well as involvement of other joints.
Clinical features. Although this condition commonly occurs
bilaterally, it can occur unilaterally. In some patients, there may
not be any significant condylar resorption and therefore may
not have an adverse effect on facial morphology or occlusion.
However, when causing condylar resorption, the following fea-
tures may be observed:
• Mandible may become progressively retruded
• Progressive worsening jaw and occlusal deformity, although
it may occur at a slow rate
• Class II occlusion and anterior open bite with premature
contact on the posterior teeth
• Common associated TMJ symptoms may include clicking,
popping, crepitus, TMJ dysfunction and pain, headaches,
myofascial pain, earaches, tinnitus, vertigo, and so on
• Other joints and body systems may be involved
Imaging. Radiographic features of reactive arthritis-causing
condylar resorption can include:
• Loss of vertical dimension and volume of the condyle
• Articular surface of the condyle may be eroded with loss of
the fibrocartilage covering the condyle and fossa
• Retruded mandible
• Class II occlusion with anterior open bite
• Decreased vertical height of the ramus and condyle
MRI will commonly show:
• Articular disc anteriorly displaced or in normal position
• Joint effusion and inflammation in T2 imaging
• Resorbing condyle
• Condylar and fossa erosions in advanced conditions (see
Figure 74-91)
Treatment options. The approach to treating this TMJ
pathology and associated deformity depends on the length of
time that the pathology has been present, the amount of
destruction to the disc and condyle at the time of surgery, and
the presence of other joint involvement (polyarthritis) or other
related systemic conditions. If the TMJ condition is identified
within the first 4 years of the onset of the disc dislocation, the
destruction is not significant, and there are no other joints
or systemic conditions present, then removing the bilaminar
tissues around the condyle and repositioning the articular disc
with the Mitek anchor technique may work well, preserving the
normal anatomical structures (see Figure 74-56).62,123,132-135 It is
possible that the resection and removal of a large portion of the
bilaminar tissue (where it is known that these bacteria reside)
during surgery may result in a major reduction of the source of
the inflammation. The orthognathic surgery can be done at the
same surgery as the joints are repaired.
If there is significant destruction of the condyle and the disc
is not salvageable, or polyarthritis or systemic disease are
present, then the most predictable treatment procedure is the
patient-fitted total joint prosthesis (TMJ Concepts) to recon-
struct the TMJ as well as reposition the mandible to its proper
position (see Figure 74-32).72,74,151-154 Fat grafts packed around
the total joint prosthesis are an important component to help
prevent fibrous tissue and heterotopic bone from forming.146,147
Trauma
Traumatic injuries to the jaws may create facial deformities
particularly involving the TMJs with unilateral or bilateral con-
dylar or subcondylar fractures that are inadequately reduced.
Patients may present with:
• Mandible retruded or deviated toward the affected side if
unilateral
• Pain and jaw dysfunction
• May exhibit deficient growth on the affected side(s) in
growing patients
• Class II skeletal and occlusal relationships
• Premature contact of the occlusion on the affected side(s)
with possible open bite and on the contralateral side
Imaging features could include:
• Evidence of previous condylar, mandibular, or midfacial
fractures
• The condyle, when fractured, may be malpositioned down-
ward, forward, and medial to the fossa
• Decreased vertical ramus/condyle length; MRI will also show
the disc position and condition
At the initial presentation of the trauma, the options for
treating subcondylar fractures are open reduction, closed
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
reduction, or no treatment. The amount of displacement and
the condition of the fracture(s) will dictate the necessary treat-
ment to fix the problem. When identified early, fractures may
be best treated by open reduction for significantly displaced
segments or closed reduction for minimally displaced segments
to achieve a symmetric face and stable occlusion. If the condyle
is minimally to moderately displaced, still salvageable along
with its articular disc but already healed, then it is possible that
orthognathic surgery could realign the jaw structures properly,
and if the disc is displaced, it can be repositioned with a Mitek
anchor (see Figure 74-56). If the condyle is severely deformed
and nonsalvageable, then the most predictable method for
reconstruction of the TMJ is using custom-fitted total joint
prostheses (TMJ Concepts) (see Figure 74-32), TMJ fat graft,
and repositioning of the mandible if there is an associated man-
dibular malalignment. Other treatment options for TMJ recon-
struction are rib grafts, sternoclavicular grafts, and so on. But
these outcomes are not as predictable as a custom-fitted total
joint prosthesis.
Temporomandibular Joint Ankylosis
TMJ bony ankylosis usually develops as a result of trauma,
inflammation, sepsis, and/or systemic diseases causing severely
limited jaw function, as well as oral hygiene and nutritional
problems. When this condition occurs during the growing
years, it can severely affect jaw growth and development. In
unilateral ankylosis, the other condyle will continue to grow but
may be retarded in its true growth potential. The common clini-
cal and radiographic characteristics of TMJ ankylosis, particu-
larly when occurring in children, include decreased jaw mobility
and function, decreased growth on the involved side, facial
asymmetry if unilateral involvement with the mandible shifted
toward the ipsilateral side, retruded mandible, usually a Class II
occlusion, and radiographic and MRI evidence of bony anky-
losis between the condyle and the fossa or heterotopic bone
surrounding the joint.
The most predictable treatment for the ankylosed TMJ
patient includes75,76:
• Release of the ankylosed joint; removal of the heterotopic
and reactive bone with thorough débridement of the TMJ
and adjacent areas
• Reconstruct the TMJs (and if indicated, advance the man-
dible) with a custom-fitted total joint prosthesis
• Coronoidotomies or coronoidectomies if the ramus is
significantly advanced or vertically lengthened with the
prosthesis
• Autogenous fat graft (harvested from the abdomen or
buttock) packed around the prosthesis in the TMJ area
• Additional orthognathic surgery if indicated; in these cases,
it is absolutely necessary that fat grafts be packed around the
articulating parts of the prosthesis to prevent the reoccur-
rence of heterotopic and reactive bone, as well as minimize
fibrosis
Other techniques that have been advocated for reconstruc-
tion of TMJ ankylosis include using autogenous tissues, such as
temporal fascia and muscle flaps, dermis-fat grafts, rib grafts,
sternoclavicular grafts, vertical sliding osteotomy, gap arthro-
plasty, and so on. The total joint prosthesis with a fat graft
packed around it is a superior technique relative to prevention
of re-ankylosis, providing jaw and occlusion stability, improv-
ing function and facial balance, and eliminating or decreasing
pain.75,76 When treating young growing patients (10 years old or
1105
older), the custom-fitted total joint prosthesis with fat graft may
still be the best option to eliminate the ankylosis. However,
because there would be no growth potential on the ipsilateral
side of the mandible (there is also no growth potential with a
bony ankylosis), orthognathic surgery will likely be necessary,
but it can be delayed until the patient has most of the facial
growth complete (females 15 years old; males 17 to 18 years
old). Then double jaw orthognathic surgery can be performed,
including a ramus sagittal split on the side of the prosthesis to
reposition the jaws into the best alignment, or the ipsilateral
side can be advanced by repositioning the mandibular compo-
nent of the prosthesis or fabrication of a new, longer mandibu-
lar component.
Congenital Deformed/Absent Temporomandibular Joint
(Hemifacial Microsomia)
There are hundreds of congenital syndromes that can cause
facial deformities. Hemifacial microsomia (HFM) is one of the
more common syndromes. Clinical and radiographic features
of HFM usually include unilateral hypoplasia or aplasia of the
mandibular condyle, ramus, and body, as well as hypoplasia of
the maxilla, zygomatico-orbital complex, and temporal bone;
decreased ipsilateral facial height; retruded mandible deviated
toward the ipsilateral side; Class II malocclusion; transverse
cant in the occlusal plane and skeletal structures; significant soft
tissue deficiency on the involved side affecting muscles, subcu-
taneous tissues, and skin volume; and decreased oropharyngeal
airway. With growth, the facial deformity, asymmetry, and mal-
occlusion usually worsen.
Approximately one-third of the HFM cases will have dis-
placed articular discs on the contralateral side. These patients
should be evaluated for this concomitant occurrence, and a
TMJ MRI study will be warranted for the diagnosis. Our treat-
ment protocol for managing HFM for patients 14 years old or
older who have significant hypoplasia or absence of the TMJ
includes the following:
• Ipsilateral TMJ reconstruction and mandibular advance-
ment with custom-fitted total joint prostheses (see
Figure 74-32)
• Contralateral disc repositioning with Mitek anchor (see
Figure 74-56)
• Contralateral ramus sagittal split osteotomy to advance the
mandible
• Multiple maxillary osteotomies to transversely level, advance,
and rotate counterclockwise
• Fat graft to ipsilateral total joint prosthesis
• Ancillary procedures (i.e., genioplasty, rhinoplasty, turbinec-
tomies, and so on)
Surgery stage 2 may be indicated to provide additional
bony and soft tissue augmentation on the ipsilateral side. This
protocol provides the most stable and predictable treatment
outcomes.
A patient with HFM who is 6 to 12 years old with absence
of the TMJ may benefit from a growth center transplant using
a sternoclavicular graft or rib graft. Rib grafts are unpredict-
able relative to growth and stability. Sternoclavicular grafts
tend to have better growth potential, similar to normal TMJ
growth. Orthognathic surgery may be necessary at a later age
(following completion of growth) to maximize the functional
and esthetic results. Teenage or older patients with significant
deformity of the condyle and ramus may have a much
better outcome using a patient-fitted TMJ total joint prosthesis
1106 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
(TMJ Concepts) to advance and lengthen the ramus on the
ipsilateral side.
Deferring treatment until the patient is closer to completion
of facial growth (girls, 15 years old; boys, 17 to 18 years old)
helps minimize subsequent contralateral normal growth effects
on the treatment outcome. A mandibular ramus sagittal split
osteotomy can be performed on the contralateral side, and the
indicated maxillary osteotomies can be completed as well as
any other adjunct procedures. Additional reconstruction may
be necessary using bone grafts, synthetic bone, or alloplastic
implants to build up the residual deformed skeletal structures.
Soft tissue reconstruction using fat grafts, tissue flaps, and vas-
cularized free flaps, for example, may be necessary to fill out the
soft tissue defects.
Autoimmune and Connective Tissue Diseases
Etiology. Conditions included in the classification of auto-
immune and connective tissue diseases that can affect the TMJs
are rheumatoid arthritis, JIA, psoriatic arthritis, ankylosing
spondylitis, Sjögren syndrome, systemic lupus erythematosus,
scleroderma, mixed connective tissue disease, and so on. The
triggers and precise pathophysiology are unknown for most of
these disorders. Multiple systems are usually involved. Joint
damage may be mediated by cytokines, chemokines, and metal-
loproteases. Peripheral joints are usually symmetrically inflamed
resulting in progressive destruction of articular structures,
commonly accompanied with systemic symptoms.
Clinical features. Adult onset in some patients may affect the
TMJs but not cause significant condylar resorption, particularly
if caught early and placed on appropriate medications. However,
when the disease onset is in the first or second decade or adult
onset with TMJ involvement and condylar resorption, then the
following characteristics may be present:
• Progressive retrusion of the mandible with worsening skel-
etal and occlusal deformity
• Indirect involvement of the maxilla with posterior vertical
hypoplasia particularly when occurring in growing patients
• Class II occlusion with or without an anterior open bite
(Figures 74-94, A-C, and 74-95, A-C)
• TMJ symptoms could include clicking, crepitus, TMJ dys-
function and pain, headaches, myofascial pain, earaches,
tinnitus, vertigo, and so on
• Other joints and systems commonly involved
Imaging. Features may include:
• Loss of condylar vertical dimension and volume; residual
condyle may become broad in the AP direction but with
significant mediolateral narrowing
• In advanced disease, resorption of the articular eminences
• Residual condyle may function forward beneath the remain-
ing articular eminence (Figure 74-96)
• Decreased vertical height of the ramus and condyle
• Skeletal and occlusal Class II relationship; high occlusal
plane angle facial morphology with or without anterior
open bite
• Decreased oropharyngeal airway (Figure 74-97, A).
MRI imaging may show:
• Articular discs may be in position but will usually be sur-
rounded by a reactive pannus that causes resorption of the
condyles and articular eminences and eventually destroys
the discs
• AP mushrooming of the residual condyle but narrow medial-
lateral width
• May or may not demonstrate an inflammatory response (see
Figure 74-93)
Treatment. The most predictable treatment for the TMJ
affected by autoimmune and connective tissue diseases includes:
• Reconstruct the TMJs and advance the mandible in a coun-
terclockwise direction with patient-fitted total joint prosthe-
sis (TMJ Concepts; see Figure 74-32)72,74,135,151-155
• Bilateral coronoidectomy if the rami are significantly
advanced or vertically lengthened with the prostheses
• Autogenous fat graft packed around the articulation area of
the prostheses (harvested from the abdomen or buttock)75,76
• Maxillary osteotomies if indicated
• Any additional adjunctive procedures indicated (i.e., genio-
plasty, rhinoplasty, turbinectomies, septoplasty, and so on)
These diseases can stimulate reactive or heterotopic bone
formation around the prostheses. Therefore, it is necessary that
fat grafts be packed around the articulating parts of the pros-
theses to prevent this occurrence and minimize fibrotic tissue
formation.75,76 Orthognathic surgery can be performed at the
same time as the TMJ is reconstructed or performed at a later
surgery, but the TMJ surgery should be performed as the first
step in either approach.
Other techniques that have been advocated for TMJ recon-
struction in the autoimmune and connective tissue diseases
include using autogenous tissues, such as temporal fascia and
muscle flaps, rib grafts, sternoclavicular grafts, vertical sliding
osteotomy, and so on. However, the disease process that created
the original TMJ pathology can attack the autogenous tissues
used in the TMJ reconstruction causing failure of the grafts. The
patient-fitted total joint prosthesis with a fat graft packed
around it is a superior technique relative to elimination of the
disease process in the TMJ, improved function and esthetics, as
well as elimination or decrease in pain.
When treating young growing patients (8 to 10 years old or
older), the total joint prosthesis is still the best option to elimi-
nate the disease process. However, because there would be no
growth potential on the involved side(s) of the mandible,
orthognathic surgery will likely be necessary later, but it can be
delayed until the patient has most of the facial growth complete.
Then double jaw surgery can be performed, including the man-
dibular ramus sagittal split osteotomies (preferable to use an
extraoral approach so as not to contaminate the prostheses) to
reposition the jaws into the best alignment, or repositioning of
the mandibular components of the prostheses, or manufactur-
ing new longer mandibular components to achieve advance-
ment of the mandible in conjunction with maxillary osteotomies,
genioplasty, and so on. These secondary procedures are highly
predictable when performed at 14 years old or older in females
and 16 years old or older in males. However, the vector of facial
growth will change in younger patients to a downward and
backward direction because the maxillary and mandibular
dentoalveolus will continue to grow vertically until growth
cessation.44,126
Our studies show good outcomes in treating connective
tissue/autoimmune diseases affecting the TMJ with custom-
fitted total joint prostheses (TMJ Concepts) for TMJ recon-
struction and mandibular advancement, fat grafts, and
simultaneous maxillary orthognathic surgery.72,73,151-156 We have
evaluated the efficacy of using fat grafts around the prostheses
and demonstrated significant improvement in function and
decrease in pain for patients when using the fat grafts as com-
pared to patients who did not receive fat grafts.75,76 Post-surgery
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1107

A B C

D E F
FIG 74-94 This 22-year-old female has juvenile idiopathic arthritis (JIA) initiated when she was
in her first decade of life resulting in severe condylar resorption and facial deformity with severe
mandibular retrusion. A, Frontal view. B, Smiling. C, Profile view. The patient is seen at 42
months post-surgery demonstrating the significant improvement using TMJ Concepts patient-
fitted total joint prostheses and maxillary osteotomies to counterclockwise rotate and advance
the maxillomandibular complex. A genioplasty and partial nasal inferior turbinectomies were also
conjointly performed. D, Frontal view. E, Smiling. F, Profile view.

outcomes of 115 patients that received fat grafts around the
prostheses with an average post-surgery follow-up of 31 months
demonstrated significant improvement in jaw opening and
function post-surgery with no radiographic or clinical evidence
of heterotopic bone or significant fibrosis.
Dela Coleta and colleagues evaluated 47 female patients for
surgical stability following bilateral TMJ reconstruction using
TMJ Concepts patient-fitted TMJ total joint prostheses, TMJ fat
grafts, and counterclockwise rotation of the maxillomandibular
complex with menton advancing an average of 18.4 mm and
the occlusal plane decreasing an average of 14.9 degrees.74
Average follow-up was 40.6 months. Results demonstrated
minor maxillary horizontal changes, whereas the mandibular
measurements remained very stable.
The 22-year-old female pictured in Figure 74-94, A-C pre-
sented with JIA, which was initiated when she was in her first
decade of life, resulting in severe condylar resorption and facial
deformity with severe mandibular retrusion. She had previous
orthodontics as a teenager and repeated as an adult. She has a
Class II end-on occlusion and an anterior open bite (see Figure
74-95, A-C). She had moderate TMJ pain and headaches, severe
snoring, sleep apnea, nasal airway obstruction secondary to
1108 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B C

D E F
FIG 74-95 A to C, The pre-surgical occlusion is observed with a Class II end-on relation and an
anterior open bite. D to F, At 42 months post-surgery, the occlusion demonstrates the functional
improvement, Class I relation, and elimination of the open bite.

A B
FIG 74-96 A, This three-dimensional model demonstrates the severity of her condylar resorption.
Her previous orthodontics and mandibular posturing to increase her airway has resulted in the
condyles postured anterior of the glenoid fossa in front of the remaining articular eminence. The
green arrow points to the fossa and red arrow points to the ear canal. B, Computed tomography
(CT) scan of right temporomandibular joint (TMJ) shows the severe resorption of the condyle
and articular eminence as well as the significant forward posturing of the condyle anterior to the
fossa. The articular eminence is completely resorbed.

hypertrophied turbinates, hypothyroidism, and polyarthropa-
thy. The three-dimensional stereolithic model and right TMJ
CT scan (see Figure 74-96, A-B) demonstrates the severity of
her condylar resorption. Her previous orthodontics and man-
dibular posturing to increase her airway has resulted in the
condyles postured anterior of the glenoid fossa in front of
the remaining articular eminence. The green arrow points to
the fossa and red arrow points to the ear canal. The articular
eminence is completely resorbed.
The lateral cephalometric analysis (see Figure 74-97, A)
demonstrates the severe retrusion of the mandible, posterior
vertical maxillary hypoplasia, high occlusal and mandibular
planes, forward position of the condyles anterior to the fossae,
and decreased oropharyngeal airway contributing to her sleep
apnea. The surgical treatment plan was determined on the
prediction tracing (see Figure 74-97, B) and included:
• Bilateral TMJ reconstruction and mandibular counterclock-
wise rotational advancement with TMJ Concepts patient-
fitted total joint prostheses
• Multiple maxillary osteotomies for counterclockwise
rotation, leveling the occlusal plane, and expansion
• Bilateral coronoidotomies
• Bilateral TMJ fat grafts (harvested from the abdomen);
• Bilateral partial nasal turbinectomies
• Genioplasty
The patient is seen 42 months after surgery, demonstrating
significant improvement and stability in function and esthetics
(see Figures 74-94, D-F, and 74-95, D-F). She is pain free, has
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1109

not promote soft tissue stretching, a solid stability would be

expected once appropriate IRF was used. Mandibular growth,
condylar hyperplasia (and other less frequent hyperplastic
condyle pathologies), and the degree of clockwise movement of
the proximal segment are among the most frequently men-
tioned causes for mandibular setback instability.79-81,83,158-160
Mandibular setback instability can also be affected by the
decrease of the oropharyngeal airway dimensions. In such cases,
87 the physiological need of airway space maintenance promotes
74 forward posturing of the tongue that results in proclined lower
25 19 incisors and may stimulate remodeling of the anterior region
4 20 of the mandible in a forward direction.
Condylar hyperplasia is a relatively common condition that
2 can affect orthognathic surgery outcomes. Condylar hyperplasia
A is a generic term describing conditions that cause excessive
5 growth and enlargement of the mandibular condyle. There
are a number of suggested etiologies of condylar hyperplasia,
15
40 including neoplasia, trauma, infection, abnormal condylar
44
loading, and aberrant growth factors.161 These condylar pathol-
-2.5 ogies can adversely affect the size and morphology of the man-
dible, alter the occlusion, and indirectly affect the maxilla with
resultant development or worsening of dentofacial deformities,
such as mandibular prognathism; unilateral enlargement of the
condyle, neck, ramus, and body; facial asymmetry; malocclu-
sion; pain; and post orthognathic surgery stability. Some con-
dylar hyperplasia pathologies occur more commonly within
S.S. STO particular age ranges and genders. Identifying the specific con-
dylar hyperplasia pathology provides insight to its progression
if untreated; the clinical, imaging, and histologic characteristics;
as well as treatment protocols proven to eliminate the patho-
logical processes and provide stable and predictable functional
and esthetic outcomes.
Wolford and colleagues introduced a condylar hyperplasia
8
classification system differentiating between horizontal and ver-
tical growth vectors that are usually related to specific but dif-
18 ferent mandibular condylar pathological conditions.80,81 The
8 3
4 two most common conditions that can adversely affect orthog-
nathic surgery stability are condylar hyperplasia types 1 and 2.
Condylar hyperplasia type 1 results in predominately a horizon-
tal vector of mandibular growth; bilateral or unilateral creating
mandibular prognathism, symmetric or asymmetric. Condylar
B 17 hyperplasia type 2 is an abnormal unilateral excessive vertical
12 growth of the mandible usually caused by a condylar osteo-
29 chondroma accompanied with unilateral compensatory down-
ward growth of the maxilla.
FIG 74-97 A, Lateral cephalometric analysis demonstrates the Condylar hyperplasia type 1 occurs in adolescence, and the
severe retrusion of the mandible, high occlusal and mandibular pathological process is usually initiated during the pubertal
planes, forward position of the condyles anterior to the fossae, growth phase suggesting a hormonal etiology. Approximately
and decreased oropharyngeal airway. B, The prediction tracing one-third of the cases may be genetically related, but the other
illustrates the counterclockwise rotation advancement of the two-thirds occur spontaneously.162 The gender distribution in
maxillomandibular complex with the TMJ Concepts patient- our study was 60% female.89 Normal jaw growth is usually 98%
fitted total joint prostheses and maxillary osteotomes, as well complete in females at 15 years old and in males at 17 to 18
as the genioplasty to maximize the functional and esthetic years old.125 Condylar hyperplasia type 1 is an accelerated and
outcomes. excessive growth of the “normal” condylar growth mechanism
creating overgrowth of the mandible predominately in a hori-
zontal vector (mandibular prognathism) with the growth often
good jaw function (incisal opening 46 mm), eats a normal diet, continuing into the patient’s early to middle 20s, but condylar
and reports elimination of snoring and sleep apnea. hyperplasia type 1 is a self-limiting growth aberration. Patients
may begin with a Class I occlusal and skeletal relationship as
Mandibular Setback they enter their pubertal growth phase and grow into a Class
Mandibular setback instability has been reported with surpris- III skeletal and occlusal relationship or begin as a Class III
ingly frequency.157 Considering that mandibular setback does and develop into a worse Class III relationship. Condylar and
1110 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
mandibular growth can be accelerated bilaterally (condylar
hyperplasia type 1A) or unilaterally (condylar hyperplasia type
1B) in a horizontal or uncommonly a vertical vector. The
increase in the mandibular growth rate occurs in the condyle
but causes elongation of the condylar head, neck, and mandibu-
lar body, which leads to development of a Class III skeletal and
occlusal relation, as well as dental compensations where the
mandibular incisors can become lingually inclined and the
maxillary incisors overangulated.79,81,125 If orthognathic surgery
is performed on patients with this condition prior to the cessa-
tion of growth (early to middle 20s), post-surgical relapse can
be expected.
Not all prognathic mandibles are caused by condylar hyper-
plasia; only those demonstrating accelerated, excessive man-
dibular growth that continues beyond the normal growth years.
Differential diagnosis includes the following:
• Class III skeletal relationship with normal mandibular and
maxillary growth
• Deficient maxillary growth with a normal growing
mandible
• Condylar hyperplasia type 1 with or without deficient maxil-
lary growth
Differentiation must be clarified between condylar hyperpla-
sia type 1 and maxillary growth deficiency (maxillary hypopla-
sia). Maxillary hypoplasia can also result in a Class III occlusal
and skeletal relationship in the presence of a normal growing
mandible with a resultant progressive worsening occlusion
through the normal facial growth process (usually completed at
15 years old for females, 17 to 18 years old for males) with
stability of the jaw and occlusal relationship after that time.
Maxillary hypoplasia creating the Class III relationship is
usually evident years before the pubertal growth phase. Maxil-
lary hypoplasia can also be present with accelerated mandibular
growth (condylar hyperplasia type 1) creating a more extreme
dentofacial deformity. However, the accelerated mandibular
growth is usually not evident until initiated during pubertal
growth. Deviated mandibular prognathism is usually related to
bilateral condylar hyperplasia type 1A where one side is growing
faster than the opposite side or condylar hyperplasia type 1B
where only a unilateral condyle is involved.
Analysis of serial lateral cephalometric and lateral tomo-
grams that include the TMJ, ramus, and mandibular body
should allow determination of the growth rates of the maxilla
and mandible to differentiate the source of the Class III occlusal
and skeletal relationship. In condylar hyperplasia type I, growth
can usually be determined by worsening functional, esthetic,
skeletal, and occlusal changes with serial assessments (prefera-
bly at 6 to 12 month intervals) consisting of clinical, dental
model, and radiographic evaluations.44,125
During pubertal growth, the normal yearly growth rate of
the mandible measuring from condylion to point B is 1.6 mm
for females and 2.2 mm for males.46 Growth significantly greater
than the normal rate indicates accelerated growth likely related
to condylar hyperplasia type 1. With asymmetric condylar
growth, the amount of growth may be more difficult to deter-
mine from the lateral cephalogram because of the mandible
shifting toward the side with less growth, essentially hiding
some of the forward growth and elongation on the faster
growing side. Thus, using lateral TMJ tomograms that include
the mandibular body, ramus, and condyle will allow superim-
position of the body, ramus, and posterior teeth to analyze the
amount of condylar growth over time for each side. A horizon-
tal mandibular growth vector extending beyond the normal
growth years will likely be condylar hyperplasia type 1, and the
growth can continue into the middle 20s until cessation.
Bone scintigraphy of the TMJs in most cases will be nondi-
agnostic in determining active condylar hyperplasia type 1
growth, because the active growth center is extremely narrow
and will not produce detectable increased activity. Healthy
growing TMJs normally light up some in scintigraphy. The
growth rate of condylar hyperplasia type 1 is not a tumorous
rate, as seen in condylar hyperplasia type 2, but only somewhat
faster than the normal condylar growth rate; thus, it is usually
difficult to differentiate condylar hyperplasia type 1 from
normal growth, particularly if both joints are involved. In uni-
lateral cases, it may also be difficult to determine an increased
uptake on the involved side, particularly if the contralateral
TMJ develops a displaced disc and associated arthritic changes
(a common contralateral development), because this contralat-
eral TMJ may also have a slight increased uptake. Wrist/hand
radiographs provide no insight to condylar hyperplasia type 1
growth, because there is no correlation between normal physi-
ological development and the pathological process affecting the
mandibular condyles.
Histologically, a normal condyle is approximately 15 to 20
mm long mediolaterally and 8 to 10 mm wide anteroposteri-
orly and is composed of the following tissue layers beginning
from the outside and progressing inward: fibrous connective
tissue layer forming the articulating surface, undifferentiated
mesenchyme proliferation layer, intermediate layer, cartilage
layer, compact bone, and spongy bone.163 In condylar hyper-
plasia type 1, histology of the affected condyle commonly
looks like a normal growing condyle without any notable path-
ological abnormalities. In some cases, the proliferative layer
may demonstrate greater thickness in some areas. The activity
of the proliferative layer may regulate the rate at which the
condyle and condylar neck (which is formed from the condyle
by remodeling) will grow. In normal condyles, the formation
of cartilage from the proliferative layer and the replacement
of cartilage by bone ceases by approximately 20 years old. The
marrow cavity is entirely occluded from the remaining carti-
lage by the closure of the bone plate.164 The inability of this
plate to close in the presence of an active proliferative cartilage
layer may be a major etiological factor in condylar hyperplasia
type 1, and it may correlate to our observation that cessation
of growth related to condylar hyperplasia type 1, which may
not occur until the early to mid-20s.44,125 Clinically, we have
observed an increased vertical height of condyle covered by
the cartilaginous cap compared to the normal condyle. Con-
ditions that initiate excessive accelerated mandibular growth
after the pubertal growth phase (15 years old for females; 17
to 18 years old for males) are most often related to an osteo-
chondroma (condylar hyperplasia type 2) or other types of
proliferative condylar pathology (condylar hyperplasia type
3 or 4).
Condylar Hyperplasia Type 1A
Clinical characteristics. Patients with bilateral active condy-
lar hyperplasia type 1A may have some or all of the following
characteristics:
• Development or progressive worsening of mandibular
prognathism
• Worsening Class III malocclusion
• Anterior and posterior crossbites
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
• Dental compensations including decreased angulation of
lower incisors and overangulation of maxillary incisors
• Facial shape more triangular and tapered often with weakly
defined mandibular angles
• Masseter muscles have less bulk than normal
• Relatively asymptomatic for TMJ symptoms in patients with
symmetric growth of the mandible
In asymmetric cases where one side grows faster than the other,
patients may develop the following:
• Facial asymmetry with the mandible shifting toward the
slower growing side
• Anterior and unilateral posterior crossbite on the slower
growing side
• Greater Class III occlusion on the faster growing side
• Displaced articular disc in the TMJ on the slower growing
side and sometimes on the faster growing side
• TMJ symptoms (such as, clicking, TMJ pain, headaches,
masticatory dysfunction, ear symptoms, and so on) may be
present
Imaging. Lateral cephalometric and tomographic analyses
will demonstrate:
• Class III skeletal and occlusal relationship, except in patients
with high occlusal plane angulation where the occlusion
will be Class III but the skeletal relation could be closer to
Class I
• Condylar head and neck are elongated, but the top of the
condyle will have a smooth, relatively normal appearing
morphology
• In the coronal view, the top of the condyle will appear more
rounded than normal
• Mandibular body is elongated
• Gonial angle may be more obtuse
• Vertical height of the posterior mandibular body may be
decreased
• AP thickness of the symphysis and alveolus may be
narrower
• Medio-lateral width and AP dimension of the rami may be
narrower compared to normal
• Cranial base length tends to be decreased and the cranial
base angulation (Sella-Nasion to Nasion-Basion) tends to be
increased compared to normal
• Slope of the posterior border of the ramus compared to
Frankfort horizontal plane may be angled forward greater
than normal, particularly in the faster growing cases
In the MRI (see Figure 74-5, A), the articular discs are com-
monly thin and may be difficult to identify. Occasionally, the
articular discs can be posteriorly displaced. Posterior disc dis-
placement only occurs in these conditions where there is an
increased rate of vertical condylar growth that is faster than the
rate of upward migration of the posterior ligament attachment
of the disc, thus pulling the disc posterior to the condyle as the
condyle continues to grow at an accelerated rate. In asymmetric
condylar hyperplasia type 1A, disc dislocation can occur unilat-
erally (greater risk on the slower growing side) or bilaterally.
Treatment protocol. Treatment of condylar hyperplasia type
1 depends on whether the growth is still active or arrested.
Because condylar hyperplasia type 1 is self-limiting relative to
growth, patients in their middle 20s or older will not have
further jaw growth related to condylar hyperplasia type 1 so that
routine orthognathic surgical procedures can usually be per-
formed to correct the dentofacial deformity and malocclusion.
However, if the TMJ discs are displaced and salvageable, the
1111
discs may require repositioning. If the patient is still a teenager
or even in their early 20s, the growth process can be active and
progressive. If there is active growth and only the orthognathic
surgery is performed, then there will be predictable relapse with
the mandible growing out into a Class III skeletal and occlusal
relationship.44,125 If growth is active, then there are two predict-
able treatment options.
Option 1. Wolford’s surgical protocol for active condylar
hyperplasia type 1A includes:
• High condylectomy removing 4 to 5 mm of the top of the
condylar head on the involved side (both sides for bilateral
condylar hyperplasia), including the medial and lateral pole
areas that will arrest any further AP growth of the mandible
• Reposition the articular discs using the Mitek anchor (Mitek
Products Inc., Westwood, MA) technique
• Perform the appropriate orthognathic surgical procedures,
including bilateral mandibular ramus osteotomies and max-
illary osteotomies if indicated
• Additional ancillary procedures as indicated (third molar
removal, genioplasty, turbinectomies, rhinoplasty, and so on)
This protocol provides predictable and stable results. These
procedures can be done in one operation or divided into two
or more operations depending on the surgeon’s skills and expe-
rience, but the TMJ surgery should be performed first.
Option 2. Delay surgery until growth is complete; then
perform orthognathic surgery only. However, because these
patients often continue to grow into the middle 20s, the surgery
should be delayed until it is confirmed that the growth has
stopped. The longer the abnormal growth is allowed to proceed,
the worse the facial deformity, asymmetry, and dental compen-
sations will become affecting the dentoskeleton along with
excessive soft tissue development. This may increase the diffi-
culties in obtaining an optimal functional and esthetic result,
besides the adverse effects on the occlusion, dental compensa-
tions, mastication, speech, and psychosocial development. If the
TMJ articular discs are displaced, then TMJ surgery may still be
indicated to reposition the discs.
Wolford’s surgical protocol for treating active condylar
hyperplasia type 1A is a highly predictable treatment that will
stop the abnormal growth and allow completion of the orthog-
nathic surgery at the same operation with long-term stable
functional and esthetic outcomes.44,125 Except in select cases,
surgical correction of condylar hyperplasia type 1A requiring
double jaw surgery should be deferred until at least 14 years old
in females and 16 years old in males, which is when normal
maxillary and mandibular growth are closer to completion.
Because no further AP growth of the mandible and maxilla can
be expected after high condylectomies and Le Fort I osteoto-
mies, residual maxillary vertical growth results in a downward
and backward rotation of the maxillomandibular complex, but
the occlusion should remain stable.44-46,126 If only the high con-
dylectomies and mandibular osteotomies are performed (no
maxillary osteotomies), then surgery should be delayed until 15
years old for females and 17 to 18 years old for males, because
the maxilla can continue to grow in the AP and vertical direc-
tion, potentially developing a Class II occlusion if surgery is
performed earlier because of cessation of mandibular growth
from the high condylectomies.
Wolford and colleagues have demonstrated in comparative
studies of active condylar hyperplasia type 1 patients divided
into two groups.79,81 Group 1 patients were treated with conven-
tional orthognathic surgery only and the mandible continued
1112 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
to grow post-surgery, whereas Group 2 patients that also had
high condylectomies and orthognathic surgery performed had
resultant stable Class I occlusal and skeletal outcomes. These
studies confirm that high mandibular condylectomies stop
mandibular AP growth, providing a means to achieve predict-
able and stable treatment outcomes.
Condylar Hyperplasia Type 1B
Clinical characteristics. Condylar hyperplasia type 1B is the
unilateral form with the following common characteristics:
• Usually grows in a horizontal direction, although there occa-
sionally can be a vertical directional component
• The left to right vertical facial heights are usually relatively
symmetric, but the ipsilateral side sometimes can be verti-
cally longer
• The mandible becomes prognathic and deviated toward the
contralateral side
• Increased worsening of the ipsilateral Class III occlusion,
whereas the contralateral side usually remains Class I
• Crossbites develop anteriorly and on the contralateral side
• The mandibular dental midline and chin shift off the facial
midline toward the contralateral side
• The mandible continues to grow more asymmetric beyond
the normal growth years but usually will complete its growth
in the early to middle 20s
• Unilateral condylar hyperplasia may cause articular disc dis-
placement, particularly on the contralateral side, creating
typical TMJ symptoms
Imaging. Radiographic imaging for condylar hyperplasia
type 1B patients commonly shows the following features:
• Mandibular deviated prognathism
• Mandibular asymmetry primarily in a transverse direction
(however, there can occasionally be a vertical component)
with the mandible and chin shifted toward the
contralateral side
• Condylar head and neck on the involved side are longer in
length as compared to the contralateral side
• The ipsilateral body of the mandible may be more bowed
and the contralateral side may be more flat, creating signifi-
cant asymmetry in the axial plane of the mandible
• Bone scans may or may not be of value in diagnosing con-
dylar hyperplasia type 1B because the growth rate, although
accelerated, is still relatively slow but continuous on the
involved side
In addition, if there is a displaced disc and mild arthritis on
the contralateral side, there may not be much differentiation in
the amount of isotope uptake comparing one side to the other.
Serial radiographs (lateral cephalograms, cephalometric tomo-
grams, and so on), dental models, and clinical evaluations are
usually the best diagnostic methods to determine if the growth
process is still active.
MRI may show a displaced articular disc on the contralateral
side with mild arthritis (see Figure 74-5, C) and sometimes
disc displacement on the ipsilateral side of condylar hyperplasia
type 1B. The disc on the ipsilateral side is often thinner than a
normal disc, making it sometimes difficult to identify on MRI.
Occasionally there can be a posteriorly displaced disc on the
ipsilateral side.
Treatment protocol. The treatment options for condylar
hyperplasia type 1B are similar to those of condylar hyperplasia
type 1A, where confirmed non-growing patients can be treated
with traditional orthognathic surgery. The TMJs only need to
be addressed if the articular discs are displaced; a relatively
common occurrence is facial asymmetries. If active growth is
confirmed, then there are two options for treatment.
Option 1. Wolford’s surgical protocol for active condylar
hyperplasia type 1B is:
1. Unilateral high condylectomy to arrest the aberrant condylar
growth and disc repositioning
2. Contralateral disc repositioning if indicated
3. Orthognathic surgical procedures, often requiring double
jaw surgery to optimize the functional and esthetic outcome
4. Other ancillary procedures as indicated
This protocol predictably stops ipsilateral mandibular
growth and provides highly predictable and stable outcomes
with normal jaw function and good esthetics.89,165
Option 2. Delay surgery until growth is complete, which
could be in the early to middle 20s; then perform orthognathic
surgery only. However, the longer the abnormal growth is
allowed to proceed, the worse the facial deformity, asymmetry,
occlusion, and dental compensations will become, along with
warping of the mandible, and ipsilateral excessive soft tissue
development. This increases the difficulties in obtaining an
optimal functional and esthetic result, besides the adverse
effects on the occlusion, dental compensations, mastication,
speech, and psychosocial development. If the TMJ articular
discs are displaced (a common occurrence), these patients may
also suffer from TMJ pain, headaches, and myofascial pain. TMJ
surgery may still be indicated to reposition the discs and stabi-
lize the joints, as well as eliminate the pain factors.
Surgery for condylar hyperplasia type 1B cases should be
deferred until 15 years old for females and 17 to 18 years old
for males. The severity of the deformity, however, may warrant
earlier surgery. If the ipsilateral high condylectomy is done too
early (before 15 years old in females and 17 to 18 years old in
males) where normal jaw growth is still occurring, then there is
the risk of the unoperated contralateral condyle continuing
with normal growth and shifting the mandible toward the ipsi-
lateral side until normal growth cessation. In condylar hyper-
plasia type 1B, the contralateral TMJ articular disc is commonly
displaced. Therefore, disc repositioning with the Mitek anchor
technique would be indicated but without the high condylec-
tomy. However, if surgery is indicated at an earlier age during
active growth, then a high condylectomy can also be performed
on the contralateral side so that the mandible will not grow and
will remain symmetrical.
Condylar Hyperplasia Type 2
Condylar hyperplasia type 2 is a unilateral mandibular condylar
enlargement caused by an osteochondroma that vertically
lengthens the ipsilateral mandible, can shift it toward the
contralateral side, and is not self-limiting relative to growth.162-
164
The growth rate for this pathology varies from slow to mod-
erate, but some cases can have a more rapid growth rate.
Confirmation of the condylar pathology usually requires histo-
logical assessment. Osteochondromas are one of the most
common benign tumors of bone, representing approximately
35% to 50% of all benign tumors and 8% to 15% of all primary
bone tumors, and it is the most common tumor of the man-
dibular condyle.
Histology. Osteochondromas (condylar hyperplasia type 2)
include a cartilaginous cap similar to that seen in a normal
growth cartilage, endochondral ossification, cartilaginous
islands in the subcortical bone, and a marrow space contiguous
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
with the underlying bone. It has been reported that the carti-
laginous cap may be 1 cm or greater in thickness in the axial
skeleton. However, it tends to be thinner in the maxillofacial
region and may even be absent in long-standing cases. Gray and
colleagues reported that the bony trabeculae are often thickened
and irregular, resulting in a consistently large volume of tra-
becular bone and a higher than normal percentage of surfaces
covered in osteoids.166,167 They also point out the presence of an
uninterrupted layer of undifferentiated germinating mesenchy-
mal cells, hypertrophic cartilage, and islands of chondrocytes in
the subchondral trabecular bone, as well as made the direct
correlation between the scintigraphic activity and the frequency
of cartilage islands at depth in the trabecular bone. The cartilage
islands are mini growth centers producing bone, causing
enlargement of the condyle.
Clinical characteristics. Common clinical features of condy-
lar hyperplasia type 2 include the following:
• Develops at any age but for most cases in the second decade
(68% of cases)
• Predominately occurs in females (76% of cases)
• Increased unilateral mandibular height involving the condyle,
neck, ramus, body, and dentoalveolous of the ipsilateral
mandible
• Increased soft tissue volume on the ipsilateral side of the face,
including elongation of the muscles of mastication
• Low mandibular plane angle facial type morphology
• Chin asymmetry vertically and transversely with shifting
toward the contralateral side
• Compensatory downward growth of the ipsilateral maxillary
dentoalveolous
• Lateral open bite on the ipsilateral side particularly in more
rapid-growing pathology
• Labial tipping of the mandibular ipsilateral posterior teeth
and lingual tipping of the contralateral posterior teeth
may occur
• Transverse cant in the occlusal plane
• Mandibular anterior teeth crowns may be tipped toward the
ipsilateral side and the long axis of the roots angled toward
the contralateral side
• Commonly contralateral TMJ arthritis and articular disc dis-
location (75% of cases) from the functional overload caused
by the ipsilateral pathology accompanied by symptoms, such
as clicking, popping, TMJ pain, headaches, and so on
Imaging. Radiographic features include the following:
• Enlarged, elongated, deformed ipsilateral condyle (condylar
hyperplasia type 2A), and commonly there may be exophytic
extensions of the tumor off of the condyle (condylar hyper-
plasia type 2B)
• Increased AP and mediolateral thickness of the ipsilateral
condylar neck
• Increased vertical height of the ipsilateral mandibular
condyle, neck, ramus, body, symphysis, and dentoalveolous
(see Figure 74-11, A)
• Increased vertical height of the ipsilateral maxillary
dentoalveolus
• Transverse cant in the occlusal plane
• Facial asymmetry
• Posterior border of the ipsilateral mandibular ramus may be
more vertical than normal
• Coronoid process is usually normal in size and may be dis-
placed below the zygomatic arch with elongation of the tem-
poralis muscle
1113
• Loss of antegonial notching with downward bowing of the
inferior border on the mandible
• The inferior alveolar nerve canal may be positioned adjacent
to the apices of the teeth but more commonly toward the
inferior border of the mandible
• Chin vertically longer on the ipsilateral side and may be
prominent in profile
MRI may show a displaced articular disc on the contralateral
side (76% of the cases) and associated arthritic condylar
changes. The disc is commonly in position on the ipsilateral
side, although it can also be displaced. Unless the tumor is very
slow growing, bone scintigraphy will usually show increased
uptake particularly in the more active tumors.
Condylar hyperplasia type 2 can be subdivided into two
primary groups based on tumor morphology. Condylar hyper-
plasia type 2A indicates an enlargement of the condylar head
and neck with a predominate vertical growth vector of the
osteochondroma without significant exophytic tumor develop-
ment. There can be unevenness or lumpiness on the condyle.
Condylar hyperplasia type 2B indicates exophytic tumor exten-
sions off the condyle, usually forward and medially, with the
head becoming significantly enlarged and deformed. The exo-
phytic growth can also occur posterior and lateral but are less
common. These tumors usually have a significant vertical
growth vector, but the exophytic growths, when relatively large,
can disarticulate the condyle down and out of the fossa creating
a greater exaggeration of the ipsilateral vertical height of the
jaws and face. When performing surgery to remove the tumors,
the incision for removal of condylar hyperplasia type 2A can
usually be smaller compared to a large condylar hyperplasia
type 2B that may require greater access and difficulty for
removal. Condylar hyperplasia type 2B may have a greater risk
of intraoperative and post-surgical vascular and neurological
complications.
The different growth patterns of the tumors for condylar
hyperplasia type 2A and 2B may be related to the anatomical
origin of the tumor on the condylar head, rate of growth, and
elongation adaptation of the muscles of mastication and other
soft tissues on the ipsilateral side. The constraints of the rate of
muscular and soft tissue adaptation and elongation compared
to the rate of tumor growth may redirect the tumor develop-
ment in the direction of least resistance; anterior and antero-
medial. The roof and posterior wall of the fossa, as well as the
lateral and medial capsular ligaments, may act as barriers,
directing the growth forward. We have treated cases with the
rare development of the exophytic growth extending laterally
and posteriorly.
Treatment protocol. There are two basic treatment approaches
for managing condylar hyperplasia type 2. Because this pathol-
ogy is usually progressive and deforming, both options include
a condylectomy to remove the tumor.
Option 1. Wolford’s surgical protocol for condylar hyper-
plasia type 2 includes:
1. Low condylectomy removing the ipsilateral condyle at the
condylar base, preserving the condylar neck
2. Reshape the condylar neck to function as the new condyle
3. Reposition the articular disc over the top of the condylar
neck and stabilize
4. Reposition the articular disc on the contralateral side when
displaced
5. Orthognathic surgery to correct the associated maxillary and
mandibular deformities
1114 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
6. Inferior border ostectomy on the ipsilateral side to reestab-
lish vertical height balance of the mandibular ramus, body,
and symphysis if indicated
This last procedure requires dissection and preservation of
the inferior alveolar nerve if it is located low in the mandible
where the ostectomy will be performed. This protocol provides
predictable and stable outcomes, as well as optimizes the func-
tional and esthetic results. This treatment approach allows
removal of the tumor, yet still uses the enlarged condylar neck
as the new condyle. The articular disc on the ipsilateral side and
frequently on the contralateral side (if that disc is displaced)
requires repositioning and stabilization to provide the best
treatment outcome relative to function, esthetics, and elimina-
tion of any associated pain and dysfunction.80,83 If the disc
is nonsalvageable, then the authors prefer a custom-fitted
total joint prosthesis to reconstruct the ipsilateral and/or
contralateral TMJ.
Option 2. The most popular approach for treating condylar
hyperplasia type 2 is performing only an ipsilateral condylec-
tomy, either partial or complete, without any orthognathic
surgery. With a partial condylectomy, usually no other surgery
is recommended. When the condylectomy results in significant
functional and occlusal instability, or where the entire condyle
and neck have been removed, then condyle reconstruction tech-
niques may include the following: TMJ total joint prosthesis,
sliding ramus osteotomy, rib graft, sternoclavicular graft, free
bone graft, pedicled osseous graft, and so on. When only the
ipsilateral condyle is addressed with no additional orthognathic
surgery included, the patient is often left with a compromised
functional and esthetic result because the significant facial
asymmetry remains, as well as a possible malocclusion. This is
particularly the case if significant ipsilateral downgrowth of the
maxilla and vertical elongation of the ipsilateral mandibular
body and ramus has occurred. Some of these patients may
require secondary orthognathic procedures to achieve a func-
tional occlusion and to restore good facial balance and esthetics.
Without maintaining a functional ipsilateral articular disc when
using the autogenous condylar reconstruction techniques, sig-
nificant post-surgical TMJ dysfunction may develop.
When condylar hyperplasia type 2 is identified during the
normal growth years, then surgery should be deferred, if pos-
sible, until 15 years old for females and 17 to 18 years old for
males after normal jaw growth is relatively complete. The sever-
ity of the deformity, however, may warrant earlier surgery. If the
ipsilateral low condylectomy is done too early (before 15 years
old in females and 17 to 18 years old in males) where normal
jaw growth is still occurring, then there is the risk of the contra-
lateral condyle continuing with normal growth shifting the
mandible toward the ipsilateral side until growth cessation. In
condylar hyperplasia type 2, the contralateral TMJ articular disc
is commonly displaced (76% of cases), and therefore, disc repo-
sitioning would be indicated. However, if surgery is indicated
at an earlier age, then a high condylectomy can be performed
on the contralateral side so that no further growth will occur
and the mandible will remain symmetric. Another option
would be to perform the unilateral condylectomy and plan for
orthognathic surgery as a second stage after cessation of growth.
Ideal facial balance may be difficult to achieve after surgery
because of the excessive amount of soft tissue development that
occurs with the unilateral elongation and transverse asymmetry
that develops. In addition, the ipsilateral mandibular body
becomes more curved and the contralateral body contour is
flatter. Thus, with vertically shortening the ipsilateral bony
structures and rotation of the chin toward the ipsilateral side,
there is excessive soft tissue bulk, including the masseter muscle
that will make the ipsilateral side appear fuller, even with the
most accurate skeletal correction.
A 15-year-old Class III female patient presented with active
condylar hyperplasia type 1A, maxillary hypoplasia, Class III
malocclusion, and impacted third molars × 4 (Figures 74-98,
A-E). Pre-surgical growth is demonstrated in Figure 74-99
where red is 1 year pre-surgery and white is immediate pre-
surgery. The condylar growth is demonstrated in Figures 74-100
and 74-101 where red represents 1 year pre-surgery and white
immediate pre-surgery. This excessive growth is compatible
with condylar hyperplasia type 1A. The patient was successfully
treated with Wolford’s protocol of bilateral high condylectomies
and simultaneous maxillomandibular osteotomies, as well as
removal of the impacted third molars. Skeletal stability is dem-
onstrated in Figure 74-102 at 9 months post-surgery with no
significant detectable change comparing the immediate post-
surgery and 9-month follow-up superimpositions. Condylar
changes and remodeling after high condylectomy is well dem-
onstrated in this clinical case with no detectable further growth
(Figures 74-103 and 74-104). Figure 74-105 shows the 1-year
post-surgery clinical results with improved function and esthet-
ics, as well as excellent stability. Figure 74-106, A-C, confirms
the changes accomplished comparing the pre-surgery position
(white) to the 9-month post-surgery position (light blue).
Figure 74-107 and Figure 74-108 show the condylar changes
from pre-surgery (white) to 9 months after surgery (light blue)
that includes the high condylectomies and post-surgical
remodeling.
Healthy and stable TMJs are necessary for quality treatment
outcomes in orthognathic surgery. If the TMJs are not stable
and healthy, orthognathic surgery results may be unsatisfactory
relative to function, esthetics, and skeletal and occlusal stability,
as well as pain. The oral and maxillofacial surgeon should be
suspicious of possible TMJ problems in the following types of
patients:
• Class II high occlusal plane angle and retruded mandibular
morphological type, particularly those with anterior
open bites
• Progressively worsening Class II occlusal and jaw
relationship
• Class III prognathism with progressive worsening
• Facial asymmetry, particularly with progressive worsening
• Patients reporting headaches, TMJ pain, myofascial pain,
clicking and popping of the TMJs, and/or ear symptoms
The surgeon should not ignore these symptoms. With one
or more of these symptoms, patients should be evaluated
for possible TMJ pathology. An MRI of the TMJs can aide
in identification of the specific TMJ pathology. Failure to
recognize and treat these conditions can result in significant
relapse, increased pain, and a greater complexity of subsequent
treatment.
During the past two decades, major advancements have been
made in TMJ diagnostics and the development of surgical pro-
cedures to treat and rehabilitate the pathological, dysfunctional,
and painful TMJ. Research has clearly demonstrated that TMJ
and orthognathic surgery can be safely and predictably per-
formed at the same operation, but it does necessitate the correct
diagnosis and treatment plan, and it requires the surgeon
to have expertise in both TMJ and orthognathic surgery.
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1115

A B

C D E
FIG 74-98 A to E, This 15-year-old female presents with bilateral condylar hyperplasia (condylar
hyperplasia type 1A) demonstrating an accelerated and prolonged development of Class III occlu-
sion and mandibular prognathism. She was treated with bilateral mandibular high condylecto-
mies, articular disc repositioning with Mitek anchors, maxillary osteotomies, as well as bilateral
mandibular ramus osteotomies to correct the jaw deformity.

A B C
FIG 74-99 A to C, Cone beam computed tomography (CT) surface models with voxel-wise cranial
base superimposition of immediate pre-surgery (white) and post-surgery (red).
1116 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

FIG 74-100 Right condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-
wise cranial base superimposition of immediate pre-surgery
(white) and post-surgery (red). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling
in mm.
FIG 74-101 Left condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-
wise cranial base superimposition of immediate pre-surgery
(white) and post-surgery (red). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.

A B C
FIG 74-102 A to C, Cone beam computed tomography (CT) surface models with voxel-wise
cranial base superimposition of post-surgery (red) and 9 months follow-up (light blue) showing
very minimal change in skeletal and dental position.

The surgical procedures can be separated into two or more
surgical stages, but the TMJ surgery should be done first. With
the correct diagnosis and treatment plan, combined TMJ and
orthognathic surgical approaches provide complete and
comprehensive management of patients with coexisting TMJ
pathology and dentofacial deformities.
Maxillary Stability
Studies have indicated superior repositioning of the maxilla is
a very stable procedure whether stabilized with wire fixation
or bone plates. Most concerns are in reference to maxillary
advancements and maxillary down grafting procedures relative
to stability. The state of the art today is in reference to using
rigid fixation for maxillary stabilization. Therefore, only papers
where rigid fixation was employed will be included in this max-
illary stability section and studies with exclusively wire fixation
techniques will be excluded.
Comparison Wire and Rigid Fixation
Satrom and colleagues compared wire fixation and rigid fixa-
tion for outcome stability in 35 patients following superior
repositioning of the maxilla and mandibular advancement with
sagittal split osteotomies.37 Rigid fixation was superior to wire
fixation for maxillary (relapse 0.1 mm for rigid fixation and 0.8
mm for wire fixation) and mandibular stability (relapse 6% for
rigid fixation and 26% for wire fixation) resulting in less relapse.
Egbert and colleagues evaluated 25 patients and showed
there was better stability with rigid fixation compared to wire
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability 1117

FIG 74-103 Right condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of post-surgery (red) and 9 months
follow-up (light blue). Vector maps (bottom figures) show direc-
tion and amplitude of displacement/remodeling in millimeters.
FIG 74-104 Left condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of post-surgery (red) and 9 months
follow-up (light blue). Vector maps (bottom figures) show direc-
tion and amplitude of displacement/remodeling in millimeters.

A B

C D E
FIG 74-105 A to E, The patient is seen 1 year after surgery demonstrating good facial balance
and a good stable occlusal relationship.
1118 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A B
FIG 74-106 A to C, Cone beam computed tomography (CT) surface models with voxel-wise
cranial base superimposition of pre-surgery (white) and 9 months follow-up (light blue).
FIG 74-107 Right condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of pre-surgery (white) and 9
months follow-up (light blue). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.
fixation, but the difference was not statistically different in the
horizontal direction; in the vertical direction, there was a sta-
tistically significant difference with the rigid fixation providing
better stability.168
Maxillary Advancements
Luyk and Ward-Booth reviewed 11 patients with a mean maxil-
lary advancement of 3.7 mm.169 Seven patients had mandibular
osteotomies, and the maxillae were stabilized with four bone
plates and no bone grafting. They noted there was no significant
relapse and concluded that bone grafting was not necessary for
maxillary advancements.
Louis and colleagues looked at three different groups based
on the amount of advancement with group 1 having a maxillary
advancement of 4.7 mm, group 2, 8.2 mm, and group 3,
C
FIG 74-108 Left condyle cone beam computed tomography
(CT) surface models (front, top, and back views) with voxel-wise
cranial base superimposition of pre-surgery (white) and 9
months follow-up (light blue). Vector maps (bottom figures)
show direction and amplitude of displacement/remodeling in
millimeters.
12.3 mm.170 All were stabilized with miniplates and had man-
dibular osteotomies performed as well. There was more relapse
as the maxillae were advanced a greater amount, but apparently
no statistically significant difference between the groups.
Stork and colleagues presented results on 53 patients under-
going the quadrangular Le Fort I osteotomy design.171 The cases
were bone grafted. The average maxillary advancement was 7.2
mm with a relapse of 1.2 mm (17% relapse). They noted no
significant difference between cleft and non-cleft patients.
Maxillary Inferior Repositioning
Santos and colleageus reported performing maxillary down
grafts on eight patients without bone grafting the maxillary
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
defects with an average inferior movement of 4.7 mm.172 Post-
surgical vertical relapse was 46%, demonstrating that down
grafting the maxilla without bone grafts will create a predictably
high relapse rate.
de Mol van Otterloo and colleagues reported five cases with
an average maxillary inferior positioning of 3.6 mm included
in the rigid fixation group.173 All patients also had bilateral
mandibular vertical oblique osteotomies with intermaxillary
fixation for 6 weeks, demonstrating reasonably good stability
with a relapse of 0 to 1.0 mm. Rigid fixation was with a single
anterior bone plate with one screw on each side of the osteot-
omy level.
Maxillary Stability in Cleft Patients
There are a number of studies evaluating the stability of Le Fort
osteotomies in cleft lip and palate patients.174-181 Studies had a
mean horizontal movement of the maxilla of 3 to 8 mm. Hori-
zontal relapse at point A ranged from 20% to 40%. In the verti-
cal dimension, relapse ranged from 50% to 65% at point A. The
increased relapse of maxillary advancement in cleft patients
may include the presence of scarred palatal and lip tissues, as
well as an increased difficulty mobilizing the maxilla on cleft
patients compared to non-cleft. In addition, patients with pos-
terior pharyngeal flaps that remain intact provide additional
difficulties.
Chua and colleagues also included use of distraction osteo-
genesis in patients with cleft lip and palate with an advancement
of 7 mm and a relapse of 8.24% with a 5-year follow-up.182
Based on this group of studies, maxillary advancement in cleft
patients with a Le Fort osteotomy can be expected to relapse
25% to 35% after a 5 to 6 mm horizontal advancement.
Maxillary Stability with Synthetic Bone Grafts
(Porous Block Hydroxyapatite)
The use of synthetic bone grafts in orthognathic surgery was
initiated in the mid-1980s.38 The use of porous block hydroxy-
apatite (Interpore International, Irvine, CA) was a major break-
through for applying this technology (see Figures 74-45 and
74-46). Basic research on this material and early clinical studies
have shown that the use of porous block hydroxyapatite is an
efficacious method to bone graft the maxilla with good predict-
ability.38,39,183-185 The initial study performed on humans for
orthognathic surgery was initially published by Holmes and
colleagues in 1988, demonstrating good bone and soft tissue
growth through the porous hydroxyapatite in human subjects
creating a bony union in maxillary and mandibular osteoto-
mies.39 Nunes and colleagues and Ayers and colleagues evalu-
ated long-term bone ingrowth and identified that the micro
hardness of porous block hydroxyapatite following bone
ingrowth is equally as hard and strong as the normal adjacent
bone.184,185 Wolford and colleagues introduced the use of porous
block hydroxyapatite in orthognathic surgery in 1987.38 The
authors reported a high success rate in 92 consecutive patients.
Wardrop and Wolford presented records on 24 patients with
greater than 5 mm of advancement and 5 mm down graft of
the maxilla using rigid fixation and porous block hydroxyapa-
tite grafting.42 All 11 of the maxillary down graft patients, 14
maxillary advancement patients, and three Le Fort III midface
advancement patients showed less than 1 mm of relapse. Biop-
sies of the porous block hydroxyapatite grafts taken on six
patients in this study at 6 months to 10 months after surgery
showed connective tissue ingrowth and 11.3% to 36.1% bone
1119
ingrowth throughout the pores of the implant and no inflam-
matory response.
Mehra and colleagues evaluated records on 74 patients who
had Le Forte I maxillary advancements using rigid fixation and
porous block hydroxyapatite grafting.186 All patients also had
simultaneous sagittal split osteotomies. Seventeen of the patients
were cleft palate patients and group 2 consisted of 57 non-cleft
patients. Additionally, patients were subdivided as to whether
the maxilla was down grafted 3 mm or more. Average advance-
ment in all groups was about 5.4 mm. Relapse in the cleft group
was 0.75 mm and in the non-cleft group 0.47 mm. Vertical
relapse for those that were down grafted was less than 1 mm for
the cleft group and 0.5 mm for the non-cleft group. This study
demonstrated the significant stability with using porous block
hydroxyapatite for maxillary advancement and/or down graft-
ing in cleft and non-cleft patients with good predictable stabil-
ity. This was the first study reporting stability of cleft compared
to non-cleft patients. Advantages of porous block hydroxyapa-
tite were presented and included:
• No donor site morbidity
• No resorption of the graft
• No known hypersensitivity or immune response
• Ease of manipulation
• No constraints on working time
• Shorter overall surgical time compared to bone grafting
• Shorter recovery time
• Unlimited volume available
• Bone and soft tissue growth into the graft
Mehra and colleagues reported on 78 patients with greater
than 5 mm of maxillary advancement stabilized with rigid fixa-
tion and porous block hydroxyapatite grafts.187 Three groups
were evaluated relative to whether concurrent superior or infe-
rior repositioning of the maxilla was performed. Twenty-seven
patients were inferiorly repositioned, 21 patients superiorly
repositioned, and 30 patients had straight horizontal advance-
ment. All groups showed 0.5 mm or less horizontal and vertical
relapse.
Multiple Maxillary Osteotomies
Maxillary osteotomies and three-dimensional repositioning
have predictable results when properly performed. Maxillary
downward repositioning and maxillary widening with multi
maxillary osteotomies are the two procedures that require
special attention for stable results. Our group has used 2.0 mm
screws and 1.1 mm thickness bone plates in L shape with four
holes (for zygomatic buttress) and in T shape with seven holes
(for lateral nasal pillar). Two additional L shape 1.1 mm thick-
nesses with six holes can be added in cases that include signifi-
cant downward repositioning. These long and rigid plates are
placed at the posterior region of the zygomatic buttress and will
improve stability. Passive adaptation of plates and precise per-
forations made at the center of each plate hole are mandatory
for accurate maxillary positioning and prevent condylar dis-
placement into the articular fossa.
Bone grafts and/or porous block hydroxyapatite are recom-
mended to fill all gaps in order to have better vertical, sagittal,
and transverse stability, as well as enhance the healing process.
Iliac crest harvesting is certainly an option but should be used
only for unusual cases that evolve large downward maxillary
movement. In most of the cases, bone grafts can be harvested
from the proximal segment of the mandible during BSSRO (that
should be completed prior to maxillary osteotomies).
1120 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
The majority of the patients requiring orthognathic surgery
for high occlusal plane angle facial profile will benefit from
maxillomandibular counterclockwise rotation of the occlusal
plane. This maxillary movement includes anterior upward
repositioning and/or posterior downward repositioning. It is
very important to thoroughly mobilize the maxilla in order to
avoid post-surgical vertical relapse at the posterior region. The
development of posterior open bite short- or long-term follow-
ing orthognathic surgery may require reoperation to correct the
bite. This situation can easily be avoided with trans-surgical soft
tissue mobilization and appropriate grafting techniques.
Post-surgical intermaxillary elastics should be used with
caution to avoid extrusion or intrusion of teeth and subsequent
unwanted dental or skeletal relapse. We recommend light elas-
tics in the anterior and posterior teeth during the minimal
number of weeks possible for a good occlusion to be achieved
and maintained stable. The selective use of intermaxillary elas-
tics at the anterior teeth only will lead to posterior open bite
and serious consequences (mentioned in the previous para-
graph). In addition, it is usually important to have a palatal
splint on the maxilla when using vertical elastics for an extended
time to prevent transverse shift of the maxillary teeth toward
the palate that creates a posterior crossbite.
Post-surgical development of a slight Class II malocclusion
and anterior open bite can be controlled with Class II light
elastics. Patients that present post-surgically with large Class
II with anterior open bite tendency cannot have their occlusion
corrected with intermaxillary elastics. The attempt to use heavy
elastics and/or for longer periods will bring instability to the
maxillary positioning originally accomplished. Dentoalveolar
extrusion of anterior teeth and widening of the lower arch are
the most common related side-effects and will cause increase
of teeth-to-upper lip vertical relationship, increase of inter-
labial gap, mouth breathing, and tongue interposition between
upper and lower incisors. Lower dental arch widening second-
ary to excessive use of Class II elastics is less frequent, but it
can aggravate the relapse tendency because a posterior crossbite
can be created. The tongue may be positioned lower and ante-
riorly affecting the transversal stability of the maxilla. Excessive
use of Class II intermaxillary elastics is a common mistake
that frequently happens due to two reasons: (1) Undiagnosed
TMJ pathology prior to surgery will lead to post-surgical clock-
wise rotation of the mandible secondary to condylar resorp-
tion, and (2) improper condylar seating during bone plates
fixation.188
Undiagnosed TMJ pathology—the consequences of per-
forming orthognathic surgery in patients with previous TMJ
pathology—were extensively described earlier in this chapter.
Excessive use of intermaxillary elastics to control post-surgical
Class II malocclusion will be ineffective and add vertical and
transversal instability to the maxilla.
Regarding improper condylar seating, less experienced sur-
geons may face difficulties on maxillary posterior impaction or
with large clockwise rotation of the maxillary posterior segment.
Both of these maxillary movements will result in a posterosu-
perior maxillary movement that can be easily handled with
pterygoid process fracture (with or without removal).189 Lack
of intentionally fracture the pterygoid process can prevent the
posterior region of the maxilla from being properly positioned
resulting in downward condylar displacement during intermax-
illary fixation and bone plates positioning. Right after the
removal of the intermaxillary fixation, the attempt to check the
bite will show some Class II malocclusion associated with an
anterior open bite tendency. The right thing to do in this situ-
ation is to remove bone plates and screws, proceed to pterygoid
process and fracture, and appropriate maxillary and condylar
sitting, followed by new fixation (bone plates and screws). Less
experienced surgeons might instead try to get the occlusion
with extensive use of intermaxillary elastics after surgery and
will face the same side-effects and instability to the maxilla that
were described previously.
Pharmacological control of muscle activity following surgery
is of paramount importance for maxillary stability. Right after
surgery, muscle function may be irregular and can be excessive
due to involuntary contraction, spasms, pain, and bruxism. Par-
ticularly in the cases of downward repositioning of the maxilla
(at the anterior and/or posterior region), pharmacological
control of muscle activity is imperative. We successfully have
used clonazepam, 1 mg at bedtime for approximately 3 months.
Tricyclic antidepressants could alternatively be used as muscle
relaxants and central modulators of pain, whereas some selec-
tive inhibitors of serotonin and noradrenalin should be used
with caution because they may increase muscle activity.
Maxillary widening with three-piece maxillary segmentation
is one of the most versatile procedures in orthognathic surgery.
It allows three-dimensional repositioning of all the three dis-
tinct segments in one single surgery, and it adjusts for tooth size
discrepancies, adjustment of upper incisors axial inclination,
and skeletal leveling of bone segments in cases of accentuated
upper arch curve of Spee and anterior open bite. Maxillary
widening with multi-maxillary osteotomies have been pointed
out as the least stable procedure among all orthognathic surger-
ies.86,87,90 From previous studies, the observed rate of instability
of Le Fort I osteotomy ranges from 11% to 60%. Phillips and
colleagues found an instability at the second molar region of
49% (mean expansion of 5.4 mm), 30% at the first premolar
region (mean expansion of 2.8 mm), and 11% at the canine
region (mean expansion of 2 mm).190 Limitations of this
study include non-detailed description of the surgical tech-
nique, post-treatment retention, measurements being under-
taken on teeth, and failure to separate skeletal and dental
displacements.
Hoppenreijs and colleagues found instability percentages
ranging from 41% at the anterior region, 46% at premolar
region, and 73% at molar region after 2.2 mm, 2.9 mm, and 3.4
mm of maxillary widening respectively.191 These results were
extracted from samples that had undergone different surgical
procedures and different post-surgical protocols. Moreover,
dental measurements were performed on dental casts.
Marchetti and colleagues observed an average expansion
of 2.75 mm at the canine region and 3.75 mm at the molar
region.192 Instability was 0.25 mm (25%) at the canine region
and 0.75 mm (20%) at the molar region. However, because
of the small sample size—only 10 patients—these results may
be questionable.
Kretschmer and colleagues observed an average instability of
0.20 mm (9%) in the skeletal base (expansion of 2.13 mm), 1.20
mm (60%) in the molar region (1.99 mm expansion), and 0.76
mm (68%) in the bicuspid region (expansion of 1.11 mm)
showing dental instability, but skeletal stability.193
Regardless of the controversy found in the literature, maxil-
lary segmentation has been performed with significant fre-
quency testifying for the procedure’s versatility and relevance in
clinical practice.194
 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability
A B
FIG 74-109 A, Palatal splint is shown that is used to provide transverse stability for multiple-piece
maxillary osteotomies. B, The osteotomies for the three-piece maxillary segmentation are
observed.
A recent study designed to examine and compare the skeletal
and dental effects of surgically assisted rapid palatal expansion
(SARPE) and multi-maxillary osteotomies using cone beam CT
concluded that there was greater correlation between dental and
skeletal changes in the multi-maxillary Le Fort I segmentation,
indicating bodily separation of the segments, whereas the
SARPE showed noteworthy dental and skeletal tipping.195
Dental relapse was greater than skeletal relapse for these two
procedures.
Our group retrospectively investigated (ongoing unpub-
lished study) three-dimensional spatial changes of three-piece
maxillary osteotomy during surgery and 1-year follow-up sta-
bility with a semi-automatic mensuration algorithm.196 The aim
of this study was to evaluate maxillary segment displacement in
all three planes of space rather than the transverse dimension
only. The sample was a set of tomographic images from 30
high occlusal plane facial profile patients who underwent
multi-segmented orthognathic surgery. The surgical technique
included maxillary segmentation made in a Y shape with single
midline osteotomy and two anterior, interdental osteotomies
between canines and lateral incisors. Following Le Fort I down-
fracture and prior to the interdental midline osteotomies that
had been completed, the patients received one or two para-
midline palatal incisions followed by mucosal detachment to
free up all the median region of the palatal mucosa from the
palatal bone.197 The mucosal detachment was performed to
avoid tissue stretching due to maxillary segment replacement.
Palatal splint used was made of chemically cured acrylic resin
that surrounded the entire palatal surface of upper canines,
bicuspids, and molars and had no occlusal contact. It had
approximately 3 mm homogeneous thickness to provide trans-
verse resistance and control both posterior segments inclina-
tion. No splint contact with anterior teeth was provided.
Interproximal holes were made with a 701-fissure bur to allow
the splint fixation on first bicuspids and first molars bilaterally
with circum-dental wires after complete maxillary segment
mobilization and passive adaptation on the splint (Figure
74-109). Four titanium bone plates were used to stabilize all
three maxillary segments in the new position. Splint removal
was done 4 to 8 weeks after surgery, depending on the amount
of segment displacement performed.
Our results showed that three-piece Le Fort I osteotomy is a
procedure with instabilities on average smaller than 1 mm. Less
1121
than 20% of the patients showed 50% or more instability at
the posterior segments relative to the surgical changes, and less
than 10% of the sample showed more than 2 mm of absolute
transversal instability. No correlation was found between the
amount of maxillary surgical change and post-surgical instabil-
ity (Figure 74-110, A). In fact, our data suggest that surgeons
should be careful with small and large maxillary repositioning,
because all surgical displacements seem to have similar risk of
instability.
In conclusion, the stability of maxillary osteotomies is highly
dependent of surgical technique, post-surgical retention, and
surgeon expertise. Excellent and predictable results can be
achieved with three-piece maxillary osteotomies that improve
significantly dental, skeletal, and facial outcomes.
PITFALLS
• Treating clinicians must be able to provide appropriate clinical assess-
ment, indicated imaging and interpretation, dental model analysis,
and comprehensive treatment planning and must be able to carry out
the treatment plan accurately to completion in order to provide good
treatment outcomes. Failure in any of these areas can result in a
compromised or unfavorable result.
• The surgeon should have a wide base of surgical knowledge, experi-
ence, and surgical skills to provide the appropriate and required surgi-
cal treatment. Deficiencies in any of these areas can result in
compromised or catastrophic results.
• Research has shown that the use of rigid fixation in orthognathic
surgery, as well as appropriate bone grafting, leads to improved
predictability and treatment outcomes. The use of wire fixation to
stabilize bone segments results in significant relapse problems, insta-
bility, and significant compromise in treatment outcomes.
• In double jaw surgery, the selective alteration of the occlusal plane
may improve the functional and esthetic results for patients signifi-
cantly. For example, counterclockwise rotation of the maxilloman-
dibular complex may benefit patients with sleep apnea and may be
the primary method for correcting disorders in patients with this
particular condition functionally and esthetically.
• The TMJs are the foundation for orthognathic surgery. Failure to
diagnose or ignoring pre-existing TMJ dysfunction and pathosis can
result in unfavorable orthognathic treatment outcomes, such as post-
operative pain, condylar resorption, malocclusion, jaw dysfunction,
and facial deformity.
1122 CHAPTER 74 Surgical Planning in Orthognathic Surgery and Outcome Stability

A B
FIG 74-110 A, Displacements, distributions and averages in the coordinates X and Y (superior
panel) and Z (inferior panel). The mean displacements and their respective competence intervals
in the coordinates X, Y, and Z are respectively dx, dy, and dz. B, Relative and absolute displace-
ment stability. Magnitude of the surgical displacement versus the magnitude of the long-term
post-surgical displacement for all 30 cases at each of the seven sampled landmarks.

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