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British Journal of Oral and Maxillofacial Surgery 50 (2012) 533–536

Preoperative incisor inclination in patients with Class III

dentofacial deformities treated with orthognathic surgery
Cecília L. Pereira-Stabile a,b,c,∗ , Mark W. Ochs d , Márcio de Moraes a , Roger W.F. Moreira a
a Division of Oral and Maxillofacial Surgery, Piracicaba Dental School, Campinas State University, Piracicaba, SP, Brazil
b University of Grande Rio, Duque de Caxias, RJ, Brazil
c Londrina State University, Londrina, PR, Brazil
d Department of Oral and Maxillofacial Surgery, University of Pittsburgh, Pittsburgh, PA, USA

Accepted 3 October 2011

Available online 10 December 2011

Abstract

Our aim was to evaluate cephalometrically the preoperative inclination of the incisors in a group of 50 patients with Class III dentofacial
deformities whose immediate preoperative lateral cephalometric radiographs were analysed after they had been treated by maxillary advance-
ment. The radiographs were hand-traced by the same operator who made the cephalometric analysis. Mean values for each measurement were
compared with the normal values using Student’s t-test (p < 0.05). Results showed significantly increased inclination of the upper incisors,
with a mean U1-NA angle of 27.58◦ and a mean U1-PP angle of 116◦ . The lower incisors were also inclined lingually, with a mean L1-NB
angle of 22.53◦ and a mean IMPA of 83.13◦ . Thirty-five of the patients had labial inclination of the upper, and 28 lingual inclination of the
lower, incisors. Mean inclinations of upper and lower incisors differed from the normal values, and the inclination of the lower incisors was
more likely to be decompensated than that of the upper incisors.
© 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Incisor inclination; Orthognathic surgery; Class III; Maxillary advancement

Introduction Dental compensations are common among Class III

Class III dentofacial deformities are skeletal discrepancies
that can be treated with orthognathic surgery or, in less severe
cases, by orthodontic compensation. These deformities have
a genetic basis, and their prevalence varies among differ-
ent ethnic groups.1 Class III dentofacial deformities may be
the result of malpositioning of the mandible, the maxilla, or
both. The surgical treatment of these cases is based on facial
analysis, cephalometrics, studies of models, and the patient’s
complaints.2
∗ Corresponding author at: Rua Amador Bueno, 268 - Londrina, PR,
Brazil. Tel.: +55 43 3025 2526.
E-mail address: ceciliastabile@gmail.com (C.L. Pereira-Stabile).
patients, typically proclined upper incisors, and retroclined
lower incisors. These abnormal inclinations allow for bet-
ter function and also help to mask the dentofacial deformity.
When surgical treatment is planned an optimal result depends
on decompensation.3
Orthosurgical treatment of Class III deformities consists
of preoperative orthodontic preparation followed by sur-
gical correction of the position of the affected jaw. After
recovery, the patient has further orthodontic intervention
for occlusal detailing. In patients with Class III deformi-
ties, decompensation typically consists of retroclining the
upper, and proclining the lower, incisors to achieve adequate
axial positions in the corresponding bony bases. This often
results in a worse facial appearance during the preoperative
period.Preoperative orthodontic decompensation has a major

0266-4356/$ – see front matter © 2011 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2011.10.016
534 C.L. Pereira-Stabile et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 533–536

Table 1a
Mean (SD) and standard values for the sexes.
Measurement Female Male

Mean (SD) Standard Mean (SD) Standard

Anteroposterior (mm)
N perp-A −0.84 (4.08) 0.4 −1.98 (4.18)* 1.1
Pg-N perp 5.48 (7.7)* −1.8 5.18 (8.48)* −0.3
Vertical
Facial height (mm) 74.18 (6.49)* 66.7 83.44 (6.12)* 75.6
FH-MP (◦ ) 26.04 (8.2) 22.7 25.86 (7.67)* 21.3
Dental (mm)
U1-A 6.90 (3.57)* 5.4 7.22 (3.66)* 5.3
L1-A-Pg 5.68 (3.31)* 2.7 6.16 (3.29)* 2.3

N perp, nasion perpendicular; Pg, pogonium; A, A point; B, B point; FH, Frankfurt horizontal; MP, mandibular plane; U1, upper incisor; L1, lower incisor.
∗ p < 0.05.

influence on the magnitude and type of operation required.
Incomplete decompensation may influence the quality and
magnitude of surgical movements. Previous studies have
shown that inadequate decompensation contributes to less
adequate postoperative results.4–8
The aim of the present study was to analyse the pre-
operative inclinations of incisors in patients with Class III
deformities after maxillary advancement with the help of
cephalometric radiographs.
of the intraexaminer reliability, and the intraclass correlation
coefficient was >0.95 in all but one of the measurements.
Data were analysed using a statistical analysis software
(BioEstat 5.0) to compare each measurement with its corre-
sponding normal value using Student’s t-test. Probabilities of
less than 0.05 were accepted as significant.
Results

Patients and methods Twenty-five of the patients were women, and 48 were white.
Their mean age was 22 (range 14–41) years. The mean max-
The research protocol was approved by the Research Ethics illary advancement was 5.9 (2–12) mm. Only one patient
Committee – FOP – Unicamp (021/2008) and the University required maxillary segmentation (2 pieces). In 7 patients
of Pittsburgh Institutional Review Board (45 CFR 46.110(5)). saggital split osteotomies were necessary for midline correc-
We studied the casenotes of all patients who had orthog- tion without anteroposterior movement. Most patients were
nathic operations by RWFM and MM at the Division of Oral treated orthodontically by different private orthodontists in
and Maxillofacial Surgery, FOP – Unicamp, Brazil, from the areas of Piracicaba, SP, Brazil, and Pittsburgh, PA, USA,
January 1997 to December 2007, and all patients operated and some were treated in the orthodontic departments at the
on by MWO at the Department of Oral and Maxillofacial respective dental schools.
Surgery, University of Pittsburgh, USA, from January 2003 Tables 1a and 1b show the mean and standard values
to October 2008. Inclusion criteria were: clinical diagnosis for each measurement. Measurements that have sex-specific
of maxillary anteroposterior deficiency not associated with standard values were analysed separately (Table 1a). Thirty-
clefts or craniofacial syndromes; the presence of an immedi- five patients presented with increased inclination of the upper
ately preoperative cephalometric radiograph; and the patient incisors, and 28 with decreased inclination of the lower
treated by maxillary advancement (without mandibular set- incisors.
back), with or without a genioplasty. Planning of treatment
and operation was coordinated by the attending surgeon and
Table 1b
done by the attending surgeon and a chief resident or fel-
Mean (SD) and standard dental measurements for all patients.
low. Fifty patients met the inclusion criteria – 33 from the
Measurement Mean (SD) Standard
University of Pittsburgh and 17 from Unicamp.
All cephalometric radiographs were obtained at the last U1-NA (mm) 7.34 (3.8)* 4
U1-NA (◦ ) 27.58 (9.49)* 22
preoperative appointment using the conventional cephalo-
U1-PP (◦ ) 116.02 (9.69)* 110
metric method, as described by Broadbent,9 in the dental L1-NB (mm) 5.61 (3.02)* 4
radiology departments of the two universities. Radiographs L1-NB (◦ ) 22.53 (6.19)* 25
were traced by a single operator in a dark room using a light- IMPA (◦ ) 83.13 (7.57)* 87
box, 0.07 mm tracing paper, and a 0.3 mm mechanical pencil. Interincisal (◦ ) 132.24 (10.08) 131
Linear and angular measurements10,11 were obtained using N, nasion; A, A point; B, B point; U1, upper incisor; L1, lower incisor; PP,
ruler, protractor, and set squares. The cephalometric tracings palatine plane; IMPA, lower incisor to mandibular plane.
∗ p < 0.05.
and measurements were repeated after a month for analysis
 C.L. Pereira-Stabile et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 533–536
Discussion
All patients were treated by maxillary advancement for cor-
rection of Class III dentofacial deformities in two different
academic institutions that use facial analysis as the basis for
planning surgical treatment. A mean maxillary advancement
movement of 5.9 mm was found, which is compatible with
single jaw procedures. Seven patients required an operation
on the mandible for midline corrections with no planned
anteroposterior modifications, so the patients were included
in the sample.
In 35 patients the inclination of the upper incisors was
increased. The mean U1-NA angle was 27.52◦ , and a mean
U1-PP angle of 116◦ . Troy et al.3 found similar results in
their series of patients with Class III deformities treated with
orthognathic surgery. They compared the inclination of the
incisors before treatment (T1), before operation (T2), and
after treatment (T3), and found that it was similar in periods
T1 and T2. Decompensation causes less discrepancy, and
this limits the amount of movement, particularly in single
jaw procedures. That limitation may have an adverse impact
on facial harmony and aesthetics. In addition to its influence
on the amount of surgical movement and outcomes, incom-
plete decompensation of upper incisors may itself promote
a less attractive smile. Cao et al.12 considered the effect of
the inclination of the maxillary incisors on the aesthetics of
the smiling profile when it was evaluated by dentists and
laypeople. They thought that evaluators rated profiles that
presented inadequate inclination of the incisors as signifi-
cantly less attractive than those with normal inclination, and
profiles with labial inclination of the maxillary incisors were
rated as less attractive than those with lingual inclination.
Inclination of lower incisors was reduced in 28 patients,
with a mean L1-NB angle of 22.53◦ and a mean IMPA of
83.13◦ . Troy et al.3 reported that preoperative inclination of
lower incisors was improved when compared with before
treatment, but it remained different from the standard values.
Capelozza Filho et al.5 also reported that maxillary incisors
are more difficult to decompensate than mandibular incisors,
which may be the result of the different muscle forces acting
on the incisors, particularly the tongue on the mandibular
incisors that favours labial inclination.
The shape of the root can also influence orthodontic move-
ment, and the smaller size of inferior incisor roots may have
influenced our results. When teeth are crowded, vestibular
torque of the incisors may be a consequence of dental align-
ment. Ahn and Baek8 evaluated the influence of the amount of
skeletal anteroposterior discrepancy and the vertical type on
the preoperative decompensation of lower incisors in patients
with skeletal Class III, and found that patients with severe
Class III deformity with a hyperdivergent vertical type (high
mandibular plane angle) had more preorthodontic and preop-
erative dental compensation than the hypodivergent vertical
type. They also said that this group of patients had a reduced
lower alveolar width in the mandible, which could impair the
decompensation of severe inclinations of lingual incisors.
535
We did not evaluate postoperative results in the present
study, but it can be inferred that more decompensation,
with a maximised reduced overjet, would result in greater
advancement or the option for double jaw surgery. Capelozza
Filho et al.5 evaluated the relation between the presence of
remaining dental compensations in the immediate preopera-
tive cephalometric radiographs and the magnitude of surgical
movements. They reported that patients who were considered
adequately decompensated had larger surgical movements
and presented postoperative cephalometric values more com-
patible with the standard values. However, patients with
remaining dental compensations had smaller surgical move-
ments and presented with considerably increased anterior
facial height postoperatively.
Johnston et al.6 evaluated the result of orthognathic
surgery for correction of Class III dentofacial deformi-
ties. As in the present study, they found remaining dental
compensations in the immediate preoperative period. When
postoperative results were analysed, even though a correction
of the overjet was achieved in most cases, skeletal improve-
ment was not as good. They stated that patients who had
double jaw surgery had better cephalometric values than
those treated with single jaw procedures. Studies that evalu-
ated patients with Class II deformities treated surgically also
reported less than ideal movements when dental compensa-
tions were present, which impaired the final results.4,7
The patients analysed in this study were treated in two
academic institutions, but orthodontic treatments were by
different orthodontists in private practice. Even though the
difference in sample size did not allow statistical comparison
between Brazilian (n = 17) and American (n = 33) patients,
both presented remaining dental compensations. As previous
studies have suggested, incomplete decompensation seems to
be a common finding in orthognathic surgery.
Patients with Class III dentofacial deformities often have
aesthetic complaints, which are the reason for seeking treat-
ment in many cases.13 It has been reported that even laypeople
tend to identify those with Class III deformities in pho-
tographs as less attractive than those in Class I.14 Although
optimal occlusion and function are the main purpose of the
orthosurgical treatment, facial harmony should always be
considered as a goal. The search for aesthetic improvement
is one of the reasons that patients with Class III deformi-
ties choose surgical treatment in borderline cases for which
orthodontic compensation is possible. Adequate preopera-
tive decompensation should therefore be achieved during
orthodontic preparation for orthognathic surgery, so that the
negative overjet is maximised and surgical movements with
more aesthetic effects can be achieved.
The use of temporary anchoring devices such as implants
or miniplates should be considered in those for whom con-
ventional decompensation mechanics would not produce
adequate results. These devices may also significantly reduce
total orthodontic time; however, anatomical limits and peri-
odontal condition must be considered.8 In patients in whom
the maxillary arch length is deficient, dental crowding exists,
536 C.L. Pereira-Stabile et al. / British Journal of Oral and Maxillofacial Surgery 50 (2012) 533–536
or there is excessive and unacceptable proclination of max-
illary incisors, consideration should be given to extraction
of the maxillary first bicuspids (without lower extractions)
for preoperative alignment of the arch and establishment
of proper inclination of the incisors. This would result in
Class II first molar relations in the finished orthodontic
result.
Appreciable advances have been made in the diagnosis
and treatment of patients who require orthognathic surgery.
Stable internal fixation and recent innovations such as three-
dimensional soft tissue analysis and computer-based surgical
planning were introduced to improve precision and minimise
errors in these procedures. However, the evaluation of the
patient by both orthodontist and maxillofacial surgeon, and
the constant communication between professionals during
the course of treatment, remain the key to excellent treatment.
Acknowledgement
Dr. Pereira-Stabile received an international scholarship from
the Brazilian Ministry of Education, PDEE program, schol-
arship # 0151/08-4.
References
1. Bui C, King T, Proffit W, Frazier-Bowers S. Phenotypic characterization
of Class III patients. Angle Orthod 2006;76:564–9.
2. Baik HS, Han HK, Kim DJ, Proffit WR. Cephalometric characteris-
tics of Korean Class III surgical patients and their relationship to plans
for surgical treatment. Int J Adult Orthodon Orthognath Surg 2000;15:
119–28.
3. Troy BA, Shanker S, Fields HW, Vig K, Johnston W. Comparison of
incisor inclination in patients with Class III malocclusion treated with
orthognathic surgery or orthodontic camouflage. Am J Orthod Dentofa-
cial Orthop 2009;135:146.e1–9.
4. Burden D, Johnston C, Kennedy D, Harradine N, Stevenson M. A
cephalometric study of Class II malocclusions treated with mandibular
surgery. Am J Orthod Dentofacial Orthop 2007;131:7.e1–8.
5. Capelozza Filho L, Martins A, Mazzotini R, da Silva Filho OG.
Effects of dental decompensation on the surgical treatment of mandibu-
lar prognathism. Int J Adult Orthod Orthognath Surg 1996;11:
165–80.
6. Johnston C, Burden D, Kennedy D, Harradine N, Stevenson M. Class
III surgical-orthodontic treatment: a cephalometric study. Am J Orthod
Dentofacial Orthop 2006;130:300–9.
7. Proffit WR, Phillips C, Douvartzidis N. A comparison of outcomes of
orthodontic and surgical-orthodontic treatment of Class II malocclusion
in adults. Am J Orthod Dentofacial Orthop 1992;101:556–65.
8. Ahn HW, Baek SH. Skeletal anteroposterior discrepancy and vertical
type effects on lower incisor preoperative decompensation and postoper-
ative compensation in skeletal Class III patients. Angle Orthod 2011;81:
64–74.
9. Broadbent BH. A new X-ray technique and its application to orthodontia.
Angle Orthod 1931;1:45–66.
10. McNamara Jr JA. A method for cephalometric evaluation. Am J Orthod
1984;86:449–69.
11. Steiner CC. The use of cephalometrics as an aid in the plan-
ning and assessing of orthodontic treatment. Am J Orthod 1960;46:
721–35.
12. Cao L, Zhang K, Bai D, Jing Y, Tian Y, Guo Y. Effect of maxillary
incisor labiolingual inclination and anteroposterior position on smiling
profile esthetics. Angle Orthod 2011;81:121–9.
13. Shaw WC. The influence of children’s dentofacial appearance on their
social attractiveness as judged by peers and lay adults. Am J Orthod
1981;79:399–415.
14. Fabré M, Mossaz C, Christou P, Kiliaridis S. Orthodontists’ and layper-
sons’ aesthetic assessment of Class III subjects referred for orthognathic
surgery. Eur J Orthod 2009;31:443–8.