Cẩm Nang Điều Trị Chỉnh Hình Hàm Mặt (Tiếp Cận Đa Chuyên Khoa)

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Handbook of
Orthognathic
Treatment
A TEAM APPROACH

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Handbook of
Orthognathic
Treatment
A TEAM APPROACH
Ashraf Ayoub,
Balvinder Khambay,
Philip Benington
and
Lyndia Green,
Khursheed Moos,
Fraser Walker

This edition first published 2014
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Library of Congress Cataloging-in-Publication Data
Ayoub, Ashraf, author.
  Handbook of orthognathic treatment : a team approach / Ashraf Ayoub [and five others].
      p. ; cm.
  Includes bibliographical references and index.
  ISBN 978-0-470-65905-2 (cloth : alk. paper) – ISBN 978-1-118-70940-5 – ISBN 978-1-118-70943-6 –
ISBN 978-1-118-70949-8 (epub)
  I.  Title.
  [DNLM:  1.  Orthognathic Surgical Procedures–methods–Case Reports.  2.  Orthognathic Surgical
Procedures–psychology–Case Reports.  3.  Maxillofacial Abnormalities–psychology–Case
Reports.  4.  Patients–psychology–Case Reports. WU 600]
  RK521
  617.6'43–dc23

2013017937
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in
print may not be available in electronic books.
Cover images: Top left and top right: reproduced with permission from Elsevier; bottom left:
source – 123RF.COM © fixer00; background: reproduced with permission from Greater Glasgow &
Clyde NHS Trust; middle left: courtesy of the authors.
Cover design by Sandra Heath
Set in 8.5/11 pt Stone serif by Toppan Best-set Premedia Limited, Hong Kong
1  2014

Contents
v
List of authors, vii
Foreword, ix
Preface, xi
1  Psychological considerations for the orthognathic patient, 1
2  Dentofacial assessment, 16
3  The treatment planning process, 51
4  The role of orthodontics, 62
5  Orthognathic technical procedures, 80
6  Prediction planning, 94
7  Basic orthognathic surgical procedures, 111
8  High level osteotomies, 146
9  Case reports, 155
9.1  Class II, division 2 malocclusion, 157
9.2  Vertical maxillary excess, 160
9.3  Class III malocclusion, 163
9.4  Mandibular asymmetry with 3D planning, 166
9.5  Anterior open bite, 170
9.6  Class II, division 1 with hypodontia, 173
Index, 177

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List of authors
vii
Professor Ashraf F. Ayoub
BDS, MDS, PhD, FDS RCS(Ed), FDS RCPS(Glas),
FDS(OS) RCS(Ed)
Professor of Oral & Maxillofacial Surgery
The University of Glasgow
Glasgow, UK
Dr Balvinder S. Khambay
BDS, PhD, FDS RCS(Eng), MOrth RCS(Ed),
FDS(Orth) RCS(Eng)
Clinical Associate Professor in Orthodontics
Faculty of Dentistry
The University of Hong Kong
Hong Kong
Mr Philip C.M. Benington
BDS, FDS(Orth) RCS(Ed), FDS RCPS(Glas), MSc,
MOrth RCS(Eng)
Consultant and Honorary Clinical Senior Lecturer
in Orthodontics
Glasgow Dental Hospital and School
Glasgow, UK
Dr Lyndia Green
BA(Hon), DClinPsy, MAppSci
Consultant Clinical Psychologist
Glasgow Royal Infirmary
Glasgow, UK
Professor Khursheed Moos
BDS, MBBS, FRCS(Ed), FDS RCS(Eng), FDS RCS(Ed),
RCPS(Glas), FRCPS(Glas)
Honorary Research Fellow
The University of Glasgow
Glasgow, UK
Mr Fraser Walker
MSc, FIMPT
Consultant Maxillofacial Prosthetist
Regional Maxillofacial Unit
The Southern General Hospital
Glasgow, UK

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Foreword
ix
This new textbook on orthognathic surgery is to be
commended for its holistic, or whole body, approach
to the topic. Although there have been only relatively
minor changes to the surgical techniques utilised in
orthognathic surgery over the past 20 years, the
recent past has seen dramatic changes in some of the
psychological aspects of orthognathic surgery, some
of the treatment planning techniques, and the overall
concept of the team approach. These aspects are par­
ticularly well described in this textbook. The team
approach for orthognathic surgery now involves the
surgeon, an orthodontist (normally required for pre­
paring the occlusion preoperatively and fine tuning
the occlusion postoperatively), a restorative dentist
(to restore missing or badly displaced teeth and
perform cosmetic dentistry where required), labora­
tory staff (to carry out model surgery and prepare
splints), psychologists (to evaluate the overall psy­
chological indications for orthognathic surgery and
the postoperative psychological changes that may
occur), and of increasing importance someone to
manipulate the software in the rapidly developing
field of digital treatment planning. This textbook
covers all these aspects in excellent detail.
Some of the most exciting developments in
orthognathic surgery are in digital treatment plan­
ning with particular reference to three-dimensional
planning. The ability to capture the patient’s hard
and soft tissues in three dimensions, manipulate
them digitally on a monitor, and segmentalise the
different components and simulate the surgery
enables a new dimension in treatment planning. We
are now able to accurately determine the effects of
movement of the jaw in three dimensions with par­
ticular reference to areas like the mandibular angles
and the lower borders of the mandible which have
been somewhat difficult to predict previously. This is
leading to added sophistication and changes in sur­
gical techniques.
This textbook will appeal to those who are new to
the field of orthognathic surgery as well as those who
are experienced in orthognathic surgery.
M. Anthony (Tony) Pogrel, DDS, MD, FRCS, FACS
Professor and Chair
Associate Dean for Hospital Affairs
Department of Oral and Maxillofacial Surgery
University of California San Francisco

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Preface
xi
This handbook is our attempt to provide a short,
contemporary textbook on the management of den­
tofacial deformities. There should be a chapter of
interest to clinicians of all specialties and levels
involved with orthognathic treatment, although we
have written it with trainees particularly in mind.
Although there has been little change in the fun­
damentals of orthodontics, maxillofacial technology
and orthognathic surgery over the past few decades,
some important advances have occurred which have
had a profound impact on our clinical practice. The
most significant of these are:
1. An increasing awareness of the need to take the
patient’s psychological wellbeing into account as
part of their journey through treatment. Psycho­
logical input to an orthognathic clinic should
ideally not be limited to pre-treatment assessment,
but also pre-surgical preparation and the provision
of support at other times when needed, including
post-operatively. We now consider this to be a key
element of our inter-disciplinary approach.
2. The identification and analysis of the errors inher­
ent to conventional face bow transfer records and
articulators and their effect on the accuracy of
model surgery. An understanding of these errors,
their potential impact on treatment outcome, and
how to eliminate them, is essential for all clinicians
involved in delivering orthognathic treatment.
3. A paradigm shift from profile planning based on
two-dimensional radiographs and photographs, to
three-dimensional facial planning based on cone-
beam computerised tomography and stereophoto­
grammetry. The 3D revolution is being fuelled by
the rapid advance of image capture and computer
technology and is increasingly becoming a routine
part of our clinical practice.
In this book we aim to update the reader in these
important areas of progress, in addition to covering
the basic aspects of orthognathic treatment and
describing the contribution of each team member
within our integrated approach. We hope the content
is clear and easy to read as well as thought provoking
and, where possible, evidence based.
Ashraf Ayoub
Balvinder Khambay
Philip Benington
Lyndia Green
Khursheed Moos
Fraser Walker
Acknowledgements
We, the authors, would like to express our sincere
thanks and appreciation to Mrs Carol McIvor, nurse
co-ordinator of the dento-facial planning clinic at
Glasgow Dental Hospital and School, and Mr James
Eyland, medical photographer at the Southern
General Hospital, Glasgow.
We would also like to acknowledge the contribution
of all the past and current clinical and clerical support
staff towards the running of the clinic, and without
whom this handbook would not have been possible.
We also owe a great debt of gratitude to our families
for their continual patience and support.

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Intended learning outcomes
By the end of this chapter the reader should:
• Understand the role of a clinical psychologist in
an Orthognathic Service.
• Be able to explain the psychological impact of
dentofacial anomalies.
• Be able to identify factors which may impact on
patient satisfaction with treatment.
• Be able to identify psychological conditions
which may not be helped by orthognathic
treatment.
Psychological considerations for
the orthognathic patient
1
Chapter overview
Intended learning outcomes, 1
1.1 Psychological issues associated with facial
appearance, 1
1.2 Psychological assessment, 2
1.2.1 Patient perception of the presenting clinical
problem, 3
1.2.2 Patient expectation of treatment, 4
1.2.3 Patient motivation for treatment, 4
1.2.4 Patient’s psychological status, 5
1.2.5 Outcome from psychological assessment, 5
1.3 Advice on management of patients
following assessment, 6
1.4 Red flag and amber flag patients, 6
1.4.1 Red flags, 7
1.4.2 Amber flags, 10
1.5 Psychological therapeutic input to
patients during treatment, 11
1.5.1 Pre-surgical orthodontics, 11
1.5.2 Surgical planning stage – patient preparation for
surgery, 12
1.5.3 Psychological input following surgery, 13
1.6 Conclusion, 14
1.7 References, 14
1.1  Psychological issues associated
with facial appearance
A person’s face is the most visible aspect of their
appearance and is what other people focus on, during
social interaction. Those with severe malocclusions
may have been stared at, bullied, discriminated
against most of their lives. Even when their condition
may evoke a sympathetic response there may be an
unintentional, negative non-verbal response from
others which may be difficult for those people to
suppress. As a result of these negative experiences,
people with a facial deformity may go on to exhibit
shyness and defensiveness in social situations, which
compounds their social difficulties. Even those with
more minor physical problems may be seen as less
attractive, less socially competent and they may also
have been subjected to teasing with resulting impact
on their body image and self-esteem. MacGregor
(1970) suggests that people with a minor anomaly
such as “buck teeth” may evoke amusement, be a
target of jokes and experience more actual direct
Handbook of Orthognathic Treatment: A team approach, First Edition. Ashraf Ayoub, Balvinder Khambay, Philip Benington,
Lyndia Green, Khursheed Moos, and Fraser Walker.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
1
This chapter describes the role of a clinical psycholo­
gist, as an integral part of the multi-disciplinary team,
in a dentofacial planning clinic. It covers:
• Psychological issues in facial appearance.
• Psychological assessment.
• Advice on the management of patients’ psychologi­
cal issues.
• Identification of patients with psychological prob­
lems which impact treatment.
• Psychological therapeutic input within this setting.

2
Handbook of Orthognathic Treatment
cases, it is the aesthetic outcome from treatment that
will determine their satisfaction with treatment.
Patients’ expectation of orthognathic treatment is
that it will improve both physical problems and their
appearance, with resulting improvement in their
body image, self-esteem and social functioning. In
some cases the change in appearance can be quite
marked, whereas in others the changes may be more
subtle. Patients have to adapt to the change in their
appearance and to deal with the response of others,
or conversely the lack of response, to these changes.
Most patients cope well with the treatment process
and are happy with the outcome; for a minority
however, treatment appears to have some negative
psychological effects. Equally, psychological factors
have an impact on physical response to treatment
and to patients’ level of satisfaction with it. There is
therefore a complex interaction between oral func­
tional and aesthetic factors in orthognathic treat­
ment and between the physical and psychological
aspects of treatment.
1.2  Psychological assessment
The psychological assessment takes place within the
dentofacial planning clinic, before the patient is seen
by the rest of the multi-disciplinary team. It is con­
ducted in a one to one setting, in order to maximise
the information obtained, as patients are much more
likely to disclose information in that situation. The
assessment does require a clinical psychologist with
considerable experience of both psychological prob­
lems associated with appearance and also of the issues
relating to the transitional period from late adoles­
cence to adulthood (as the majority of patients seen
are in this age group). It is a brief, focused psychologi­
cal assessment covering the areas known to be relevant
to patient satisfaction with the process and outcome
of orthognathic treatment. The kind of information
provided to the multi-disciplinary team includes:
• Patient’s perception of the presenting problem and
associated functional impact.
• Patient’s motivation for and expectation of
treatment.
• Patient’s current psychological status and early
identification of those patients who may need psy­
chological support during treatment.
• Identification of those whose perceived problem is
unlikely to be resolved by treatment.
• Assessment of risk factors predicting dissatisfaction
with treatment.
comments about their appearance than those with
more severe problems. Bull and Rumsey (1988) have
conducted a number of experiments, in real life situ­
ations, which demonstrate the negative responses of
others to a minor facial anomaly. Having an atypical
facial appearance can therefore constitute a severe
handicap in a wide range of situations and can affect
social acceptance and social functioning in addition
to the associated physical problems.
In addition to the objective features of the face, with
its social implications, the psychological aspects of
appearance also include the concept of body image.
This is the person’s subjective representation of
their bodily experience and appearance. Cash (2006)
has described body image as a multi-dimensional
construct, encompassing both an individual’s percep­
tion of and attitude towards their appearance. This
involves their thoughts, feelings and behaviour in
relation to their appearance. Their body image evalu­
ation influences their level of satisfaction with appear­
ance and will be influenced by cultural, ethnic and
gender issues. The salience of attractive appearance,
for that person, will also influence their associated
distress with an objective or perceived anomaly. This
helps explain why there is not a linear relationship
between degrees of facial deformity and associated
psychological disturbance.
Dental appearance plays an important part in body
image assessment both in adolescence and adult­
hood. It is only one aspect of someone’s face but it
can independently influence how attractive a person
is perceived to be. Both the individual themselves
and other people rate someone with severe malocclu­
sion as less popular and less sociable. Cunningham
et al. (2000) found that orthognathic patients had
poorer body image and facial body image than a
matched non-clinical control group. Those most dis­
satisfied with their dental appearance are reported to
be firstly those having an extreme overjet, secondly,
an extreme deep bite and thirdly, space abnormali­
ties (Helm et al., 1985). Combined orthodontic and
orthognathic surgical treatment is now more readily
available and there is more awareness of it. The
majority of people undergo such treatment in order
to improve function, but it also has an impact on the
aesthetic appearance of their face. Indeed many
people presenting for treatment in clinics do not
have a severe malformation and are seeking treat­
ment primarily for aesthetic reasons. In this situa­
tion, surgery is being carried out with the objective
of improving the individual’s body image. Even for
those people who report a clear physical reason for
undergoing orthognathic treatment, in a majority of

Psychological considerations for the orthognathic patient
3
disturbance associated with appearance reported by
patients. So that someone presenting with marked
facial problems may report little aesthetic concern,
whereas others with some minor anomaly, which
clinicians may consider to be within a normal range,
may present with significant aesthetic concern. This
latter group may require further more detailed assess­
ment from a psychological perspective.
Not all patients who are offered surgery will accept
this approach. In a study of patients with an equal
objective need for surgery Bell et al. (1985) found
that the patient’s own perception of their face was a
more important determinant of whether or not they
accepted treatment. In general, lay people are more
likely to judge a face as normal compared to surgeons
and orthodontists. The authors of the study suggest
that the patient’s perception of their facial aesthetics
should be of primary concern when alteration of
facial aesthetics is being considered.
Impact on life
The reported impact that concern about appearance
is having on the patient’s everyday life is also assessed.
This may require careful assessment in order to gain
a realistic picture and to avoid both under-reporting
and over-reporting of associated difficulties. Informa­
tion about the onset of their concern, when this
happened and if there were any particular triggers for
it. Occasionally, patients may be referred who have
not been aware of problems with their facial appear­
ance prior to initial referral, but when the problem
has been identified and named, may begin to become
more self-conscious about their appearance. Equally,
there may be patients who have been concerned
about their facial appearance from an early age and
this may have had a significant impact on their social
and emotional development. The reported impact of
the perceived problem is therefore assessed both in
the past and on their current functioning.
Patients are asked if they have consulted anyone
else in the past about the problem or had any previ­
ous treatment for it. A more general assessment of
their body image is also made, asking for example, if
there are other aspects of their face or body that they
dislike and have considered changing by surgery or
some other means. A history of any previous cos­
metic type procedures undergone is also noted and
this should include cosmetic dentistry.
In addition to the patient’s description of the
impact of their concern about their appearance, the
psychologist will also observe their behaviour. For
example, observing a patient automatically cover
their mouth with their hand when smiling, gives
1.2.1  Patient perception of the presenting
clinical problem
Assessment of the patient’s perception of the present­
ing clinical problem seeks to identify what exactly
bothers them, how severe they perceive it to be and
the impact it is having on their everyday life.
Patient’s view of the clinical problem
It is important, at this initial stage, to understand
what the patient thinks about the referred problem
because a patient’s perceived need for treatment may
not always match the clinician’s view. They may have
a relatively uninformed view of the problem or they
may be quite knowledgeable. Initially they are asked,
irrespective of what they have been told or heard or
read, what exactly bothers them and why. A more
structured format follows the initial open ended
questions in order to cover the relevant areas.
Functional and aesthetic concerns
It is important to understand the relative importance
of physical functional problems and aesthetic con­
cerns for the patient, associated with the malocclu­
sion they present with. Patients may find it easier to
discuss the functional concerns but may feel that
their aesthetic concerns will be considered to be less
important by clinicians. Jensen (1978) maintains that
the evidence suggests that many patients conceal
their aesthetic motivation for surgery. It may there­
fore be necessary to encourage patients to describe
the aesthetic aspect of their concern. The relative
importance of the functional and aesthetic concern,
for the patient, is important when decisions are being
made to proceed with treatment. If for example, the
patient is primarily interested in aesthetic change
and the team concludes that there is little chance of
noticeable aesthetic change or the possibility of a
negative effect then clearly the patient’s concerns will
not be met and they are likely to be dissatisfied with
the outcome.
Perception of severity
The need to proceed with treatment is also influenced
by the perceived severity of the problem both by the
clinicians and the patient. The use of a Visual Ana­
logue Scale, with defining markers at each pole, can
be helpful in assessing the degree of concern a patient
feels both about how severe they feel that the physi­
cal problem is and also the degree of distress they
experience associated with the problem. There is no
linear relationship between the degree of objective
physical deformity and the severity of psychological

4
Handbook of Orthognathic Treatment
change with reassurance) or do they simply have a
different view from their parents. The maturity of
this decision is also important to assess; for example
to establish whether or not it is part of a more general
oppositional stance with their parents or whether it
is a considered view, taking into account the likely
future impact of any facial anomaly they may have.
If the referral was primarily instigated by the
patient themselves and is largely an aesthetic issue,
the question of whether this is as a result of a sus­
tained concern or one prompted by recent events
(positive or negative) in the patient’s life, is an impor­
tant area of assessment. The recent event may be a
negative one such as a relationship breakdown and
the concern about facial appearance may just be part
of a resulting general negative evaluation of self.
There may be a more complex issue underlying
patient motivation for treatment such as gender
dysphoria or ethnic identity difficulties which may
influence an aesthetic dissatisfaction with facial
appearance. The question of why exactly the patient
is seeking surgery, at this particular time in their life,
is an important one because if surgery is in response
to a more sustained concern, then they are more
likely to be satisfied with the outcome of treatment.
Sarwer (2002) has described the concept of internal
and external motivation for treatment. Internal moti­
vation is driven by factors within the individual, for
example, a wish to improve appearance or increase
self-esteem. External motivation he suggests is con­
cerned with factors external to the individual such as
a desire to please others or the notion that if they
changed their appearance they will get promotion at
work and so on. The importance of the division
between internal and external motivation has some
relevance for patient satisfaction with outcome from
treatment because it is suggested that more internally
motivated patients are more likely to be happy with
the outcome from surgery.
The likely motivation of a patient to continue with
treatment through a relatively long treatment pro­
gramme is also an important issue to explore. Patients
are required to make frequent clinic visits, to adhere
to an excellent standard of oral hygiene and to cope
with many months of the initial treatment probably
worsening their facial appearance, during the ortho­
dontic preparation. The issue of motivation is more
pertinent if they have a history of avoiding treatment
offered or of defaulting from treatment. We know
that past behaviour is the best predictor of future
behaviour and therefore people who have not con­
tinued treatment in the past are more at risk of
defaulting again, compared to those with no such
important information about the behavioural aspects
of their body image concern. Again, if a patient has
problems establishing or maintaining eye contact
then this may indicate a severe body image problem
or a psychological condition such as social anxiety.
The assessment of the patient’s perception of the
presenting clinical problem is important for the team
discussion and comparisons made with the clinical
view of the problem, in order to avoid problems
associated with disproportionate concern about ap­
pearance and dissatisfaction ultimately with treat­
ment outcome.
1.2.2  Patient expectation of treatment
A second main area of the psychological assessment
involves looking at the patient’s expectation of treat­
ment both from a physical and a psychological point
of view. If patient’s expectations are vague or unreal­
istic, it may be possible to alter those views by giving
them very clear information during the multi-
disciplinary assessment, about what is possible from
treatment. If their expectation about the effect that
treatment will have on their lives is unrealistic, it may
be possible to work with them psychologically in
order to help them begin to make necessary changes
in their lives, both prior to and following surgery, so
that they can achieve a good outcome from treat­
ment. If patients, however, continue to hold unreal­
istic views about what could be achieved both from
a physical and a psychological point of view, despite
input, then their expectations of surgery cannot be
met and they are likely to be unhappy with the
outcome from treatment.
1.2.3  Patient motivation for treatment
A third area of assessment is patient motivation both
in relation to why they are seeking treatment and
also to their likely adherence to what will be a long
and demanding course of treatment. It is therefore
important to establish if they have just agreed to be
referred at the suggestion of their dental practitioner
or another clinician and they are there unquestion­
ingly. If this is the case, it is important to ask if they
are keen to proceed once they have fully understood
the nature of the clinical problem. This is particularly
important if they are young or a vulnerable adult. If
the referral was sought on their behalf primarily as a
result of parental concern for example; it is important
to establish whether they do actually share that
concern and want to pursue treatment themselves. If
they express a desire not to proceed, it is important
to establish if this is because they have particular
fears about the surgery (which may be inaccurate and

Psychological considerations for the orthognathic patient
5
1.2.5  Outcome from psychological
assessment
At the end of the psychological assessment the psy­
chologist has a discussion with the patient about
relevant issues which have emerged during the assess­
ment and informs them about issues which will be
fed back to the rest of the clinical team. Some prepa­
ration for the rest of the assessment process is done,
encouraging patients to ask questions or voice any
concerns they may have during the process. If the
patient indicates that they may have difficulty
voicing their concerns they are reassured that they
will have some help with that and they will also have
a family member or partner or friend present with
them. They are reminded that they have been referred
for elective treatment and that they should only
make the final decision to proceed, if treatment is
recommended, after hearing all the risks and benefits
of the treatment options. They are also reassured that
they can take some time to make a decision as delay
in starting treatment is better than withdrawing pre­
maturely from treatment later.
Occasionally a recommendation will be made from
the psychological assessment to delay the start of
treatment because of the patient’s current life situa­
tion, psychological difficulties or current mental
health problems. For example if someone is suffering
from post-natal depression and struggling to cope
with a new baby, then a period of delay before
embarking on treatment may be better. Sometimes
patients may have difficulty in expressing concern
about the timing of treatment because they think
they will not be offered it again or they feel guilty
that they have taken up an appointment slot. Post­
ponement of the decision-making process may also
be recommended if it emerges that the patient is
under pressure, for whatever reason, to make a deci­
sion and they are not sure about it. This is particularly
important if they are young, perhaps over-compliant
or vulnerable in some way.
On rare occasions, the psychologist may recom­
mend that treatment is not offered at all because
there are contra-indicators for surgery from a psycho­
logical perspective (Red Flags) and these will be
detailed in a later section. In addition, there may be
other occasions where significant issues are identified
by the psychologist (Amber Flags), which will influ­
ence the discussion and decision about whether or
not to offer orthognathic treatment to particular
patients. This may be particularly relevant in situa­
tions where the physical indicators for treatment are
slight and the desire for treatment is primarily an
aesthetic one. In some cases, the psychologist may
history. It is therefore important to find out what the
cause of the previous failure to complete treatment
and if it is likely to recur in their current life situation.
The patient’s likely supportive network during treat­
ment is ascertained, particularly for the immediate
post-surgery period.
Motivation for treatment is affected both by the
patient’s perception of the problem and its relative
importance to them and they need to make a very
clear decision to proceed with treatment. If patients
seem ambivalent about proceeding or if their moti­
vation is questionable, then a delay in starting
treatment is indicated. Those requiring additional
support to attend, such as those with mental health
problems, can be identified and the necessary
support arranged.
1.2.4  Patient’s psychological status
A psychological assessment, based on an expert
knowledge of normal development, will also include
taking a brief history of early childhood experience,
their interpersonal relationships and of how they
have functioned at school, work and in social set­
tings. This will include some assessment of personal­
ity and the assessment of reported psychological
difficulties currently or in the past.
A brief screening for a history of psychiatric illness
is carried out and if such a history emerges then a
more detailed assessment of current psychological
status follows. This will include any history of
alcohol or other substance abuse or of self-harm. If a
significant psychological history emerges, a second
assessment session may be required before the assess­
ment is complete. This may include contacting the
mental health professionals currently treating the
patient, in order to obtain their opinion about any
likely impact of the patient’s illness on orthognathic
treatment.
Finally to complete the assessment, a brief assess­
ment of how patients have coped with illness, surgery
or trauma in the past is made. There is some discus­
sion about the patient’s educational, work or family
plans over the next two years because many patients
seen in the dentofacial clinic are at a transitional
stage of their lives and clearly this has to be taken
into account when the treatment planning is being
considered. An assessment of the social support avail­
able to them currently and any likely change to this,
around the time of the surgery, is also carried out.
The quality of social support has been found to be
important for patient outcomes and it is important
to try to identify patients who may need some addi­
tional support around the time of surgery.

6
Handbook of Orthognathic Treatment
structure information for that patient may be made.
If the learning disability is severe and the patient is
accompanied by their carer, attempts should still be
made to ensure that communication is primarily
with the patient and understood by them. Liaison
with the family or carers will be essential if the
patient has any likely difficulties in relation to treat­
ment which they are unable to express.
If a patient has a history of sexual or physical
abuse identified during assessment and patients feel
uncomfortable with some procedures, the psycholo­
gist will have discussed what is going to be particu­
larly difficult for them in clinical situations and be
able to advise team members accordingly. For
example, if a patient finds it particularly difficult to
have someone standing behind them, out of sight,
then care should be taken to minimise the time this
happens. In general, it may be necessary to take more
time to explain procedures before approaching the
patient than would normally be necessary. Having
various procedures or an anaesthetic may again be
particularly difficult for patients with a history of
abuse and particular care to support the patient at
this time or devising procedures to increase the
patients’ sense of control in those situations may be
necessary.
Advice may also be given about a variety of other
relevant issues including gender, cultural or religious
issues which may have been discussed at psychologi­
cal assessment if this will have any implication for
how the patient is managed during treatment. Under­
standing of psychological issues will contribute to
better management of the patient.
1.4  Red fllag and amber fllag patients
The evidence suggests that most people being referred
to orthognathic clinics do well with the treatment
and are happy with the outcome. There are, however,
a number who are not satisfied with the outcome of
treatment and for some this will be due to psycho­
logical problems rather than any physical problem
with their treatment. It is important that they are
identified because in some cases orthognathic treat­
ment may worsen their psychological condition. In
other cases, it is important that they receive appropri­
ate treatment for their psychological difficulties.
There is a generally held view, expressed in the
orthognathic literature, that their patients are quite
different from those seeking plastic surgery. In particu­
lar, they are said to be more psychologically stable and
not dissimilar to the general population. There are
however issues which should be noted in relation to
arrange to see them again, contact the relevant
mental health services for more information if neces­
sary and carry out a more detailed assessment. If the
patient agrees to appropriate treatment for the psy­
chological condition identified, then a referral to the
appropriate services is made.
Immediate feedback from the psychological assess­
ment is given to the team prior to the orthodontic
and surgical assessment of the patient. The feedback
will also include recommendations about the patient’s
psychological needs during assessment and treat­
ment. The psychologist takes part in the final discus­
sion with the team after assessment of the patient is
complete and during the discussion with the patient
about treatment options, at the end of the multi-
disciplinary assessment.
1.3  Advice on management of
patients following assessment
When the psychologist has identified patients with
psychological difficulties or conditions during the
initial assessment, some recommendations about
management of the patient during treatment is
made. The issues might be quite wide ranging but a
few typical examples are patients who have:
• generalised anxiety;
• history of depression;
• learning disability;
• history of sexual or physical abuse.
If a patient is assessed as having generalised anxiety
at assessment then clearly clinical settings and pro­
cedures are likely to evoke anxiety in such patients.
Advice about their likely presentation at clinics, how
to manage that and encouragement to use their
anxiety management techniques should help to
reduce the patient’s anxiety.
A patient with a past history of depression will have
been given advice by the psychologist at the initial
assessment. In particular, patients are warned about
the possibility of lowered mood following surgery
and they are encouraged to report any symptoms of
depression so that they can receive the appropriate
input. The team is also advised about the previous
history, or the current well managed depression so
that they can refer the patient to psychology if they
feel subsequently that the patient’s mood is worsen­
ing. The exacerbation of depression may not just
present as obvious low mood, but typically in
increased irritability, change in treatment compliance
or poorer self-care.
If a patient presents with a learning disability, then
advice about the level of language use and how to

Psychological considerations for the orthognathic patient
7
anomaly is present, the individual’s concern is
markedly excessive.
• The preoccupation must cause significant distress
or impairment in social, occupational or other
important areas of functioning.
• The preoccupation is not better accounted for by
another mental disorder (DSM-IV-TR 2000).
The prevalence of Body Dysmorphic Disorder
(BDD) in the general population is thought to be
between 1%–2% but is known to be much higher in
plastic surgery (5–5%) and dermatology (9–15%)
clinical populations (Sarwer and Crerand, 2008;
Phillips et al., 2000). The rate of BDD seen by
orthodontists is reported as 7.5% of adult patients
(Hepburn and Cunningham, 2006). The rate of BDD
in orthognathic treatment clinics is not known,
however given that the face is one of the main
focuses of concern in BDD, it is highly likely that
the rate is higher than in the general population.
Veale et al. (1996) for example, found that 86% of
their BDD sample mentioned their face as one focus
of their concern. The average age of onset of the
condition is late adolescence (Phillips et al., 1993;
Veale et al., 1996) which is also the average age of
those presenting in a dentofacial planning clinic.
BDD is thought to be equally prevalent in men and
women.
The key clinical features of people presenting with
BDD are that they present with marked distress and
intense pre-occupation with the imagined defect.
They may try to camouflage the defect with their
hairstyle, heavy makeup, and scarf or hat for example.
They may spend long periods checking the imagined
defect in a mirror or other mirrored surfaces and
repeatedly check with family members about the
appearance of the area involved. Alternatively, they
may describe avoiding looking in mirrors and have
them removed from their house; or never discussing
their problem with anyone they know, to avoid
drawing attention to it. There may also be marked
avoidance of social and occupational settings and of
forming relationships despite a wish to do all of those
things. At the more extreme end of the spectrum,
they may have dropped out of college or work and
have become quite socially isolated.
There will inevitably be a marked difference
between the objective evaluation of the patient with
BDD and the patient’s thinking about their perceived
anomaly, which may be delusional or at a level of
overvalued ideation. Phillips and McElroy (1993)
maintain that although there may be a spectrum of
severity along which the patient’s beliefs may vary
over time, they will continue to present with impaired
insight about their condition. Clinical opinion and
this assumption of normality. Firstly these conclu­
sions have often been based on average population
scores rather than looking at the proportion of partici­
pants meeting “caseness” for psychological conditions
which has not been considered in the past. Secondly,
psychological “normality” is assumed because many
are referred at the instigation of their general dental
practitioner or orthodontist and have a clear physio­
logical need for surgery. However, many studies show
that aesthetic concern about facial appearance is a
prime motivator for seeking orthognathic surgery and
is also the main criterion for patient satisfaction with
treatment. Thirdly, a sizable minority of patients are
reported to have instigated the referral themselves and
there is a suggestion that there is a change in the clini­
cal population seeking orthognathic surgery since the
1990s, as more people have increased concern about
appearance and are more aware of orthognathic
surgery. Given that some people present in an orthog­
nathic clinic with minor anomalies and an appearance
within an average range, but reported associated psy­
chological distress, may mean that this subgroup of
orthognathic patients may be more similar to plastic
surgery populations. Therefore some psychological
issues, which have been more extensively researched
in the plastic surgery literature, may be relevant to a
sizeable minority of orthognathic patients and it is
important to ensure that there are no conditions
present which may make the surgery inadvisable.
Finally it has to be remembered that “normal” or
“average” populations will also include a percentage
of people with psychiatric disorders and psychological
problems; it does not mean that they are problem free.
Although patients described in the following sec­
tions are relatively rare, they may cause considerable
disruption in clinical work, become more distressed
following treatment and in rare cases, litigious. One
way to think about the issue in relation to proceeding
with treatment is a Red, Amber, Green flag system.
The following section goes into some detail about
those patients who:
• Have RED FLAGS and should generally not be
offered surgery.
• Have AMBER FLAGS and treatment should go
ahead only after very careful evaluation by the
team.
1.4.1  Red fllags
Body dysmorphic disorder
The essential criteria for a diagnosis of body dysmor­
phic disorder are:
• A preoccupation with a defect in appearance where
the defect is imagined, or if a slight physical

8
Handbook of Orthognathic Treatment
‘applies when the central theme of the delu­
sion involves bodily functions or sensations’.
(DSM-IV-R)
Occasionally someone may present with a single
delusional belief about their face which does not
seem part of any other psychotic condition such as
schizophrenia. They may have normal appearance or
at best some minor facial anomaly and their beliefs
about their face are not consistent with an objective
assessment. They may be quite insistent about the
need for surgery and as the beliefs are delusional will
not respond to reassurance about the essential nor­
mality of their face. The condition may vary, but
tends to be chronic so they may repeatedly request
treatment (Pruzinsky, 2002). Clearly surgery would
not resolve their perception of the problem and
surgery is therefore contra-indicated.
Under the current classification of Mental Disorder
(DSM-1V-TR), BDD patients with delusional beliefs
are also classified as having somatic delusions but
experts in the field (e.g. Phillips, 2002) feel that they
are actually one disorder with patients presenting
with varying degrees of severity and are best thought
of along a dimension of insight/delusion, rather than
as discrete categories.
Major current depression
If patients present with current major depression,
then it may be advisable to delay starting treatment,
particularly if the prime reason for seeking orthog­
nathic treatment is dissatisfaction with their facial
appearance. In clinically significant depression, pa­
tients’ mood symptoms affect their thinking and
behaviour. There is a positive relationship between
depression and body image problems and clearly any
distress they may report in relation to their facial
anomaly will be influenced by their current low
mood. Their mental state may well be influencing
their decision to seek surgery and when well, they
may hold a different view. The depression will also
affect their motivation and make it more difficult to
cope with and adhere to a demanding treatment
regime. Arrangements should be made to re-assess
patients in several months, when the depression may
have resolved.
Social phobia (Social Anxiety Disorder)
Some patients may present with marked social phobia
or social anxiety and they identify their facial
anomaly as the cause of the problem. In many cases
their condition may not have been previously identi­
feedback about the essential normality of their
appearance will not alter this.
Clearly patients with BDD will pursue treatment
for the imagined defect persistently and put health
professionals under great pressure to act on their
behalf. They may have approached different clinics
in different areas, to try to have the treatment they
think they need and may well not disclose this when
seen. Anyone presenting with excessive pressure to
have surgery or treatment, needs to have a very
careful assessment. The presence of BDD is consid­
ered a contra-indicator for surgery and indeed surgery
can lead to an intensification of their symptoms or a
symptom shift to another feature of their face or
body (DSM-IV-TR). The NICE guidelines (2005) on
obsessive compulsive disorder, which includes BDD,
recommends that patients presenting with the condi­
tion should be assessed by a mental health profes­
sional with experience of the disorder. They should
be referred on to an appropriate mental health clini­
cian for treatment, preferably to a service which spe­
cialises in such conditions.
Psychotic disorders
a) Schizophrenia with delusional beliefs
about facial appearance
There are a group of patients who may have delu­
sional beliefs about their appearance which is second­
ary to a schizophrenic illness. They may at times
become very preoccupied about their facial appear­
ance for example, but at other times this preoccupa­
tion seems less intense, perhaps varying with an
overall improvement in their mental state. Pruzinsky
(2002) makes the point that very little is known
about body image disturbance in psychotic disorders
such as schizophrenia as there has been very little
systematic investigation of it despite discussion of
the phenomena in clinical case descriptions. Clearly,
treatment would not be recommended for patients
with such delusional beliefs, as it will not resolve
their concerns.
On the other hand, if someone is referred with a
schizophrenic illness with no delusional beliefs about
their face they should be considered for treatment, if
it is indicated. Contact with mental health services is
essential, in order to obtain an opinion about the
patient’s current stability and ability to cope with
treatment. An assessment of the support available to
them should be made, in order to ensure that they are
able to benefit from treatment.
b) Somatic delusions
The diagnosis of delusional disorder, somatic type
(DDST):

Psychological considerations for the orthognathic patient
9
A number of personality disorders have been asso­
ciated in the plastic surgery literature with poor
outcome and may be problematic from a psychologi­
cal perspective especially if the physical indications
for orthognathic treatment were slight. An example
would be Avoidant Personality Disorder.
A personality disorder which may sometimes be
confused with social anxiety disorder is Avoidant Per­
sonality Disorder which has been defined as:
A pervasive pattern of social inhibition, feel­
ings of inadequacy and hyper sensitivity to
negative evaluation, beginning by early adult­
hood and present in a variety of contexts.
(DSM-IV-TR)
People with this diagnosis are typically shy, lonely
and isolated because of their hypersensitivity to
possible criticism or rejection. They frequently view
themselves as inadequate or inferior to others. They
may as part of the condition, assess their appearance
as problematic and report embarrassment about some
aspect of their face and fear rejection because of it.
Orthognathic treatment is unlikely to change the
patient’s functioning, particularly if the physical
indications are slight.
Self-harm
It is important to know if someone has a history of
self-harm, whether this is recent and what form that
has taken. There is a spectrum of severity, but some
people, who harm their bodies, may interfere with
wound healing or some other aspect of their treat­
ment. A careful assessment of current stability and
contact with mental health services, if they are
being seen currently, is essential before considering
treatment.
If patients are currently abusing alcohol or drugs
significantly, then orthognathic treatment may not
be appropriate currently. They would be unlikely to
co-operate fully with treatment and may suffer
trauma to their face, during for example binge drink­
ing episodes.
Eating disorders
Current, severe eating disorders such as Anorexia
Nervosa and Bulimia Nervosa would be a contra-
indicator for treatment because of the physical effects
of the conditions. In addition, the clinical priority in
such cases would be to ensure that they are referred
for appropriate treatment for their eating disorder if
not currently in treatment.
fied and they may have had no contact with mental
health services.
The criteria for social phobia include:
A marked and persistent fear of one or more
social or performance situations in which the
person is exposed to unfamiliar people or to
possible scrutiny by others. The individual
fears that he or she will act in a way (or show
anxiety symptoms) that will be humiliating
and embarrassing. (DSM-IV-TR)
Exposure to the feared situation invariably pro­
vokes anxiety and in some cases a panic attack.
Patients with social phobia do have insight and rec­
ognise that the fear they experience is irrational, but
they will have marked social withdrawal despite a
desire for social interaction. Typically patients with a
social phobia are hypersensitive to criticism or rejec­
tion. The condition may also have a significant
impact on their work performance, social life and
interfere with relationships. The prevalence rate in
the general population of social phobia is around 2%.
A much higher percentage of the general population
will present with a degree of much milder social
anxiety and this has been suggested to be as high as
40% (Edelmann, 1992).
Individuals, who have a history of extreme shyness
in childhood or later have marked social anxiety, may
focus on an aspect of their appearance as the reason
for their difficulties. Clearly appearance can influence
sociability, but where people are presenting with
minor physical problems and seem to have marked
social difficulties, then clearly an alternative explana­
tion for their difficulties must be considered. This is
important because their expectation of surgery will
not be met (surgery will not bring about a transfor­
mation of their life) and this may precipitate a psy­
chological crises when the expected result does not
materialise or they may just shift the focus of their
concern to some other aspect of their appearance.
Personality disorders
A personality trait has been defined as:
An enduring pattern of perceiving, relating to
and thinking about the environment and
oneself that are exhibited in a wide range of
social and personal contexts. Only when per­
sonality traits are inflexible and maladaptive
and cause significant functional impairment or
subjective distress, do they constitute a person­
ality disorder. (DSM-IV-TR)

10
Handbook of Orthognathic Treatment
such as ugly or repulsive, when describing a relatively
minor anomaly, may be indicative of a degree of
BDD.
Other body image problems
If a patient is seeking orthognathic surgery primarily
for aesthetic reasons and they have very little physi­
cal indication for surgery it is important to know
whether or not they have other body image prob­
lems. It is important to establish if they have other
concerns about their face or concerns about other
aspects of their body. They may have consulted
other specialists about their presenting problem and
perhaps been refused surgery. It is also important to
know if they have had other cosmetic procedures
such as plastic surgery, regular use of botulinum toxin
injections, cosmetic dentistry and so on, in order to
establish the extent of body image dissatisfaction.
They may of course not reveal all their history and if
this is the case, then it is a cause of some concern.
Again they may be at risk of being unhappy with the
outcome from treatment.
Complex identity issues
Dissatisfaction with facial appearance can occasion­
ally be a manifestation of difficulties associated with
more complex issues of identity for the patient. For
example, particularly in adolescence when body
image issues are especially in focus, an individual
from a minority ethnic group in a society may want
a particular aspect of their appearance to be more like
the cultural ideal in the dominant ethnic group, in
that society. This may be only a temporary attitudinal
shift or part of the exploration of identity in adoles­
cence and not a long term concern.
Again patients with gender dysphoria, may present
with dissatisfaction with aesthetic aspects of facial
appearance, often in situations where they are expe­
riencing difficulties in adapting to living within their
new gender and in particular, experiencing problems
with the response of others to their change of iden­
tity. Orthognathic treatment is unlikely to resolve
their difficulties and they may well as a result be
unhappy with treatment outcome.
Undue pressure to have surgery
If clinicians feel under considerable pressure to go
ahead with treatment, perhaps in situations where
they feel that the clinical indicators for treatment are
not compelling, this should raise some concerns. The
pressure may come from parents who may be very
anxious about the implications of their child not
having treatment or from the patient themselves.
1.4.2  Amber fllags
Patients with amber flags are those patients whose
presentation may give rise to some concern. These
patients may not meet the formal criteria for psychi­
atric disorders but their presentation is suggestive of
some psychological difficulty or a concern that they
are at risk of being dissatisfied with the treatment
outcome.
Preoccupation with minor defects
Patients who present at the clinic with pre-occupation
with objectively minor physical problems or whose
appearance can be considered to be within an average
range of appearance, should be dealt with very care­
fully. They may engage in a very long and detailed
history of their problem; have prolonged discussion
about treatment options and may have researched
treatment options extensively on the Internet. Typi­
cally they may also have difficulty in making a deci­
sion about whether or not to proceed with treatment.
They may be exhibiting obsessional traits or even an
obsessive compulsive disorder, which may involve
having an extremely high level of expectation of
their appearance. Given that their level of concern
is not in keeping with objective assessment at the
start, it may be impossible to achieve the standard
of perfection they require and as a result, they may
have difficulty accepting the outcome from surgery
and request repeated surgery. They may also have
some difficult adapting to changes in their appear­
ance. Alternatively someone preoccupied with minor
defects may have BDD.
Vague concerns with their appearance
If someone is unable to articulate their particular
concerns about their face, after having been given
plenty of time and encouragement to do so, then this
is a cause for some concern. If they can only voice a
vague notion of ugliness or a general unhappiness
with their facial appearance this is equally problem­
atic. It is not possible to establish their concerns or
expectations accurately and therefore any subsequent
surgery may not resolve their particular problem. It
may also be indicative of a degree of BDD.
Use of extreme language
A patient who has a dramatic appearance and pres­
entation and who describes any anomaly, even a
minor one, in extreme language may have histrionic
personality traits. They may appear to be very confi­
dent but be unusually demanding of attention and
have some difficulty with the physical effects of
surgery and recovery. Again, the use of extreme words

Psychological considerations for the orthognathic patient
11
weigh the psychological concerns in a risk benefit
analysis. If such patients proceed to surgery they may
need some additional support or a particular manage­
ment strategy as part of their care plan.
1.5  Psychological therapeutic input
to patients during treatment
The majority of patients having orthognathic treat­
ment will have no need for psychological input.
However during treatment, a variety of stresses can
occur and psychological issues may arise requiring
some psychological input; during pre-surgical ortho­
dontics, immediately prior to surgery or post-surgery.
1.5.1  Pre-surgical orthodontics
A number of brief interventions may be made with
people, who have been identified at assessment, with
particular psychological issues. Other problems may
arise, during the fairly lengthy period of orthodontic
treatment and which may be helped by further psy­
chology assessment or intervention. For example
patients may begin missing appointments which
may be indicative of motivational issues, anxiety
about the prospective surgery or ambivalence about
completing treatment. Clinicians treating the patient
may also become aware that the patient is exhibiting
marked anxiety or low mood. The fact that the psy­
chologist is seen as part of the team and has already
spoken to them, makes the discussion about referral
to psychology much easier and reduces any perceived
“stigma”. The patient themselves may ask to be seen
as they have been told at the initial assessment that
they can access further psychological input at any
stage of treatment, if required. Some of the more
common difficulties include the following:
a) Anxiety
If patients present with anxiety disorders such as
generalised anxiety disorder or phobic anxiety, then
a brief intervention may be offered which may typi­
cally involve relaxation training, anxiety manage­
ment training or systematic desensitisation and use
of coping self-statements.
b) Depression
If a patient becomes depressed during treatment,
then a further psychological assessment would be
carried out and depending on the severity of the
problem would either refer them to mental health
services or liaise with their general practitioner
who may prescribe anti-depressant medication and
they could then be seen by the psychologist for
There may also be considerable pressure from parents
to have their child undergo treatment earlier than the
optimal age for treatment. This may be because the
patient is quite distressed about their appearance or
they are being teased or even bullied at school because
of their dental anomaly. Clearly, if the latter is the
case, then parents can be encouraged to approach the
school, as there are support services in schools too
(i.e. educational psychologists, school counsellors)
who can help support the child and any bullying
issues can be appropriately dealt with in the school.
Disproportionate social effects
If a patient describes quite disproportionate social
effects of quite minor anomalies of appearance then
this raises questions about their perception of the
physical problem and of whether they will be happy
with the outcome from treatment. It may also be
indicative of a more general social problem which
will not alter with orthognathic treatment.
Dissatisfaction with previous treatment
A patient’s description of what they consider to have
been previous failed treatment or poor relationships
with clinicians which they have seen in the past, is
of some interest, particularly if they have had a good
objective outcome. Although undoubtedly some
patients may have had poor experiences in the past,
a closer investigation may suggest that there is a
danger that they are likely to be unhappy with future
treatment also.
Narcissistic traits
People who present with narcissistic traits (morbid
self-admiration) are over-represented in those pre­
senting for cosmetic surgery and cosmetic dentistry
and may also present in a dentofacial clinic with
perhaps minor physical anomalies. They may have
unrealistic ideas about what can be achieved from
treatment or attempt to make disproportionate
demands on clinicians throughout treatment. They
will be at risk of being dissatisfied with outcome
from treatment, despite good outcomes and may
put considerable pressure on clinicians for further
treatment.
In summary, those patients presenting with red
flags are unlikely to be helped by orthognathic treat­
ment and should be referred for psychological treat­
ment by a specialist service or referred to mental
health services, if required. Patients presenting with
amber flags should have a very careful assessment
and a team discussion about whether or not the
physical indicators for surgery are sufficient to out­

12
Handbook of Orthognathic Treatment
a) Communication
Communication between the surgeon and patient
has been identified as a critical factor in the predic­
tion of positive outcome following surgery. Typically
patients will only retain a small amount of informa­
tion given, be selective in what they attend to and
anxiety in the clinical situation will affect recall. Lack
of sufficient information about post-surgical adjust­
ment problems is a frequent complaint of patients
dissatisfied with their treatment. Written information
can help, as can links to websites or with patients
who have had similar surgery, but communication
with the clinicians providing treatment, is particu­
larly potent. Ensuring that a family member or
partner has access to the information, at each stage
of treatment, is also important.
b) Patient expectation of surgery
Prior to surgery, it is also important to re-iterate some
of the issues which may not have been discussed
since the initial assessment for example, eliciting
again what patients are expecting from surgery and
ensuring that these are realistic. At this time the
orthognathic team should once again clearly express
what is hoped to be achieved by surgery and the use
of photographs or computer prediction software are
particularly helpful. A reminder that desired changes
in appearance may take some time and that they may
experience a short-lived, negative emotional response
immediately after surgery is important. They also
need to be reminded that positive changes in self-
esteem and interaction with others, if necessary, may
take considerably longer to occur and require their
own active participation in the process.
c) Patient preparation for surgery
Encouraging all patients to discuss their fears and
anxieties, about the approaching surgery, will enable
the clinician to provide relevant information about
each of their concerns. There is considerable evidence
in the pain literature that most patients cope better
with a realistic description of likely discomfort fol­
lowing surgery, rather than simple reassurance and
that this can have significant effects such as a
decreased need for analgesics and earlier discharge
from hospital. It is important that family members
are also given information about the process of and
effects of surgery; so that they are prepared for what
they see when visiting the patient post-surgery, as
their reaction may influence the patient’s immediate
post-surgical response.
d) Anxiety
Pre-surgical psychological distress has been shown to
have a negative impact on post- surgical outcomes.
Immediately prior to surgery a small number of
patients may begin to exhibit considerable anxiety
cognitive-behavioural therapy or other appropriate
intervention.
c) Unrealistic expectation of psychological
effects
If a patient has been identified as having rather unre­
alistic expectations about the psychological impact of
the treatment, but a decision has been made by the
team to proceed with orthognathic treatment, then
some brief therapeutic intervention, by the psycholo­
gist, may be helpful. The intervention would focus
on helping the patient to assess the reality of some
of their expectations, to emphasise that psychological
change may take longer than the physical change in
their appearance. It would also involve helping the
patient to identify some changes that they could
make in their functioning while undergoing orthog­
nathic treatment so that the benefit from the later
treatment is maximised. For example, if they are
socially avoidant because of their concern about their
appearance, encouraging them to begin to go into
social situations they are currently avoiding, remind­
ing them that the changes that will happen following
surgery may not be particularly obvious to other
people. Providing some training in coping strategies
for any associated anxiety can also be helpful.
d) Support of patients with psychiatric
conditions
A further role for the psychologist in the dentofacial
clinic is to support those patients being treated who
have stable mental illnesses but whose illness may
still impact on the treatment process. Liaison with
the mental health team can help resolve problems
and ensure attendance for clinics. It will also be
helpful in the period following surgery, to ensure that
the patient manages to eat appropriately.
e) Patient changing decision to proceed with
surgery
Patients may change their minds about proceeding
with surgery after orthodontic decompensation has
begun, despite it being emphasised at the start of
treatment that the orthodontic and surgical treat­
ment are a package and are co-dependent. If their
decision is due to unrealistic fears about the surgery
then a discussion with the psychologist and the
surgeon may resolve some of the issues and fears that
the patient has which would allow them to proceed
as planned.
1.5.2  Surgical planning stage – patient
preparation for surgery
Psychological factors have been shown to influence
physical response to surgery, play an important part
in surgical outcomes and contribute to patient
satisfaction.

Psychological considerations for the orthognathic patient
13
tant, continuing influence on satisfaction with
treatment.
There may be a mismatch between support and the
patient’s process of adjustment following surgery and
particularly during the period when they are still
adjusting to their changed appearance and respond­
ing to wider social reactions to their changed appear­
ance. Family and friends may be supportive in the
very early stages of surgical recovery, but may assume
that the patient has no need for continued support
beyond this and at a time when clinical input is also
reduced. This may be a period when dissatisfaction
with outcome from surgery will manifest itself, so
that for example Kiyak et al. (1984) found that self-
esteem scores were lower nine months after surgery
but had improved again at 24 months after surgery.
Kiyak et al. (1985) found that a subset of about 20%
had increased mood disturbance and this group were
more likely to experience significant life changes after
surgery including divorce and family problems. The
author suggests that social support, from significant
others, is a continuing influencing factor for patient
satisfaction with treatment for up to two years fol­
lowing surgery.
c) Mood disturbance
Immediately following surgery, patients typically
have to cope with facial swelling, bruising, discom­
fort associated with the surgery and the orthognathic
wafer. Patients vary considerably in how they cope
with the immediate post-surgical period and may
need reassurance about the temporary nature of the
problems they are experiencing. Transient low mood
following surgery is quite common and some have
suggested that this may be linked to anaesthesia,
steroid and analgesic drugs commonly prescribed at
this time and to weight loss (Stewart and Sexton,
1987).
However, some patients appear to have a much
more sustained low mood but little clear information
is available, in the literature, about the proportion of
patients involved. Derwent et al. (2001) reported that
around 30% of parents and patients independently
rated the patient as having depressed mood during
the three months following surgery. Kiyak (1985) sug­
gested that a 20% subset of patients have symptoms
of depression. Kiyak (1981) found that low mood
measured by questionnaire did not improve until
about six months after surgery and not until the fixed
braces were removed. A minority of patients may
therefore have a more sustained depression and may
require psychological support and treatment.
There is a consistently high correlation between
low mood and dissatisfaction with the outcome of
surgery (e.g. Kiyak et al., 1985). Depressed patients
about it and they should receive additional support.
In some cases information alone may not be enough
to alleviate their anxiety and such patients may need
some input from psychology focusing on the use of
relaxation, coping self-statements and distraction
techniques.
In summary, the issues of communication; realistic
information giving; patient preparation; input to
potentially vulnerable patients prior to surgery are all
important issues because the patient’s emotional
state will not only determine their sense of well-being
and satisfaction with surgery but also their physical
response to the surgery.
1.5.3  Psychological input following surgery
The majority of patients adjust quickly to changes
following orthognathic surgery but a number of psy­
chological issues are known to influence the patient’s
progress after surgery:
a) Process of adaptation
After orthognathic treatment, patients have to adapt
to changes in their appearance and oral functioning.
If the alteration to a patient’s facial appearance has
been marked they may also have to adjust to change
in how people respond to them. The majority of
patients, however, appear to adapt quite quickly and
are satisfied with the outcome of their treatment.
However, not all patients adapt at the same pace and
for example Kiyak et al. (2006) reported that men
report less satisfaction with body image in the months
following surgery compared to women. The sug­
gested reason for this is that men may take longer
to adjust to changes in their physical appearance.
Adaptation is a process of change and it may be
that psychological changes, associated with positive
change in appearance, take longer than the physical
changes.
b) Reaction of others
Social evaluation is a critical factor in a patient’s
adjustment to change after surgery. If a patient has
had a severe disfigurement prior to surgery, then they
are likely to receive considerable positive feedback
from others about the improvement in their appear­
ance (Kiyak, 1995). The change in social acceptance
of their appearance will be obvious to them and will
therefore have an impact on patient satisfaction with
surgery. Conversely, patients may be disappointed if
people in their social sphere do not notice any change
to their appearance and may begin to feel that the
treatment was not worthwhile.
The role of partners or families, providing the
prime emotional support for a patient, is critical.
They have a significant influence on a patient’s origi­
nal decision to opt for treatment and are an impor­

14
Handbook of Orthognathic Treatment
1.7  References
Bell, R., Kiyack, H.A., Joondeph, D.R., McNeill, R.W. and
Wallen, T. (1985) Perceptions of facial profile and their
influence on the decision to undergo orthognathic
surgery. American Journal of Orthodontics, 88, 323–332.
Bull, R. and Rumsey, N. (1988) The Social Psychology of Facial
Appearance. London: Springer-Verlag.
Cash, T.F. (2006) Body image and plastic surgery. In David
B. Sarwar, Thomas Pruzinsky, Thomas F. Cash, Robert M.
Goldwyn, John A. Persing and Linton A. Whitaker. (eds.)
Psychological Aspects of Reconstructive and Cosmetic Plastic
Surgery. Clinical, Empirical and Ethical Perspectives. Philadel­
phia: Lippincott Williams & Wilkins, p. 37.
Cunningham, S.J., Gilthorpe, M.S. and Hunt, N.P. (2000) Are
orthognathic patients different? European Journal of Ortho­
dontics, 22, 195–202.
Derwent, S.K. Hunt, N.P. and Cunningham, S.J. (2001) A
comparison of parents’ and patients views of orthognathic
treatment. International Journal of Adult Orthodontics and
Orthognathic Surgery, 16, 171–178.
DSM-IV-TR. Diagnostic and Statistical Manual of Mental Disor­
ders. Fourth Edition. Text Revision. American Psychiatric
Association. (2000). Washington, DC: Amer. Psychiatric
Pub. Inc.
Edelmann, R.J. (1992) Anxiety. Theory, Research and Inter­
vention in Clinical and Health Psychology. Chichester:
Wiley.
Helm, S. Kreiborg, S. and Solow, B. (1985) Psychosocial
implications of malocclusion: A 15-year follow-up study
on 30-year-old Danes. American Journal of Orthodontics, 87,
110–118.
Hepburn, S. and Cunningham, S. (2006) Body dysmorphic
disorder in adult orthodontic patients. American Journal
of Orthodontics and Dentofacial Orthopedics, 130, 569–
574.
Jensen, S. (1978) Psychosocial dimensions of oral and maxil­
lofacial surgery: A critical review of the literature. Journal
of Oral Surgery, 36, 447–453.
Kiyak, H.A. (1995) Discussion on the impact of interpersonal
support on patient satisfaction. Journal of Oral Maxillofa­
cial Surgery, 53, 1297–1299.
Kiyak, H.A. (2006) Orthognathic surgery. In David B. Sarwar,
Thomas Pruzinsky, Thomas F. Cash, Robert M. Goldwyn,
John A. Persing and Linton A. Whitaker (eds.) Psychological
Aspects of Reconstructive and Cosmetic Plastic Surgery. Clini­
cal, Empirical and Ethical Perspectives. Philadelphia: Lip­
pincott Williams & Wilkins, p. 161.
Kiyak, H.A., Hohl, T., Sherrick, P, West, R.A., Boucher, F.
(1981) Sex differences in motives for and outcomes of
orthognathic surgery. Journal of Oral Surgery, 39, 757–
764.
Kiyak, H.A., Hohl, T., West, R.A. and McNeill, R.W. (1984)
Psychological changes in orthognathic surgery patients. A
24 month follow-up. Journal of Oral Maxillofacial Surgery,
42, 506–512.
Kiyak, H.A., McNeill, R.W. and West, R.A. (1985) The emo­
tional impact of orthognathic surgery and conventional
report more pain, post-surgical discomfort and poorer
oral function. There appears to be a difference
between the complaint of pain and other physical
effects of surgery such as swelling and paraesthesia.
This is thought to be due to the fact that there is an
affective component in the pain experience which
will be influenced by low mood.
d) Other problems
Relatives may identify ongoing problems both physi­
cal and psychological which the patient may not
have reported themselves. A common example is a
concern that the patient is not eating enough and
this can be due to discomfort but some patients do
see this period as an opportunity to lose weight and
may become seriously underweight.
Functional improvement after surgery does not
mean that associated psychological problems will
improve at the same pace but may take much longer
and involve a dynamic effect on the process of inter­
personal relationships for example. Changes may still
be taking place two years after surgery and some
patients may require help to adjust to the changes. A
clinical psychologist working within a dentofacial
clinic can provide therapeutic input to deal with psy­
chological difficulties associated with their treatment
in the clinic.
1.6  Conclusion
Clinical experience and evidence from research sug­
gests the need for systematic selection of patients,
preparation for surgery and the careful management
of the psychological aspects of patient care through­
out the course of orthognathic treatment.
In summary clinical psychologist input to an
orthognathic clinic will provide:
• Specialist assessment of all patients prior to treat­
ment and early identification of potential problems
from a psychological perspective.
• Advice on the psychological aspects of patient care.
• Input to patients at each stage of treatment when
required.
• Reduced chance of problems associated with
patients’ psychological difficulties and therefore
improved satisfaction with treatment outcome.
• Provide specialist psychological therapy for those
not suitable for treatment or provide a signpost
to appropriate mental health services when
necessary.
The psychological aspects of patient care in orthog­
nathic treatment needs to be recognised as an inte­
gral part of patient care.

Psychological considerations for the orthognathic patient
15
Phillips, K.A., McElroy, S., Keck, P.E., Pope, H.G. and Hudson,
J.I. (1993) Body dysmorphic disorder: 30 cases of imagined
ugliness. American Journal of Psychiatry, 150, 302–308.
Pruzinsky, T. (2002) Body image disturbances in psychotic
disorders. In Thomas F. Cash and Thomas Pruzinsky. Eds.
Body Image. A Handbook of Theory, Research, & Clinical
Practice. New York: The Guildford Press, p.322.
Sarwer, D.B. (2002) Psychological assessment of cosmetic
surgery patients. In David B. Sarwar, Thomas Pruzinsky,
Thomas F. Cash, Robert M. Goldwyn, John A. Persing and
Linton A. Whitaker (eds.) Psychological Aspects of Recon­
structive and Cosmetic Plastic Surgery. Clinical, Empirical and
Ethical Perspectives. Philadelphia: Lippincott Williams &
Wilkins, p. 267.
Sarwer, D.B. and Crerand, C.E. (2008) Review Article: Body
dysmorphic disorder and appearance enhancing medical
treatment. Body Image, 5, 50–58.
Stewert, T.D. and Sexton, J. (1987) Depression: A possible
complication of orthognathic surgery. Journal of Oral Max­
illofacial Surgery, 45, 847–851.
Veal, D., Boocock, A., Gournay, I.C., Dryden, W., Shah, F.,
Wilson, R. and Walburn, J. (1996) Body dysmorphic dis­
order: a survey of fifty cases. British Journal of Psychiatry,
169, 196–201.
orthodontics. American Journal of Orthodontics, 88,
224–234.
Macgregor, F. (1970) Social and psychological implications
of dentofacial disfigurement. The Angle Orthodontist, 40,
231–237.
NICE. NHS National Institute for Health and Clinical Excellence
(2005) CG31. Obsessive Compulsive Disorder: Pathway
(OCD) and body dysmorphic disorder (BDD). Core inter­
ventions in the treatment of obsessive compulsive disor­
der and body dysmorphic disorder.
nice.org.uk/CG31/Guidance.
Phillips, K.A., Dufresne, Jr., R.G., Wilkel, C. and Vittoriao, C.
(2000) Rate of body dysmorphic disorder in dermatology
patients. Journal of the American Academy of Dermatology,
42, 436–441.
Phillips, K.A., Kiyak, H.A. and Reichmuth, M. (2002) Body
image issues in dental medicine. In: Cash, Thomas F. and
Pruzinsky, Thomas. Eds. Body Image. A Handbook of Theory,
Research & Clinical Practice. The Guildford Press: New York,
p.342.
Phillips, K.A. and McElroy, S.L. (1993) Insight, overvalued
ideation and delusional thinking in body dysmorphic dis­
order: Theoretical and treatment implications. Journal of
Nervous and Mental Disease, 181, 699–702.

Dentofacial assessment
2
2.1  Introduction
Assessment of the orthognathic patient should be
carried out systematically to ensure that a complete
picture of the presenting dentofacial dysmorphology
16
Chapter overview
Intended learning outcomes, 16
2.1 Introduction, 16
2.2 General assessment, 17
2.2.1 Patient’s concerns, 17
2.2.2 Medical, dental and social history, 17
2.2.3 History of dentofacial dysmorphology, 17
2.2.4 Stature and body form, 18
2.3 Facial assessment, 18
2.3.1 Lateral view, 18
2.3.2 Frontal view, 24
2.3.3 Bird’s eye view, 28
2.3.4 Worm’s eye view, 28
2.4 Intra-oral assessment, 29
2.4.1 Dental arches, 29
2.4.2 Teeth in occlusion, 30
2.4.3 Soft tissues, 32
2.5 Diagnostic records, 32
2.5.1 Protocol for collection of basic records, 32
2.5.2 Role of diagnostic records, 32
2.6 Cephalometrics for orthognathic
patients, 39
2.6.1 Gross inspection, 39
2.6.2 Qualitative analysis, 40
2.6.3 Quantitative analysis, 40
2.6.4 Superimposition, 49
2.7 Special investigations, 49
2.7.1 Condylar hyperplasia, 50
2.7.2 Acromegaly, 50
2.8 Summary, 50
2.9 Recommended further reading, 50
Intended learning outcomes
By the end of this chapter the reader should:
• Understand the importance of taking a full
history from the patient.
• Understand the importance of correctly
positioning the patient’s head prior to facial
assessment.
• Be aware of the systematic approach required in
carrying out a facial and intra-oral assessment of
an orthognathic patient.
• Understand the function of the basic diagnostic
records used in the management of orthognathic
patients.
• Be aware of the commonly used objective soft
tissue analyses.
• Be aware of the indications and purpose of
three-dimensional imaging, including
Stereophotogrammetry and Cone Beam
Computerised Tomography.
• Be aware of the role of cephalometric analysis,
including its limitations.
• Understand the importance of recognising
progressive facial dysmorphology and the need
for special investigations in some cases.
• Understand when referral to other medical and
dental specialists is required.
Handbook of Orthognathic Treatment: A team approach, First Edition. Ashraf Ayoub, Balvinder Khambay, Philip Benington,
Lyndia Green, Khursheed Moos, and Fraser Walker.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

Dentofacial assessment
17
tions prior to an appointment on the combined
clinic.
It is important to establish the patient’s level of
dental motivation and ensure that they will have the
ongoing support of a General Dental Practitioner for
the duration of their treatment. If there is a history
of dental anxiety it is important to make sure that
the patient will be able to cope with the challenges
of surgical orthodontic treatment.
A patient’s social history should at least include
questioning about home circumstances, smoking and
alcohol consumption. It is also important to know
about any history of mental health problems, but
specialist questioning in this area is most appropri­
ately undertaken at the psychology interview.
2.2.3  History of dentofacial dysmorphology
A history should be taken from the patient regarding
the development of their dentofacial problems. This
should include the following:
1. Congenital anomalies (e.g. growth abnormalities,
condylar hypoplasia or agenesis, hemi-facial
microsomia).
2. Familial traits (i.e. other family members with
facial dysmorphology, such as class III jaw
relationship).
3. Acquired anomalies:
a. Traumatic (e.g. TMJ trauma, before and after
cessation of growth).
b. Pathology (e.g. pituitary adenoma).
4. Racial characteristics:
a. Anterior bi-maxillary protrusion (Black African,
Chinese).
b. Zygomatico-maxillary hypoplasia (Asian).
It is important to recognise progressive facial
dysmorphology, which most commonly manifests
as follows:
1. Gradual increase in anterior open bite (e.g. idio­
pathic condylar resorption).
2. Progressive late mandibular growth (e.g. pituitary
adenoma).
3. Progressive mandibular asymmetry:
a. Unilateral condylar hyperplasia.
b. Unilateral condylar resorption.
c. Unilateral condylar tumour (e.g. osteochon­
droma).
d. Hemi-mandibular elongation.
e. Hemi-mandibular hypertrophy.
It is important to elicit the most accurate possible
history regarding the progress of these conditions.
Previous family or school photographs, if available,
can be extremely helpful.
is assembled. A pro-forma may be helpful in guiding
the clinician through the assessment in planned
sequence and documenting the findings in a struc­
tured manner. The purpose of this chapter is to
describe the level of assessment that we consider
to be essential on an inter-disciplinary planning
clinic. Psychological assessment of the patient is an
invaluable part of this and has been described in
detail in Chapter 1. The procedure on our clinic is
that all new patients are interviewed by the psy­
chologist first and then progress to clinical examina­
tion only if given the ‘green light’.
2.2  General assessment
2.2.1  Patient’s concerns
Because orthognathic surgery is largely elective in
nature, the patient’s concerns are the main reason for
pursuing treatment and must be carefully elicited
from the outset. Whilst most patients will describe
one or more clear problems, some will be more vague
and will have to be probed more thoroughly to estab­
lish exactly what they are seeking to derive from
treatment. In general, patients’ concerns fall into the
following categories:
1. Functional problems:
a. Difficulty with biting and chewing.
b. Discomfort due to the malocclusion:
i. Palatal or gingival soft tissue trauma (e.g.
deep overbite).
ii. Dental trauma (e.g. limited tooth contact).
c. Temporo-mandibular joint dysfunction.
d. Speech difficulties.
2. Aesthetic problems:
a. Facial appearance.
b. Dental appearance.
c. Gingival display.
If the psychologist can be present on the clinic
when the patient is being examined, this is valuable
in helping the patient to express their concerns and
the clinicians to understand them.
2.2.2  Medical, dental and social history
As with any surgical or dental patient, a full medical
history should be taken prior to clinical examination.
It is not within the scope of this book to detail the
medical conditions that will impact on the delivery
of orthognathic surgery, but if the patient reports any
significant illnesses at initial assessment it is prudent
to contact the General Medical Practitioner or Con­
sultant Specialist for clarification or further investiga­

18
Handbook of Orthognathic Treatment
Viewing the face from the lateral aspect allows the
assessment of:
• Jaw relationship and facial convexity.
• Forehead.
• Infra-orbital rims.
• Nose.
• Para-nasal region.
• Upper lip.
• Lower lip and chin.
• Lower lip to sub-mental plane angle.
• Mandibular plane angle.
Jaw relationship and facial convexity
The left and right sides of the head should be exam­
ined separately, since characteristic differences will be
detected in asymmetric faces.
Table 2.1a  Soft tissue profile cephalometric landmarks
Landmark
Definition
Tr
Trichion: the anterior hairline in the
midline.
G
Glabella: the most anterior point on the
soft tissue outline of the brow ridge.
N’
Soft tissue nasion: the deepest point on
the soft tissue outline below glabella.
Prn
Pronasale: the most anterior point on the
outline of the nose.
Cm
Columella: the most anterior point on the
columella of the nose.
Sn
Subnasale: the junction of the upper lip
and the columella.
A’
Soft tissue A point: the deepest point on
the anterior outline of the upper lip
below Sn.
Ls
Labrale superius: the muco-cutaneous
junction of the upper lip.
Sts
Stomion superius: the lowermost point
on the vermillion of the upper lip.
Sto
Stomion: the point of contact, in the
midline, between the upper and lower
lips, where the lips are competent.
Sti
Stomion inferius: the uppermost point on
the vermillion of the lower lip.
Li
Labrale inferius: the muco-cutaneous
junction of the lower lip.
B’
Soft tissue B point: the deepest point on
the anterior outline of the lower lip,
above Pg’.
Pg’
Soft tissue pogonion: the most anterior
point on the soft tissue outline of the chin
below B’.
Me’
Soft tissue menton: the most inferior
point on the soft tissue outline of the
chin.
2.2.4  Stature and body form
The patient’s height and general body shape should
be noted early on in the assessment, since orthog­
nathic treatment should be aimed at delivering facial
proportions that are in keeping with the patient’s
build. A tall, lean patient is unlikely to suit a dispro­
portionately reduced lower anterior face height and
a short, broad patient is unlikely to suit an increased
lower anterior face height. Similarly, a patient’s
stature may influence the surgical plan in the antero-
posterior plane. For example, in certain class III
patients, standing height might play a part in decid­
ing whether surgical correction would be by means
of a maxillary advancement or a mandibular setback.
Where a patient is clearly overweight this can be a
contra-indication for elective orthognathic surgery. In
such cases, the patient may be required to reduce their
weight before they can be considered for treatment.
The Body Mass Index (BMI) is helpful as a guide.
2.3  Facial assessment
The following is a suggested systematic approach to
clinical assessment of facial dysmorphology. See also
Tables 2.1a and b.
2.3.1  Lateral view
The patient should be seated comfortably with their
back in an upright position and asked to adopt their
natural head posture (NHP), in which they are gener­
ally viewed in everyday life. This can be made easier
by asking them to look in a mirror mounted straight
ahead of them. The alternative method of position­
ing the Frankfort Plane (FP) parallel to the floor may
place them in an artificial position, since this not a
reliable horizontal reference plane in patients with
significant facial skeletal discrepancies. It has been
shown that NHP is more reliable than FP for orienta­
tion of the head. Inappropriate head positioning can
result in a false perception of the antero-posterior jaw
relationship (Figure 2.1).
Habitual tilting of the head to the left or right side
should be avoided. However, for patients that have a
condition that produces involuntary tilting, such as
tortocollis (due to shortening of one of the sterno-
mastoid muscles), this should be accepted as their
normal posture, as it is unlikely to improve as a result
of surgery.
It is important for the peri-oral soft tissues to be
relaxed, particularly in patients with increased verti­
cal proportions, who may have incompetent lips and
will tend to habitually posture them together through
mentalis muscle hyper-activity.

Dentofacial assessment
19
Table 2.1b  Summary of soft tissue variables
Variable/
analysis
Type
Description
Function
Mean value(s)
Angle of facial
convexity
(Figure 2.2)
Angular
The small angle
between the lines
G-Sn and Sn-Pg’.
Measures the convexity or
concavity of the profile,
excluding the nose.
12 ± 4° indicates a
normal profile.
Full soft tissue
convexity
(Figure 2.2)
Angular
The angle between the
lines N’-Prn and
Prn-Pg’.
Measures the convexity of the
profile, including the nose.
137° for Males &
133° for Females
indicates a
normal profile.
Naso-labial
angle
(Figure 2.4)
Angular
Three angles can be
measured separately
between:
1.  A tangent to the
columella and the line
Sn-Ls.
2. A tangent to the
columella and
horizontal.
3. The line Sn-Ls and
horizontal.
Angle 1 measures the angle of
the upper lip to the columella,
but is affected by the slope of
the columella, which can vary
greatly between patients.
Angle 2 gives an indication of
the angle of the columella to
horizontal (or the Frankfort
Plane).
Angle 3 measures the angle of
the upper lip to horizontal (or
Frankfort Plane).
Angle 1 = 90−110°
Angle 2 = 25°
Angle 3 = 85°
Labio-mental
angle (Figure
2.5).
Angular
The angle between lines
Li-B’ and B’-Pg’.
Measures the degree of
curvature of the lower lip.
120 ± 10°
E-plane
“Esthetic”
Plane (Figure
2.6).
Linear
Line tangential to the
chin and tip of the
nose.
Provides a reference line from
which to assess the positions
of chin, lips and nose with
respect to profile balance.
Li 2 ± 2 mm
behind E-plane.
Ls 4 mm behind
E-plane
H-line
“Harmony”
line (Figure
2.6).
Linear
Line tangential to the
chin and upper lip.
Provides a reference line from
which to assess the positions
of the chin and lips with
respect to profile balance.
Li should lie on the
H-line ± 1-2 mm.
Zero-degree
meridian
(Figure 2.7)
Linear
A line dropped
perpendicular to the
Frankfort Plane (or
horizontal) from soft
tissue Nasion.
Provides a vertical reference line
from which to assess the A-P
position of the chin point
(Pg’).
Pg’ 0 ± 2 mm from
line measured
parallel to FP.
Lip-chin
– submental
plane angle
(Figure 2.8)
Angular
The angle between the
line Li-Pg’ and a
tangent to the
submental plane.
Tends to be increased with
mandibular retrusion and
increased with mandibular
prominence.
100 ± 10°
Submental
plane - neck
angle (Figure
2.8)
Angular
The angle between
tangents to the
submental plane and
the anterior border of
the neck.
Will tend to be increased with
mandibular retrusion and/or
the presence of submental/
cervical adipose tissue.
Males: 126°
Females: 121°
Frankfort
– Mandibular
Planes Angle
(FMPA)
(Figure 2.9)
Angular
The angle between the
clinical Frankfort Plane
(tragus of ear to
infra-orbital rim) and
mandibular plane.
Gives an indication of the
inclination of the lower border
of the mandible, located by
palpation using an index
finger or ruler.
25–30° (the lines
should meet just
behind the back
of the head).
(Continued)

20
Handbook of Orthognathic Treatment
Figure 2.1  The patient’s head posture
can affect the clinical impression of
their antero-posterior jaw relationship.
The relative antero-posterior positions of the max­
illa and mandible, as well as the convexity of the
profile, can be assessed subjectively by looking at the
patient’s profile in natural head position. The facial
convexity can also be measured objectively on a profile
photograph, including or excluding the nose, as illus­
trated in Figure 2.2a. A class II jaw discrepancy will
generally manifest as a convex profile (Figure 2.2b),
while a class III profile will be concave (Figure 2.2c).
In some class III cases, the drape of the upper lip
can mask the underlying maxillary deficiency to a
large extent and present a deceptively normal soft
tissue profile. This is most likely in high angle cases
where there is a degree of bi-maxillary retrusion
owing to the downward and backward position of the
chin.
In class II cases, maxillary protrusion is uncom­
mon, relative to the patient’s racial norm, but it is
not uncommon to see bi-maxillary retrusion, particu­
larly in patients with long facial types. In such cases,
the telltale signs of maxillary deficiency will be
present, such as para-nasal hollowing (Figure 2.3). In
Variable/
analysis
Type
Description
Function
Mean value(s)
LAFH/TAFH
ratio (Figure
2.10)
Proportional
The ratio of the distance
Sn-Me’ to G-Me’.
Gives a measure of the lower
anterior face height in
comparison to the total
anterior face height as seen
clinically. The points selected
are intended to give equal
upper and lower face height
dimensions to make clinical
assessment easier.
LAFH/TAFH = 50%
Upper lip
length
(Figure 2.11)
Linear
The distance from Sn to
Sts
Gives an indication of the length
of the upper lip.
Males:
24 ± 1.5 mm
Females:
21 ± 1.9 mm
Lower lip
length
(Figure 2.11)
Linear
The distance from Sti to
Me’
Gives an indication of the length
of the lower lip.
Males:
50 ± 4.5 mm
Females:
46.5 ± 3.4 mm
Table 2.1b  (Continued)

Dentofacial assessment
21
Figure 2.2  (a) Angle of facial convexity (the small angle between G-Sn and Sn-Pg’) excludes the nose, while the angle
of total facial convexity (the small angle between N’-Prn and Prn-Pg’) includes the nasal tip. These angles tend to be
increased in class II cases (b) and reduced in class III cases (c).
N’
Pg’
Prn
FP (H)
G
N’
Sn
Sn
Pg’
Prn
FP (H)
G
N’
Sn
Pg’
Prn
FP (H)
G
a)
b)
c)
class III cases, maxillary deficiency is common but
again, in high angle cases, bimaxillary retrusion with
retrogenia can be present.
Forehead
It is important to note the position and shape of the
forehead, since it is one of the parts of the face that
will remain completely unchanged by orthognathic
surgery. If frontal bossing is present or the forehead
is flat, this should be taken into account when assess­
ing the jaw positions and the effects of surgery, such
that harmonious facial balance will be achieved.
Infra-orbital rims
The antero-posterior position of the infra-orbital
rim can be assessed relative to the globe of the eye
and the supra-orbital ridge. A deficient infra-orbital
rim will tend to accompany high-level deficiency
of the maxilla and is usually a part of mid-face
hypoplasia.
Nose
The shape of the nasal dorsum and the angle of the
nasal tip may be affected by maxillary osteotomy and
it should be carefully noted whether or not such
changes are likely to be favourable. For example, a
patient with maxillary deficiency who already has an
up-turned nasal tip is likely to experience a worsen­
ing of this feature with a Le Fort 1 advancement
osteotomy. On the other hand, a patient with a long
facial type and a down-turned nasal tip may well
experience an improvement in their nasal profile as
a result of Le Fort 1 impaction osteotomy.
In addition, an assessment of the prominence of
the nose in relation to the forehead and chin is essen­
tial, in diagnosing the jaw discrepancy and planning
the required surgical correction (Figure 2.2).
Para-nasal region
The contour of the skin overlying the area just lateral
to the alar base can be seen from the side view. A lack
of bony support for the soft tissues in this region will
produce a depression described as para-nasal hollow­
ing, which is indicative of low level antero-posterior
maxillary deficiency (Figure 2.3). Although most
commonly associated with class III jaw discrepancies,
it can also be present in class II cases with bi-maxillary
retrusion.
Figure 2.3  This patient with maxillary deficiency exhibits
para-nasal hollowing, indicated by the yellow line.

22
Handbook of Orthognathic Treatment
patients present with a deficient maxilla but the pro­
clined upper anterior teeth support the upper lip.
Lower lip and chin
The curvature of the lower lip is dependent mainly on
the depth of the labio-mental fold (Figure 2.5a), which
in turn, tends to reflect the inclination of the lower
incisors, the antero-posterior position of the chin
point (soft tissue pogonion) and the lower anterior face
height. As a general rule, a reduced lower anterior face
height, with accompanying progenia, will produce an
accentuated labio-mental fold (Figure 2.5b), whilst a
flat lower lip will be associated with retrogenia and
increased vertical dimensions (Figure 2.5c).
Upper lip
It is important to assess the form and angle of the
upper lip. The naso-labial angle is often taken as an
indication of the position of the underlying maxilla
and incisors. However, it is prone to variation accord­
ing to the slope of the columella and the curvature
of the upper lip and the angle can be measured in a
number of different ways (Figure 2.4a). A patient with
maxillary deficiency will tend to show an increased
naso-labial angle (Figure 2.4b). However, an unusu­
ally short upper lip may be more furled than average,
or the columella may be down turned, giving rise to
an acute angular measurement, even in the presence
of maxillary deficiency (Figure 2.4c). Conversely, some
Figure 2.4  (a) The naso-labial angle is measured between Sn-Cm and Sn-Ls. The angles between these lines and the
Frankfort Plane (or horizontal reference line) allow the slope of the columella to be accounted for. (b) In this class III case
the naso-labial angle is increased. (c) This class III patient’s naso-labial angle is reduced due to a down turned columella,
but the angle of the upper lip to horizontal is within the normal range.
Sn
Ls
Cm

FP(H)
Sn
Ls
FP (H)
Cm
a)
b)
c)
Sn
Ls
FP (H)
Cm
Figure 2.5  (a) The labio-mental angle (between Li-B’ and B’-Pg’) gives a measure of lower lip curvature. It is reduced in
the short-faced patient shown in (b), and increased in the long-faced patient shown in (c).
L
B’
Li
Pg’
FP (H)
B’
Li
Pg’
FP (H)
B’
Li
Pg’
FP (H)
a)
b)
c)

Dentofacial assessment
23
Lower lip to sub-mental plane angle
The angle of the lower lip to the sub-mental plane
(throat) is important for pleasing facial aesthetics and
it should be close to a right angle in an average face
(Figure 2.8a). In addition to the inclination of the
lower lip, the angle is equally dependent on the slope
of the sub-mental plane, which varies with the degree
of mandibular prognathism, the chin position and
the vertical dimension of the face, as well as the pres­
ence of sub-mental adipose tissue (Figure 2.8b,c). The
appearance of excess tissue in this region can be
unaesthetic, particularly if the throat length is short,
and it is important to note how this might be affected
by surgical changes to the position of the mandible
and the chin.
Mandibular plane angle
The angle of the mandibular plane can be assessed
by placing an index finger or a ruler along the lower
border of the mandible and the Frankfort Plane. The
point of intersection of the two planes should be just
behind the back of the head where the angle is
average. The effect on this point of intersection can
be seen in low and high angle cases in Figure 2.9. In
the presence of facial asymmetry, the right and left
mandibular planes may differ and must be assessed
separately.
It must be remembered that the Frankfort Plane
can deviate from normal and, as mentioned previ­
ously, may not be horizontal with the head in NHP.
If there is any doubt then it is advisable to position
the patient correctly and then use a true horizontal
line as a reference.
Figure 2.6  The Ricketts “E” Plane is tangential to the chin
and nasal tip. The Holdaway “H” line is tangential to the
chin and upper lip.
Ls
Li
H-line
E-plane
FP (H)
Figure 2.7  (a) The Ricketts zero-meridian line is a constructed vertical line dropped perpendicular to the Frankfort Plane
(or horizontal) from N’. It gives an indication of the antero-posterior position of Pg’, which will lie behind the line in class
II cases with mandibular retrusion (b) and in front in cases with mandibular prognathism (c).
N’
Pg’
FP (H)
Pg
FP (H)
N’
Pg’
a)
b)
c)
N’
Pg’
FP (H)
zero-degree
meridian
The profile balance of the lips in relation to the
chin and nose can be assessed using various indicator
lines, including the ‘Esthetic’ or E-plane and the
Holdaway Harmony or H-line (Figure 2.6). The
antero-posterior position of the chin should be
assessed in relation to the forehead and the upper
face. The zero-meridian line (Figure 2.7a) is helpful
in clinically identifying mandibular retrognathism
(Figure 2.7b) and prognathism (Figure 2.7c), but par­
ticular attention must be paid to the patient’s head
posture since the position of the vertical line at the
level of the chin will vary significantly with any
upward or downward tilting (Figure 2.1).

24
Handbook of Orthognathic Treatment
Pg’
Li
FP (H)
Pg’
Li
FP (H)
Pg’
Li
FP (H)
a)
b)
c)
in short-faced patients and increased in long-faced
patients (Figure 2.10).
Within the lower anterior facial third, further sub-
divisions allow the vertical proportions of the upper
and lower lips to be assessed. The upper lip length is
measured from subnasale to stomion superius, which
is normally 50% of the length of the lower lip, meas­
ured from stomion inferius to soft tissue menton
(Figure 2.11). Where the lips are incompetent, it is
probably most valid to measure the heights of the
upper and lower lips individually along with the
overall lower face height proportions.
Vertical asymmetries
Upper facial asymmetry.  The evaluation of verti­
cal asymmetries is usually carried out with reference
to the inter-pupillary line. Occasionally the orbits
may be at different levels (dystopia) and, if this is the
case, judgement will be required to identify a hori­
zontal plane that allows meaningful assessment of
structures lower down the face. Vertical asymmetry
of the zygomatic bones is usually associated with
traumatic injuries, which have not been corrected
appropriately.
2.3.2  Frontal view
Viewing the face from the front allows assessment of:
• Vertical proportions.
• Vertical asymmetries.
• Transverse proportions.
• Transverse asymmetries.
• Ear shape and position.
• Scleral show and eye lid shape.
• Upper incisor show.
• Lip form and symmetry.
Vertical proportions
Viewed from the front, the face can be divided verti­
cally into thirds and the dimensions of the upper,
middle and lower facial heights compared. The verti­
cal distance from subnasale (Sn) to soft tissue menton
(Me’) represents the lower anterior face height (LAFH)
and this can be compared to the total anterior face
height (TAFH), represented by the vertical distance
from glabella (G) to Me’. These landmarks are used
so that the proportions of the upper and lower ante­
rior facial heights are approximately equal in an
average facial type. The ratio of LAFH:TAFH is reduced
Figure 2.8  (a) The lower lip to sub-mental plane angle is measured between the lines Li-Pg’ and a tangent to the
submental plane. (b) A class II case with increased vertical dimension and retrogenia, in which the angle is increased and
(c) A Class III case, in which the angle is reduced.
Figure 2.9  The clinical Frankfort-
mandibular planes angle is reduced in
short-faced patients (a) and increased
in long-faced patients (b).
FP (H)
MP
“
“
FP (H)
MP
a)
b)

Dentofacial assessment
25
Figure 2.10  (a) Normally proportioned face divided into equal vertical thirds (Tri-G’, G’-Sn and Sn-Me). Lower anterior
face height reduced in a short-faced patient (b) and increased in a long-faced patient (c).
Tr
G
Sn
Me’
Tr
G
Sn
Me’
a)
b)
c)
Tr
G
Sn
Me’
tions, then this should be assessed using a tongue
spatula in the same way as for the maxillary plane.
Transverse proportions
The face can be divided into fifths to allow trans­
verse proportions to be assessed (Figure 2.13). This is
particularly relevant in patients planned for Le Fort I
advancement or impaction osteotomy, where the alar
base is prone to flaring. A narrow alar base may well
improve in appearance through surgery, while a
broad one may be at risk of looking overly flared.
Procedures available to the surgeon for controlling
this are described in Chapter 7.
Canting of the maxillary occlusal plane.  A
common method of assessing canting of the maxil­
lary occlusal plane is by placing a wooden tongue
spatula across the premolars and relating it to the
inter-pupillary line (Figure 2.12). Care should be
taken to avoid being misled by over-erupted teeth or
canine cusps of different lengths, which may tip the
spatula in a way that does not accurately reflect the
skeletal base.
Vertical mandibular asymmetry.  Vertical man­
dibular asymmetry is evident in patients with unilat­
eral condylar hyperplasia, hypoplasia or agenesis,
which affects the height of the rami. Hemi-mandibular
hypertrophy causes a downward bowing of the lower
border on the affected side, with increased depth of
the body. If there is an accompanying cant of the
mandibular occlusal plane with any of these condi­
Figure 2.11  Vertical sub-divisions of lower anterior facial
third, showing normal ratio of upper and lower lip
lengths.
Sn
Sto
Me’
1/3
2/3
Figure 2.12  A tongue spatula is useful in assessing
canting of the maxillary occlusal plane.

26
Handbook of Orthognathic Treatment
asymmetry lower down the face could be either
accentuated or diminished.
Upper facial asymmetry.  In the upper face, it is
mainly the lateral projection of the zygomatico-
orbital complex that needs to be assessed for
symmetry.
Dental centrelines.  The upper centreline should
first be assessed in relation to the facial midline
(Figure 2.14). The exact upper centreline position can
be difficult to determine, particularly in cases where
there are other asymmetries present. Again, holding
a ruler along the envisaged facial midline is a useful
aid. The middle of the philtrum is also an important
reference for the position of the upper centreline,
particularly where nasal deviation is present. The
position of the lower centreline should then be noted
relative to the upper centreline and to the midpoint
of the chin, as well as to the facial midline. Where
there is a shift of the lower centreline relative to the
facial midline, but not relative to the midpoint of the
chin, it is important to determine whether it is due
to a true mandibular asymmetry or a displacement
on closure due to an occlusal interference, particu­
larly if a unilateral buccal segment cross-bite is
present (see also Section 2.4).
Transverse mandibular asymmetry.  In evaluat­
ing transverse mandibular asymmetry, the position
Transverse asymmetries
Before assessing the transverse symmetry of the face
it is essential to check that the patient is holding their
head level, without any side-to-side tilting. The base
of the neck and clavicles should be exposed, with the
patient’s consent, to allow full assessment of the neck
and head posture.
Envisaging the facial midline.  Every face has
subtle asymmetries and only significant asymmetries
require assessment. Before attempting to assess any
transverse asymmetry it is necessary to envisage the
facial midline. If an asymmetry involves just the
mandible then it is usually straightforward to estab­
lish a reference line running down the middle of the
forehead, bisecting the inter-pupillary line and con­
tinuing down through the middle of the dorsum of
the nose and philtrum of the upper lip. Where more
complex asymmetries are present higher up in the
face, for example, in cases with dystopia, this is less
straightforward and an element of judgement is
required to envisage a reference line that most accu­
rately represents the midline. The nose can also
exhibit asymmetry of both the dorsum and the tip.
It is essential to identify any nasal asymmetry and
ensure that it is not influencing the position of the
facial midline, before assessing the symmetry of the
lower facial structures. Otherwise the extent of an
Figure 2.13  A normally proportioned face can be divided
into equal fifths (long lines). The middle fifth should equal
the width of the alar base and the inter-canthal distance.
Further sub-divisions (short lines) illustrate that the width
of the stoma should be approximately equal to the
inter-iris distance.
Figure 2.14  The facial midline is dropped perpendicular
to the inter-pupillary line, provided the orbits are level. In
this patient, there is deviation of the nasal tip to the right
and a shift of the upper dental centreline and the chin
point to the left.

Dentofacial assessment
27
ments. It is essential that the patient’s head posture
is correct and that the lips are fully relaxed for the
resting lip line (Figure 2.16a). Equally, it is important
to ensure that the patient performs a full smile to
allow the lip to rise to its maximum height before
assessing the incisor show on smiling (Figure 2.16b).
Asking the patient to smile voluntarily may not be
reliable, particularly in the environment of a busy
clinic and it is important to watch for genuine invol­
untary smiles, which are more fully expressive.
Lip form and symmetry.  The shape of the vermil­
lion border and the symmetry of the Cupid’s bow
should be assessed. The line between the lips (the
inter-labial line) must be assessed in relation to both
vertical and horizontal reference lines. The philtrum
of the upper lip can deviate to one side, often in
Figure 2.15  Display of the sclera of the eye below the iris
is a sign of high-level maxillary antero-posterior deficiency,
including the infra-orbital rims.
of the chin point relative to the facial midline must
be carefully assessed. As mentioned above, it is
important to take into account any nasal deviation
as well as any asymmetry of the lips. Marking a dot
where the middle of the soft tissue chin point is
thought to be and then holding a ruler along the
facial midline is helpful in trying to quantify the
extent of any deviation (Figure 2.14).
Ear shape and position.  Any abnormal shape or
position of the ears should be noted during clinical
assessment. Unilateral abnormalities of the ear shape
may be part of hemi-facial microsomia and various
cranio-facial syndromes.
Scleral show and eye lid shape.  The lower eye lid
should normally rest at the inferior border of the iris,
with no sclera on display. Scleral show is a tell-tale
sign of infra-orbital rim deficiency, which usually
accompanies maxillary deficiency in class III cases
(Figure 2.15). Anti-mongoloid slanting of the palpe­
bral fissures and clobomata of the lower eyelids are
manifestations of various craniofacial anomalies and
should be taken into consideration during clinical
assessment of dentofacial deformities.
Upper incisor show.  Because orthognathic surgical
planning usually starts with a decision regarding
where to position the maxillary incisors, a key feature
in the assessment of the orthognathic patient is the
vertical relationship between the upper lip and the
upper central incisors at rest and on smiling. Varia­
tion in the height of the maxilla and/or the length
of the upper lip, as well as the length of the upper
incisor crowns, will directly affect these measure­
Figure 2.16  (a) Increased vertical display of the upper central incisors with the lips at rest. The average is approximately
2–3 mm, or about 1/3 of the clinical central incisor crown. (b) Increased gingival display on smiling in a patient with a
combination of vertical maxillary excess and a short upper lip.
a)
b)
Sts
Sts
Uie
Uie
Ging. margin

28
Handbook of Orthognathic Treatment
Nasal deviation
The bird’s eye view allows the dorsum and tip of the
nose to be assessed for transverse deviation. As with
the frontal view, it is important to envisage the facial
mid-line as a reference and care must be taken to
account for any deviation of the chin point. If both
the nose and the mandible are asymmetric, an
element of judgement may be necessary to identify
which structure is most at fault.
Upper dental centreline
This view is also valuable in confirming the position
of the upper dental centreline with reference to the
midline of the face, taking care to account for any
deviation of the nose, philtrum and mandible.
Transverse mandibular asymmetry
The bird’s eye view is essential for assessing the posi­
tion of the chin point relative to the facial midline.
As with the frontal view, it is useful to mark the
midpoint of the chin and then use a ruler on the
facial midline as a reference.
2.3.4  Worm’s eye view
Viewing the face from below (Figure 2.18) allows
assessment of:
• Asymmetries of the mandible.
• Asymmetries of the alar base.
Asymmetries of the mandible
Vertical and transverse asymmetries of the mandibu­
lar inferior borders or gonial angles are only fully
appreciated from the worm’s eye perspective.
association with a cant of the inter-labial line or an
asymmetry of the nose. The lower lip can also be
displaced to one side, usually as a result of a man­
dibular asymmetry. Asymmetry of facial animation
should also be taken into consideration.
2.3.3  Bird’s eye view
Viewing the face from above (Figure 2.17) allows
assessment of:
• Orbital rims.
• Antero-posterior asymmetries.
• Nasal deviation.
• Upper dental centreline.
• Transverse mandibular asymmetry.
Orbital rims
The view from above helps to assess the antero-
posterior position of the supra- and infra-orbital rims.
Deficiency of the infra-orbital rims will usually
accompany zygomatico-orbital deficiency, which is
usually a manifestation of mid-face deficiency and
can also be seen from this angle.
Antero-posterior asymmetries
When viewing the face from above, it is possible to
assess the presence of any antero-posterior asym­
metries of the forehead and the supra- and infra-orbital
rims, as well as the zygomatico-orbital complex and
para-nasal regions. This will need particularly careful
scrutiny in cases where an asymmetry is not just con­
fined to the mandible and the lower face, but affects
the whole face. Such patients may have a mild expres­
sion of a cranio-facial syndrome, such as hemi-facial
microsomia and will require careful three-dimensional
surgical planning. Patients suffering from plagioceph­
aly would also exhibit antero-posterior asymmetries of
the craniofacial skeleton.
Figure 2.17  Bird’s eye view in a patient with a
mandibular asymmetry, showing deviation of the chin
point to the left. The nasal tip is also deviated slightly to
the right.
Figure 2.18  Worm’s eye view of patient with mandibular
asymmetry. The medio-lateral shift of the chin is clearly
seen and it is also possible to see the vertical asymmetry
of the gonial angles.

Dentofacial assessment
29
incomplete dentitions, whether due to hypodontia or
previous tooth loss, may present either a problem or
an opportunity to the clinicians depending on the
planned orthodontic and surgical objectives.
Arch forms
The width and shape of both dental arches determine
the degree of arch coordination that can be achieved
and should be noted. If the upper arch is narrow it is
important to assess whether this is due to a genuinely
narrow maxilla or just the result of upright molars.
Looking at the inclination of the buccal segments
gives a guide as to the degree of flaring present and
palpating the alveolar bone over their roots gives an
indication of the width of the maxillary apical base.
If there is a narrow maxilla and surgical widening
is a possibility, the palatal contour should be noted,
since a high vaulted palate is more favourable for
“tenting” of the muco-periosteum following a mid-
palatal split.
If the mandibular arch is particularly broad or
narrow, a similar assessment of the skeletal and
dental contributions should be made to give an indi­
cation as to how much orthodontic adjustment of
the arch width is likely to be possible in the effort to
achieve arch coordination.
Incisor inclinations
The inclinations of the upper and lower incisors tend
to be determined by a combination of skeletal and
soft tissue factors and will often differ from average
in orthognathic patients as a result of dento-alveolar
compensation. The lower incisors will tend to be
proclined in class II cases and retroclined in class III
cases as a result of the action of the tongue and lower
lip respectively. The lower incisors should be assessed
with reference to the clinical mandibular plane,
which can be represented by a finger or ruler held
against the lower border of the mandible.
The upper incisors may be proclined in class II
cases where a lower lip trap is present but, where the
skeletal discrepancy is marked and the lower lip is
retrusive, they will often be close to normal. In class
II, division 2 cases they may be severely retroclined
as a result of the high lower lip line. In class III cases
the upper incisors will generally be proclined under
the influence of the tongue, although this will not
always be the case in severe malocclusions where the
resting tongue posture is below the upper occlusal
plane. The upper incisor inclination should be
assessed with reference to the clinical Frankfort Plane
(tragus of ear to orbitale).
Asymmetries of the alar base
Any asymmetry of the nares, or deviation of the colu­
mella, can be clearly identified.
2.4  Intra-oral assessment
Before assessing the dental arches and occlusion, it is
important to carry out a routine clinical examination
of the oral hard and soft tissues, which should be
supplemented with any necessary radiographs. Active
caries will require restoration by the General Dental
Practitioner and periodontal disease should be con­
trolled prior to definitive treatment planning, with
specialist input if necessary. Any areas of gingival
recession should be carefully documented, since
these may worsen with orthodontic treatment. Clini­
cal photographs are an essential pre-treatment record
in this regard, as well as recording any marks on the
teeth that may later be attributed to the iatrogenic
effects of fixed appliances. In most cases one would
expect that these problems will have been identified
and resolved prior to the patient being referred to the
combined planning clinic, but the clinicians should
be vigilant at all stages of the patient journey to
ensure that no relevant disease remains undiagnosed.
The patient’s role in maintaining good oral health
and plaque control should be emphasised from the
outset.
As with facial assessment, intra-oral examination
should be carried out systematically.
2.4.1  Dental arches
The key features of the dental arches to note are:
• Dentition.
• Arch forms.
• Incisor inclinations.
• Crowding and spacing.
• Curves of Spee.
• Oclusal plane canting.
Dentition
The standing teeth should be charted accurately and
any teeth of possible poor prognosis noted. If extrac­
tions are required as part of orthodontic treatment
or even segmental surgery, it may be beneficial to
remove teeth that may cause long-term problems. For
example, poor quality lower first molars might use­
fully be extracted to allow lower incisor decompensa­
tion in a class II case prior to mandibular advancement,
or a setback mandibular body osteotomy in a class
III case. Equally, edentulous spans in patients with

30
Handbook of Orthognathic Treatment
cally. It is therefore important to quantify the depth
of curve present and, whilst an estimate can readily
be made clinically, study model analysis will allow
more accurate measurement. The relevance of the
curve of Spee for orthognathic treatment is explained
more fully in Chapters 3 and 4.
Occlusal plane canting
See Section 2.3.2.
2.4.2  Teeth in occlusion
The main occlusal features to be noted are:
• Incisor relationship.
• Cross-bites.
• Centrelines.
Incisor relationship
The incisor classification should be assessed with
reference to standard definitions, which are readily
available in basic orthodontic texts. The features that
contribute to the patient’s incisor relationship are:
the incisor inclinations (see Section 2.4.1), the overjet
and the overbite.
Overjet.  The overjet normally measures 2–4 mm but
will be increased in class II division 1 patients and
decreased or negative in class III patients. In class II,
division 2 patients the overjet will usually be minimal
but can occasionally be increased in the presence
of a severe class II jaw relationship. Particular care
should be taken when recording the overjet in class
II orthognathic patients, particularly those with back­
ward mandibular rotations. This is because they tend
to have short mandibular rami with skeletal anterior
open bites, which require them to posture their man­
The normal Caucasian values for incisor inclina­
tion are approximately 90° for the lowers and 110°
for the uppers. Cephalometric analysis should nor­
mally be available to confirm the clinical findings
(see Section 2.6).
Crowding and spacing
An estimate of the degree of crowding or spacing
present in each arch can readily be made on intra-oral
examination, but more objective assessment or “space
analysis” is more appropriately carried out on study
models (see Section 2.5). Any rotated or misaligned
teeth should be noted.
Curves of Spee
Orthognathic patients frequently exhibit curves of
Spee on their occlusal planes as a result of their
underlying skeletal jaw discrepancies. Class II patients
with deep overbites and reduced vertical dimensions
will tend to have an accentuated curve on the lower
arch (Figure 2.19a), whilst patients with an anterior
open bite and increased vertical dimensions will
often present with a curve on the upper arch (Figure
2.19b).
Occasionally reverse curves of Spee are seen. In the
lower arch this is usually due to impaired eruption of
the lower incisors during growth, possibly due to an
extreme digit sucking habit or endogenous tongue
thrust (see also Section 2.4.3). In the upper arch, it is
usually over-eruption of retroclined upper incisors in
class II, division 2 cases that produces the reverse
curve effect, due to the increased inter-incisal angle.
The more severe a curve of Spee is in either arch,
the more challenging it will be to level orthodonti­
Figure 2.19  Lower arch (a) and upper arch (b) showing accentuated curves of Spee, associated with a deep overbite
and an anterior open bite, respectively. The open bite is also accompanied by a narrow maxillary arch, which has resulted
in bilateral buccal segment cross-bites.
a)
b)

Dentofacial assessment
31
open bite localised to the labial segments with an
accentuated upper curve of Spee and a good buccal
segment occlusion most likely indicates a dental
origin. Flat dental arches with occlusal contact
limited to the terminal molars, on the other hand,
will generally point to a skeletal origin. The skeletal
features that tend to accompany these occlusal
traits have already been discussed under “Facial
assessment”.
Cross-bites
Cross-bites involving only one or two teeth are often
the result of local dental irregularity or crowding
and are usually straightforward to deal with. Cross-
bites involving whole segments of teeth, either ante­
rior or posterior, usually occur either as a result of an
underlying antero-posterior or transverse skeletal
jaw discrepancy, or because of a mismatch in the
widths of the dental arches and tend to be more
common in orthognathic patients. In some cases,
both problems may be contributing factors to a
greater or lesser extent. In all cases it is essential to
not only record the presence of any cross-bites, but
also be clear as to their aetiology and whether or not
they are causing any mandibular displacement on
closure.
Anterior cross-bites.  Anterior cross-bites usually
reflect an underlying class III skeletal pattern. Where
there is only a minimal reverse overjet and a positive
overbite it is important to check whether the patient
is able to achieve an edge-to-edge contact between
the incisors with the mandible in RCP (using the
same method as above). If a forward displacement is
occurring from an initial incisal contact, then it is
dible forwards on order to gain a functional occlu­
sion. It is therefore essential to coax the mandible
into its retruded contact position (RCP). This can
usually be achieved by asking the patient to extend
their neck backwards, which stretches the supra-
hyoid muscles, and curl their tongue to the back of
the mouth, before guiding the mandible into occlu­
sion with light pressure on the chin. This will often
unmask a larger than expected overjet and anterior
open bite, which might otherwise have gone unde­
tected, resulting in erroneous planning.
Class III cases with vertical maxillary deficiency
and over-closure of the mandible also present a
problem when measuring the reverse overjet. This is
because the measurement obtained with the mandi­
ble in rest position can be significantly smaller than
that obtained when the mandible is rotated upward
and forward to bring the posterior teeth into occlu­
sion. An overjet measurement recorded with the
mandible in rest position is probably more valid from
the point of view of surgical planning. An example
of this is illustrated using two pre-surgical lateral
cephalograms in Figure 6.4.
Overbite.  The overbite should be assessed as the ver­
tical overlap of the upper central incisors over the
lower incisors, both as a percentage and in millime­
tres. The average overbite, as viewed along the occlu­
sal plane, should be approximately one third of the
lower incisors, or 2–3 mm. An increased overbite in a
class II orthognathic patient will often mean that the
lower incisal edges are occluding on the palatal
mucosa, distal to the upper incisors, and this area
should be scrutinised clinically for any signs of
trauma. This may manifest as grooving or gingival
recession. Similarly, in severe class II, division 2 cases
the retroclined upper central incisors may cause
trauma to the labial gingival margins of the lower
incisors (Figure 2.20). In extreme cases, both prob­
lems may co-exist. Traumatic overbites often present
a compelling need for treatment, particularly if the
patient is complaining of long standing symptoms.
Anterior open bite.  Where an anterior open bite is
present, the amount of vertical separation between
the upper and lower incisors should be recorded,
perpendicular to the occlusal plane, as well as its
extent on both sides (see Figure 2.19b). As already
mentioned, the presence of a curve of Spee on the
upper or lower arch often contributes to an increased
overbite or anterior open bite. In the case of anterior
open bite, it is important to assess whether the
problem is primarily dental or skeletal in origin. An
Figure 2.20  Trauma to the labial gingival margins of the
lower incisors caused by a deep overbite.

32
Handbook of Orthognathic Treatment
occlusion without the need for the mandible to
shift to one side (Figure 2.19b).
Centrelines
The assessment of the dental centrelines relative to
the facial and mandibular midlines has already been
described. Intra-orally, the dental cause of any cen­
treline shift within the arches should be noted. This
may be previous unilateral loss of a permanent tooth
or asymmetric crowding. If there is a unilateral cross-
bite present with an associated displacement on
closure then the extent of this, and its effect on the
position of the lower centreline in occlusion, should
be noted.
2.4.3  Soft tissues
Assessment of the tongue
The shape, size and movement of the tongue should
be assessed to identify any abnormalities. Where an
anterior open bite is present with the characteristic
signs of soft tissue aetiology, the resting posture and
activity of the tongue should be observed, although
it can be difficult to distinguish between a true
endogenous tongue thrust and tongue posture that
is simply adaptive to a pre-existing open bite (Figure
2.22). Where the tongue’s position, its size (e.g. mac­
roglossia) or activity is thought to be abnormal, its
possible role in post-treatment relapse will have to be
carefully evaluated.
2.5  Diagnostic records
2.5.1  Protocol for collection of basic
records
The treatment of orthognathic patients requires
numerous diagnostic records and it is important to
have a protocol in place that provides a guide as to
which basic records should be collected and when.
There will be a need for supplementary records and
investigations as the need arises for individual
patients but Table 2.2 shows the basic minimum
dataset that the authors aim to collect for each
patient.
2.5.2  Role of diagnostic records
The longitudinal management of orthognathic
patients usually extends over a prolonged period,
starting from the initial referral, often as a child, and
finishing with their discharge after several years of
post-operative follow-up. The various diagnostic
wise to take clinical measurements and diagnostic
records with the mandible in RCP or rest position,
rather than with the posterior teeth in occlusion,
which may give a false impression of the class III
skeletal pattern.
Posterior cross-bites.  Posterior cross-bites can be
either unilateral or bilateral. In orthognathic patients
with significant antero-posterior jaw discrepancies a
buccal segment cross-bite can result from the dental
arches occluding in a mismatched position, even
thought there is no true transverse arch width dis­
crepancy. The more severe the antero-posterior dis­
crepancy, the more likely it is that a cross-bite will
result. In class III patients in particular, the true arch
coordination is best checked on the study models (see
Section 2.5).
• Unilateral
cross-bites.  Unilateral
cross-bites
result from a relatively mild underlying transverse
arch width discrepancy. If a mandibular asymmetry
is also present in inter-cuspal position (ICP) it is
important to establish whether this is a true skel­
etal asymmetry or the result of a displacement of
the mandible from RCP to ICP, due to an occlusal
interference (Figure 2.21).
• Bilateral cross-bites.  Bilateral cross-bites are
usually the result of a more severe transverse arch
width discrepancy and are less likely to be accom­
panied by a mandibular displacement because the
patient is able to bite directly into an inter-cuspal
Figure 2.21  A unilateral buccal segment cross-bite caused
by a true mandibular asymmetry. Note the shift of the
lower centreline to the left.

Dentofacial assessment
33
based materials are useful in cases where the occlu­
sion is particularly awkward and there is limited
contact between the teeth. As with the clinical exami­
nation, it is also essential to ensure that the bite
registration is recorded with the mandible in the
desired position. In most cases this will be with the
teeth in ICP, but where there is a displacement on
closure associated with a cross-bite, it may be more
helpful to record the occlusion in RCP. Study models
have the following applications:
Monitoring occlusal change.  Many patients are
referred to the orthognathic team as adolescents and
records that are collected at different times along the
patient’s journey have specific purposes as follows.
Study models
Orthodontically trimmed study models are an essen­
tial basic record of the arrangement of a patient’s
teeth and their occlusion and are taken at all the key
stages of treatment. They can either be physical
plaster models or digital e-models. In orthognathic
patients the occlusion will sometimes be difficult to
accurately record and a careful occlusal registration
is required. A conventional modelling wax wafer is
usually adequate, but more sophisticated silicone
Figure 2.22  Typical habitual tongue posture in a patient with an endogenous tongue thrust (a). The associated anterior
open bite caused by divergent upper and lower curves of Spee (b).
a)
b)
Table 2.2  Protocol for basic orthognathic record collection
Record type
Pre-
ortho
planning
Pre-
surgery
planning
1 wk
post-op
Post
debond
6
months
post-op
1 yr
post-op
2 yr
post-op
3 yr
post-op
4 yr
post-op
5 yr
post-op
SMs
Yes
Yes
–
Yes
–
–
–
–
–
–
Clinical
photos
Yes
Yes
–
Yes
–
Yes
Yes
Yes
Yes
Yes
DPT
Yes
–
Yes
–
–
–
–
–
–
–
Lateral
ceph.
Yes
–
–
–
–
–
Yes
Yes
Yes
Yes
CBCT
–
Yes
–
–
Yes
–
–
–
–
–
3D capture
Yes
Yes
–
–
Yes
–
–
–
–
–
4D capture
Yes
Yes
–
–
Yes
–
–
–
–
–
SMs
Study models
DPT
Dental Panoramic Tomogram
CBCT
Cone Beam Computerised Tomogram
3D capture
3D static stereophotogrammetry
4D capture
3D motion capture

34
Handbook of Orthognathic Treatment
Clinical photographs
All patients being seen on an orthognathic clinic
should have a series of clinical photographs available
that adequately records their presenting dentofacial
problems. It is important that the facial views are
taken in natural head position with the lips at rest
and, if there is a tendency to over-closure, with the
mandible in rest position. As mentioned previously,
the right lateral view is conventionally used to carry
out any objective soft tissue analysis. Our standard
series is as follows:
Facial views:
• Frontal, with lips at rest and smiling.
• Right and left profile.
• Right and left ¾ profile.
• Bird’s eye.
• Worm’s eye.
Intra-oral views:
• Upper and lower occlusal.
• Front and sides of teeth in occlusion.
• Overjet (or reverse overjet).
As well as providing a basic record and aiding
assessment, photographs are valuable in monitoring
facial change. However, they have the limitation of
being only two-dimensional.
Stereophotogrammetry
Conventional photographs do not record the 3D
morphology of the face and are associated with mag­
nification and positioning errors. Stereophotogram­
metry provides 3D, photorealistic images of the
patient using specialised equipment. This is the only
method of accurately recording the patient’s true
appearance and is invaluable in monitoring soft
still have growth left to complete, or they have man­
dibular asymmetries that may be progressive. Study
models that are correctly bench-trimmed, or articu­
lated if necessary, allow longitudinal change of the
occlusion to be monitored and measured. In the case
of anterior open bites, it is essential to obtain an
accurate occlusal registration, which will allow the
models to be correctly articulated at a later date, for
comparison.
Checking arch coordination.  Hand held study
models allow the ‘best fit’ of the dental arch to
be assessed both at the patient’s initial assessment
and throughout pre-surgical orthodontic treatment.
Objective measurements can also be made of the
extent of any arch expansion required and the
approximate size of surgical movement needed to
correct the malocclusion in advance of definitive
laboratory-based planning. If necessary, the initial
models can be sectioned to simulate the effect of
segmental surgery. For this reason it is advisable to
have two sets of models available at the initial assess­
ment stage.
Space analysis and orthodontic planning.  The
amount of dental crowding or spacing can be meas­
ured from study models to aid orthodontic planning
and in particular the decision regarding extractions.
Diagnostic set-ups, where teeth are repositioned on
the models in wax to simulate the result of orthodon­
tic treatment, can be a useful planning aid, although
care must be taken to ensure that any simulated
tooth movements are realistic and within the con­
fines of the alveolar bone (Figure 2.23).
Figure 2.23  Planning decompensation of the severely crowded lower incisors in this class III patient (a) is helped by a
diagnostic setup of the teeth (b). It is clear that premolar extractions will be required to avoid excessive proclination.
a)
b)

Dentofacial assessment
35
digital machines often obviates the need for supple­
mentary intra-oral views, but these may still be
required in some situations.
Mandibular morphology.  It is essential that the
full mandible is included in the exposure, rather than
the truncated option that modern machines offer for
dental assessment, which often excludes part of the
ramus and the condyles. The DPT allows gross assess­
ment of the morphology of the following mandibular
structures:
• The condylar neck and head.  If the condyle is
particularly small or flattened, this may indicate
under-development or lytic disease and may warrant
further investigation. Condylar hyperplasia can
manifest as an enlarged condyle or elongated con­
dylar neck and might require further investigation.
The angle of the condylar neck also tends to reflect
the morphology of the mandible, sloping back in
the case of backward growth rotation and vice versa.
• The ramus.  The height of the ramus can vary
significantly depending on the patient’s facial
morphology, with a small, short ramus tending to
accompany a backward mandibular growth pattern
and a long facial type, whilst the short-faced patient
tends to possess a longer and wider ramus.
tissue changes over time, particularly in cases of
asymmetry (Figure 2.24). There is evidence in the
literature that orthognathic surgery affects facial ani­
mation and 4D imaging (3D with movement) is a
potentially valuable tool for recording the dynamics
and quantifying changes in facial animation before
and after surgery.
Dental Panoramic Tomogram (DPT)
The panoramic tomogram allows a basic radiographic
assessment of the teeth and jaws and is required for
all patients as part of the initial orthognathic assess­
ment. The DPT yields the following diagnostic
information:
Dental and related pathology.  Apart from check­
ing for incidental pathology, an account of which is
beyond the scope of this book, an accurate assess­
ment of the patient’s dental and supporting tissues is
essential prior to definitive treatment planning. With
orthognathic patients being primarily adults, many
will have multiple restored teeth and some may have
periodontal disease, which requires attention prior to
definitive treatment planning. The morphology of
the roots of the teeth and any dental anomalies
should be noted. The image resolution of modern
Figure 2.24  Two sequential
stereophotogrammetric images,
superimposed on the forehead.
Asymmetric mandibular growth has
produced significant unilateral left
sided changes (red = 5.0 mm
difference).

36
Handbook of Orthognathic Treatment
can be carried out. An example of such a case is illus­
trated in Figure 2.25.
Three-dimensional
orthognathic
prediction
planning.  Orthognathic
surgery
involves
jaw
movements in all three planes of space and it is
essential to know their starting positions and the
movements required to achieve the planned result.
This is particularly the case with facial asymmetries
and the advent of Cone beam CT, in conjunction
with specialised software, has made 3D planning a
recent reality, albeit in its early stages of develop­
ment (see Chapter 6).
Anatomical information.  Accurate information
regarding the relative spatial positions of anatomical
structures can only be obtained from a CBCT image.
The following are of relevance in surgical planning:
• The position and course of the inferior dental
nerves. This is important in reducing the risk of
nerve damage for all of the mandibular ramus and
body procedures (Figure 2.26).
• The position of the teeth adjacent to a planned
segmental osteotomy in order to minimise the risk
of root damage.
• The position of the infra-orbital nerves, to mini­
mise the risk of damage during higher level Le Fort
I osteotomies.
• The morphology of the maxillary sinuses and any
associated radio-opacities.
• The orientation and structure of the mandibular
rami. It is helpful to be able to assess the thickness
of the cancellous bone space, which may affect the
success of a sagittal split, and also the angle of the
rami in assessing suitability for vertical sub-sigmoid
osteotomies.
Fabrication of three-dimensional models.  Stereo
lithographic models or, more recently, 3D printouts
of the patient’s skull, jaw bones and dentition, can
be produced from CBCT data. These are particularly
useful where a physical, anatomically realistic plan is
required, such as in the correction of an asymmetry.
Note that the dentition is subject to magnification
and artefacts and should ideally be replaced prior to
planning to ensure accuracy (see Chapters 5 and 6).
Post-surgical evaluation.  If orthognathic surgery
is planned and executed in three dimensions, then
ideally its outcome should also be evaluated in three
dimensions. This is only possible if a CBCT scan is
taken post-operatively, although the exact timing of
the second scan is open to debate. If taken six
months after surgery, as is the routine on our clinic,
• The ante-gonial region.  In backward mandibu­
lar growth rotations, short rami, ante-gonial notch­
ing is usually evident, whereas a forward rotation
tends to be accompanied by a rounded lower
border.
• The body.  The shape and depth of the bodies can
be assessed, as well as the distance between the
apices of the teeth and the lower border. Significant
asymmetry of the mandible can also be detected
using comparative measurements between left and
right sides.
• The inferior dental canal.  It is important to
note the course of the inferior dental nerve in
relation to other skeletal and dental structures.
However, the two dimensional nature of the
image gives no information regarding its trans­
verse position, which is of relevance for mandibu­
lar surgery.
Other features.  Features of the middle and upper
face that can be assessed are as follows:
• The shape and vertical extent of the maxillary air
sinuses.
• The relationship of the roots of the posterior teeth
to the air sinuses.
• The depth of the maxillary alveolar processes.
Peri-apical radiographs
Peri-apical radiographs can be useful in checking the
clearance between the roots prior to segmental
surgery. However, it must be remembered that the
images are only two-dimensional and may not accu­
rately portray the true spatial position of adjacent
roots.
Cone Beam Computerised Tomography (CBCT)
This radiographic scanning technique provides
simultaneous 3D hard and soft tissue imaging of the
face and skull. As with any radiographic investiga­
tion, the radiation dose associated with CBCT must
be justified by its diagnostic yield. Its applications in
orthognathic treatment are as follows:
Assessment and diagnosis of complex dentofa­
cial
problems.  The majority of orthognathic
patients can be adequately assessed and diagnosed
using plain radiographs. Even in those with facial
asymmetries, an initial combined orthodontic and
surgical plan can usually be formulated with the aid
of two-dimensional images. However, there may
occasionally be cases whose asymmetries are more
complex, which warrant CBCT imaging at the initial
assessment stage, in order to arrive at a satisfactory
diagnosis before any provisional treatment planning