Orthognathic Surgery

541
CHAPTER 16  Complications Associated with Orthognathic Surgery
324. Susarla SM, Kaban LB, Donoff RB, Dodson
TB: Does early repair of lingual nerve
injuries improve functional sensory recovery?
J Oral Maxillofac Surg 65:1070–1076,
2007.
325. Suuronen R, Ashammakhi N, Peltoniemi H,
et al: Developments in craniomaxillofacial
surgery: Use of self-reinforced bioabsorbable
osteofixation devices. Plast Reconstr Surg
108:167, 2001.
326. Suzuki H, Saito E, Hashimoto K: Dissecting
aneurysm of the internal carotid artery after
a mandibular osteotomy. J Oral Maxillofac
Surg 55:747, 1997.
327. Svartz K, Ahlborg G, Finne K, Nethander G:
Nerve disturbances after sagittal split
osteotomy. Int J Oral Surg 12:279, 1983.
328. Taher AAY: Facial palsy: A complication of
sagittal ramus osteotomy (Obwegeser-Dal
Pont technique): Report of a case.
Quintessence Int 19:229, 1988.
329. Takasaki Y, Noma H, Masaki H, et al: A
clinical analysis of the recovery from sensory
disturbance after sagittal splitting ramus
osteotomy using a Semmes-Weinstein
pressure aesthesiometer. Bull Tokyo Dent Coll
39:189, 1998.
330. Takeuchi T, Furusawa K, Hirose I:
Mechanism of transient mental nerve
paraesthesia in sagittal split mandibular
ramus osteotomy. Br J Oral Maxillofac Surg
32:105–108, 1994.
331. Tay AB, Go WS: Effect of exposed inferior
alveolar neurovascular bundle during surgical
removal of impacted lower third molars.
J Oral Maxillofac Surg 62:592, 2004.
332. Tay AB, Poon CY, Teh LY: Immediate repair
of transected inferior alveolar nerves in
sagittal split osteotomies. J Oral Maxillofac
Surg 66:2476–2481, 2008.
333. Teerijoki-Oksa T, Jääskeläinen S, Forssell H,
et al: Risk factors of nerve injury during
mandibular sagittal split osteotomy. Int J
Oral Maxillofac Surg 31:33–39, 2002.
334. Teerijoki-Oksa T, Jääskeläinen S, Forssell K,
et al: An evaluation of clinical and
electrophysiological tests in nerve injury
diagnosis after mandibular sagittal split
osteotomy. Int J Oral Maxillofac Surg
32:15–23, 2003.
335. Teltzrow T, Kramer FJ, Schulze A, et al:
Perioperative complications following sagittal
split osteotomy of the mandible.
J Craniomaxillofac Surg 33:307, 2005.
336. Theodossy T, Jackson O, Petrie A, et al: Risk
factors contributing to symptomatic plate
removal following sagittal split osteotomy.
Int J Oral Maxillofac Surg 35:598, 2006.
337. Thygesen TH, Bardow A, Norholt SE, et al:
Surgical risk factors and maxillary nerve
function after Le Fort I osteotomy. J Oral
Maxillofac Surg 67:528, 2009.
338 Tomasetti BJ, Broutas M, Gormley M, et al:
Lack of tearing after Le Fort I osteotomy.
J Oral Surg 34:1095, 1976.
339. Tomazzoli-Gerosa L, Marchini G, Monaco
A: Amaurosis and atrophy of the optic nerve:
An unusual complication of
mandibular-nerve anesthesia. Ann
Ophthalmol 20:170, 1988.
340. Trimble LD, Tideman H, Stoelinga PJ: A
modification of the pterygoid separation in
low-level maxillary osteotomies. J Oral
Maxillofac Surg 41:544, 1983.
341. Tuinzing DB, Greebe RB: Complications
related to the intraoral vertical ramus
osteotomy. Int J Oral Surg 14:319, 1985.
342. Tung TC, Chen YR, Bendor-Samuel R:
Surgical complications of the Le Fort I
osteotomy: A retrospective review of 146
cases. Changgeng Yi Xue Za Zhi 18:102,
1995.
343. Turvey TA: Intraoperative complications of
sagittal osteotomy of the mandibular ramus:
Incidence and management J Oral Maxillofac
Surg 43:594, 1985.
344. Turvey TA, Bell BB, Tejera TJ, Proffit WR:
The use of self-reinforced biodegradable bone
plates and screws in orthognathic surgery.
J Oral Maxillofac Surg 60:59–65, 2002.
345. Turvey TA, Bell RB, Phillips C, Proffit WR:
Self-reinforced biodegradable screw fixation
compared with titanium screw fixation in
mandibular advancement. J Oral Maxillofac
Surg 64(1):40–46, 2006.
346. Van de Perre JP, Stoelinga PJ, Blijdorp PA,
et al: Perioperative morbidity in maxillofacial
orthopedic surgery: A retrospective study.
J Craniomaxillofac Surg 24:263, 1996.
347. Van Merkesteyn JPR, Groot RH, van
Leeuwaarden R, et al: Intra-operative
complications in sagittal and vertical ramus
osteotomies. Int J Oral Maxillofac Surg
16:665, 1987.
348. Van Sickels JE: Concomitant removal of
mandibular third molars during sagittal split
osteotomies minimizes neurosensory
dysfunction: Comment. J Oral Maxillofac
Surg 70:2164, 2012.
349. Van Sickels JE, Hatch JP, Dolce C, et al:
Effect of age, amount of advancement and
genioplasty on neurosensory disturbance
after a bilateral sagittal split osteotomy.
J Oral Maxillofac Surg 60:1012, 2002.
350. Van Sickels JE, Tucker MR: Management of
delayed union and nonunion of maxillary
osteotomies. J Oral Maxillofac Surg 48:1039,
1990.
351. Vaughan TC, Cronin A: Neurosurgery
required following a sagittal split osteotomy.
Br J Oral Maxillofac 47:e23, 2009.
352. Veterans Administration Ad Hoc
Interdisciplinary Advisory Committee on
Antimicrobial Drug Usage: Prophylaxis in
surgery. J Am Med Assoc 237:1003–1008,
1977.
353. Waack D: Perioperative complications
associated with Le Fort I osteotomies. J Oral
Maxillofac Surg 52 (suppl 2):92, 1994.
354. Walter JM, Jr, Gregg JM: Analysis of
postsurgical neurologic alteration in the
trigeminal nerve. J Oral Surg 37:410, 1979.
355. Wang JH, Waite DE: Evaluation of the
surgical procedure of sagittal split osteotomy
of the mandibular ramus. Oral Surg Oral
Med Oral Pathol 38:167, 1974.
355A.
Ward Booth P: Discussion: Risk factors
contributing to symptomatic plate removal
in orthognathic surgery patients. J Oral
Maxillofac Surg 57:682, 1999.
356. Watts PG: Unilateral abducent nerve palsy:
A rare complication following a Le Fort I
maxillary osteotomy. Br J Oral Maxillofac
Surg 22:212, 1984.
357. Weber CR, Griffin JM: Evaluation of
dexamethasone for reducing postoperative
edema and inflammatory response after
orthognathic surgery. J Oral Maxillofac Surg
52:35, 1994.
358. Westermark A, Bystedt H, von Konow L:
Inferior alveolar nerve function after
mandibular osteotomies. Br J Oral Maxillofac
Surg 36:425–428, 1998.
359. Westermark A, Bystedt H, von Konow L:
Inferior alveolar nerve function after sagittal
split osteotomy of the mandible: Correlation
with degree of intraoperative nerve encounter
and other variables in 496 operations. Br J
Oral Maxillofac Surg 36:429–433, 1998.
360. Westermark A, Bystedt H, von Konow L:
Patient’s evaluation of the final result of
sagittal split osteotomy: Is it influenced by
impaired sensitivity of the lower lip and
chin? Int J Adult Orthodon Orthognath Surg
14:135, 1999.
361. Westermark A, Englesson L, Bongenhielm
U: Neurosensory function after sagittal split
osteotomy of the mandible: A comparison
between subjective evaluation and objective
assessment. Int J Adult Orthodon Orthognath
Surg 14:268–275, 1999.
362. Westwood RM, Tilson HB: Complications
associated with maxillary osteotomies. J Oral
Surg 33:104, 1975.
363. Willmar K: On Le Fort I osteotomy. Scand J
Plast Reconstr Surg Suppl 12, 1974.
364. Willmar K, Hogeman KE, Thiseus S: Sagittal
split osteotomy in our experience: A
follow-up study of 100 operated patients.
Scand J Plast Reconstr Surg 13:445, 1979.
365. Wilson ME, Ellis FR: Predicting malignant
hyperpyrexia. Br J Anaesth 51:66, 1979.
366. Wilson MW, Wheatley MJ, Shults WT:
Secondary fractures of Le Fort I osteotomy.
Ophthal Plast Reconstr Surg 16:258, 2000.
367. Woo SB, Hellstein JW, Kalmar JR:
Systematic review: Bisphosphonates and
osteonecrosis of the jaws. Ann Intern Med
144:753–761, 2006.
368. Ylikontiola L, Kinnunen J, Laukkanen P,
et al: Prediction of recovery from
neurosensory deficit after bilateral sagittal
split osteotomy. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 90:275, 2000.
369. Ylikontiola L, Kinnunen J, Oikarinen K:
Comparison of different tests assessing
neurosensory disturbances after bilateral
sagittal split osteotomy. Int J Oral Maxillofac
Surg 27:417, 1998.
370. Ylikonitiola L, Kinnunen J, Oikarinen K:
Factors affecting neurosensory disturbance
after mandibular bilateral sagittal split
osteotomy. J Oral Maxillofac Surg 58:1234,
2000.

542 SECTION 2  Planning, Surgical Technique, & Complications
371. Yoshida T, Nagamine T, Kobayashi T, et al:
Impairment of the inferior alveolar nerve
after sagittal split osteotomy.
J Craniomaxillofac Surg 17:271, 1989.
372. You ZH: A study of maxillary and
mandibular vasculature in relation to
orthognathic surgery [article in Chinese].
Zhonghua Kou Qiang Yi Xue Za Zhi 26:263,
1991.
373. You ZH, Zhane ZK, Zhane XE: Le Fort I
osteotomy with descending palatal artery
intact and ligated: A study of blood flow and
quantitative histology. Contemp Stomatol
5:71, 1991.
374. Young RA, Epker BN: The anterior maxillary
osteotomy: A retrospective evaluation of
sinus health, patient acceptance, and relapse.
J Oral Surg 30:69, 1972.
375. Yrastorza J: Indications for antibiotics in
orthognathic surgery. J Oral Surg 34:514,
1976.
376. Yun KI, Lee JA, Park JU: Intubation
granuloma: Report of a case. J Oral
Maxillofac Surg 66:1263, 2008.
377. Zarrinkelk HM, Throckmorton GS, Ellis E,
III, et al: A longitudinal study of changes in
masticatory performance of patients
undergoing orthognathic surgery. J Oral
Maxillofac Surg 53:777, 1995.
378. Zaytoun HS, Jr, Phillips C, Terry BC:
Long-term neurosensory deficits following
transoral vertical ramus and sagittal split
osteotomies for mandibular prognathism.
J Oral Maxillofac Surg 44:193, 1986.
379. Zijderveld SA, Smeele LE, Kostense PJ,
Tuinzing DB: Preoperative antibiotic
prophylaxis: A randomized, double-blind
and placebo-controlled clinical study.
J Oral Maxillofac Surg 57:1403–1406,
1999.
380. Zuniga JR, Essick GK: A contemporary
approach to the clinical evaluation of
trigeminal nerve injuries. Oral Maxillofac
Surg Clin North Am 4:353, 1992.
381. Zuniga JR, Meyer RA, Gregg JM, et al: The
accuracy of clinical neurosensory testing for
nerve injury diagnosis. J Oral Maxillofac Surg
56:2, 1998.

543

17
Malocclusion after Orthodontics and
Orthognathic Surgery: Prevention
and Treatment Pitfalls
JEFFREY C. POSNICK, DMD, MD
• Sagittal Split Ramus Osteotomies of the
Mandible: Skeletal Stability and Relapse
• Le Fort I Osteotomy: Skeletal Stability and
Relapse
• Orthodontic Treatment: Dental Stability and
Relapse
• Management of Transverse Maxillary
Deficiency: Techniques and Relapse Patterns
• Conclusions
Sagittal Split Ramus Osteotomies of
the Mandible: Skeletal Stability and
Relapse
Immediate (Early) Malocclusion after Sagittal
Split Ramus Osteotomies
An immediate (early) malocclusion that is recognized either
intraoperatively or soon after surgery (i.e., during the
first several days or weeks afterward) will occur after sagittal
split ramus osteotomies of the mandible unless each of
the following intraoperative conditions is met* (Figs. 17-1
through 17-4):
1. The proximal segment is successfully split from the
distal mandible (i.e., no “bad” split) on each side
(right and left).
2. The distal mandible is placed in the preferred occlu­
sion and tightly held in intermaxillary fixation (IMF).
Unless the natural occlusion between the upper and
lower teeth is precise (i.e., without centric relation–
centric occlusion slides), the IMF should be main­
tained with the use of an accurate prefabricated
acrylic splint.
3. Each proximal segment is positioned with the condyle
seated in the terminal hinge position. Each proximal
segment is then secured to the distal segment with
the use of either passively placed bicortical screws or
monocortical screws and plates. This is accomplished
without torquing or overseating the proximal
segment. The following conditions should be present:
There are inherent limitations to the orthodontic movement
of teeth and the surgical repositioning of the jaws and jaw
segments; these limitations are imposed by the alveolar bone
and the periodontium, the overlying soft-tissue envelope,
the masticatory and facial musculature that surrounds the
maxillomandibular skeleton, and the temporomandibular
joints. If the biologic boundaries are not respected during
the movement of teeth, and the surgical repositioning of
the jaws, malocclusion is one potential adverse consequence
that may follow. The vector changes of the jaws, the jaw
segments, and the teeth that are more prone to relapse are
known, and so are many of the reasons why. The intent of
this chapter is to review the most prevalent causes of maloc­
clusion after osteotomies used to reposition the jaws and
orthodontic mechanics used for the movement of teeth in
the correction of dentofacial deformities.
*References 1, 5, 8, 39-41, 43, 44, 52, 53, 58, 74, 75, 84, 86, 88, 90,
91, 98, 102, 106-108, 111-113, 116, 126-128, 131, 132, 136, 137, 140,
150, 153, 155, 156, 160-163, 165, 166, 173, 180, 181, 183, 184, 188,
189, 194, 198, 209, 230, 255, 262, 263, 265, 271, 279, 292-295, 299,
301, 304, 305, 307, 309-311, 313, 318-321, 326
Text continued on p. 555

544 SECTION 2  Planning, Surgical Technique, & Complications
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• Figure 17-1  A woman in her late 20s was referred by her orthodontist for surgical evaluation.
She suffered with masticatory muscle discomfort while chewing and had a jaw deformity, maloc­
clusion, and a lifelong history of obstructed nasal breathing. A long face Class II growth pattern
was evident from her childhood onward. She had undergone attempted orthodontic growth
modification and then a camouflage approach, without success. She then underwent orthodontics
(including upper bicuspid extractions) and surgery at another institution; this included a Le Fort I
osteotomy and bilateral ramus osteotomies. Analysis confirmed both inadequate positioning of the
jaws at the time of operation and then dental relapse of the maxillary arch form over time. When
she presented to this surgeon, her clinical problems included the following:
• TMD with masticatory muscle discomfort
• Maxillary deformity (transverse constriction, vertical excess, horizontal deficiency, and clock­
wise rotation)
• Mandibular deformity (horizontal retrusion and clockwise rotation)
• Chin deformity (excess vertical length and horizontal retrusion)
• Obstructed nasal airway (septal deviation, high nasal floor, constricted aperture, and inferior
turbinate enlargement)
The patient was treated for temporomandibular disorder and then with a comprehensive orthodon­
tic and surgical approach. Splint therapy was useful to relieve masticatory muscle comfort, and
orthodontic dental decompensation was then carried out over approximately 12 months. Her
surgery included maxillary Le Fort I osteotomy in segments (horizontal advancement, vertical intru­
sion, counterclockwise rotation, and transverse widening); bilateral sagittal split ramus osteotomies
(horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical reduction
and horizontal advancement); and septoplasty, inferior turbinate reduction, and recontouring of the
nasal floor. After initial healing and splint removal (i.e., 5 weeks after surgery), orthodontic mainte­
nance and detailing continued for 9 months. A, Frontal and occlusal views before retreatment.
B, Profile and cephalometric views before retreatment.

545
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
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Prior to retreatment
C, Frontal facial views before and after retreatment. D, Profile views before and after
retreatment. E, Occlusal views before and 2 years after retreatment.
• Figure 17-1, cont’d 
Continued

546 SECTION 2  Planning, Surgical Technique, & Complications
Arch expansion
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before
and after retreatment.
• Figure 17-1, cont’d

547
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
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Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
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gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
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gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C. Pos
os
os
os
os
o nicicicicici k
B
• Figure 17-2  A man with a developmental jaw deformity that was characterized as an asymmetric mandibular excess
growth pattern (i.e., hemimandibular elongation) presented for treatment. His orthodontist originally attempted growth
modification followed by orthodontic camouflage that included four bicuspid extractions, without success. When he was
19 years old, the patient underwent further orthodontics and a surgical approach at another institution. His jaw surgery at
the time included maxillary Le Fort I osteotomy and bilateral vertical oblique ramus osteotomies. An initial satisfactory surgi­
cal result was not achieved, and further orthodontic camouflage was attempted. During ongoing orthodontic treatment,
alveolar bone loss and gingival recession occurred along the buccal aspect of the posterior maxillary dentition and the
labial aspect of the anterior mandibular dentition. At the time of referral to this surgeon, the patient was 35 years old; thus,
it had been 16 years since his suboptimal treatment. Evaluations were arranged with a periodontist; an orthodontist; a
speech therapist; and an ear, nose, and throat specialist. After periodontal treatment, orthodontic decompensation was
carried out in preparation for reconstruction. The patient’s surgery included maxillary Le Fort I osteotomy in segments (cant
correction, transverse expansion, and minimal horizontal advancement); sagittal split ramus osteotomies (asymmetry cor­
rection and minimal horizontal advancement); osseous genioplasty (vertical reduction and horizontal advancement); and
septoplasty and inferior turbinate reduction. A, Frontal and occlusal views before retreatment. B, Current profile view shown
next to a lateral cephalometric radiograph taken before original surgery, when the patient was 19 years old.
Continued

548 SECTION 2  Planning, Surgical Technique, & Complications
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
C
D
C, Frontal views in repose before and after retreatment. D, Frontal views with smile before and after
retreatment.
• Figure 17-2, cont’d

549
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
E
F
E, Oblique facial views before and after retreatment. F, Profile views before and after retreatment.
• Figure 17-2, cont’d 
Continued

550 SECTION 2  Planning, Surgical Technique, & Complications
Prior to retreatment with 4 bicuspid extractions
Pre surgery
After retreatment
G
G, Occlusal views before orthodontic retreatment, with orthodontic decompensation in progress, and after
retreatment.
• Figure 17-2, cont’d

551
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Arch expansion
Roll Orientation Correction
H
I
H, Articulated dental casts after analytic model planning. I, Lateral cephalometric radiographs after first
surgery and then after retreatment.
• Figure 17-2, cont’d

552 SECTION 2  Planning, Surgical Technique, & Complications
Or
Or
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Or
Or
Or
Or
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Orthththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatathicicicic Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicici k
A
B
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
o nicicicick
• Figure 17-3  A 28-year-old woman was referred by her orthodontist for the evaluation of residual malocclusion and facial
asymmetry. Eight years earlier, the patient had presented with an asymmetric mandibular excess growth pattern and underwent
a combined orthodontic and surgical approach at another institution. The surgery included maxillary Le Fort I osteotomy (three
segments) with iliac interpositional grafting in combination with bilateral sagittal split ramus osteotomies. Immediately after
surgery, the occlusion that had been achieved was recognized to be unsatisfactory. The patient was taken back to the operat­
ing room 1 week later for the removal of the fixation of the right ramus of the mandible, the adjustment of the occlusion, and
the reapplication of fixation. The occlusion remained unsatisfactory. Six months later, the patient was taken back to the operat­
ing room again, where she underwent a left vertical oblique ramus osteotomy without fixation followed by 6 weeks of inter­
maxillary fixation. Over the long term, the occlusion remained unsatisfactory, and the patient also had a minor degree of facial
asymmetry as seen in the frontal view. At the time of referral to this surgeon, the patient stated that she hoped for the cor­
rection of the occlusion and an improvement in her current lip asymmetry. The decision was made to not operate on the
mandible again. Options to improve the occlusion included maxillary Le Fort I osteotomy in segments versus surgically assisted
rapid palatal expansion. Segmental maxillary surgery with immediate repositioning and interpositional grafting was carried out.
The occlusion was maintained with a prefabricated acrylic splint for 6 weeks, which was followed by the immediate placement
of a transpalatal arch. A, Frontal facial and occlusal views before retreatment. B, Profile facial view and lateral cephalometric
radiograph before retreatment.

553
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
D
6mm
6mm
E
Prior to retreatment
Pre surgery
C
C, Occlusal views before retreatment and preoperatively with orthodontic appliances in place. D, Articulated
dental casts that indicate surgical planning. E, Demonstration of the use of the maxillary surgical model to construct a transpalatal
arch wire for immediate placement at the time of splint removal (i.e., 5 weeks after surgery). The roof of the patient’s mouth is shown
with the transpalatal wire in place in accordance with the surgical model. The use of orthodontic mechanics for 6 months to actively
maintain the arch width achieved at operation is useful to limit a tendency toward relapse. It is also important to limit any orthodontic
mechanics that may position the teeth outside of the alveolar housing, because this situation will be prone to long-term dental relapse.
• Figure 17-3, cont’d

554 SECTION 2  Planning, Surgical Technique, & Complications
A
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththth
r ogn
gn
gn
gn
gn
g atatatatatata hicicicic Su
Su
Su
Surg
r ery
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicicicicicicicici k
B
X
X
X
• Figure 17-4  A 21-year-old man who was born with bilateral cleft lip and palate arrived for surgical evalu­
ation. He had undergone suboptimal orthognathic surgery (Le Fort I osteotomy and osseous genioplasty) at
another institution 4 years earlier. The history, physical examination, and radiographs suggested a combina­
tion of both unfavorable initial surgical healing and late dental relapse. The patient was referred to this surgeon
and underwent a comprehensive surgical and dental rehabilitative approach. After periodontal evaluation and
treatment, orthodontic decompensation was undertaken. The patient’s surgery included maxillary Le Fort I
osteotomy in three segments with differential repositioning (cant correction, closing down of cleft dental gap,
closure of fistula, horizontal advancement, counterclockwise rotation, and vertical adjustment); bilateral sagit­
tal split ramus osteotomies (asymmetry correction); and septoplasty and inferior turbinate reduction. This
was followed by planned prosthetic rehabilitation of the maxillary and mandibular arches and ongoing peri­
odontal surveillance. A, Frontal and occlusal views at the time of surgical evaluation (i.e., 4 years after the
suboptimal orthognathic procedures at another institution). B, Cephalometric and Panorex radiographs at
the time of surgical evaluation. C, Articulated dental casts that indicate analytic model planning.
C

555
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththth
r ogn
gn
gn
g atathicicic Su
Surg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatathicicicicicicicic Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
o n cicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicick
D
E
*References 14, 16, 18, 20, 45, 54, 69, 76, 85, 89, 97, 101, 104, 105,
110, 120, 152, 154, 158, 164, 169, 170, 174, 192, 196, 197, 203, 204,
207, 210, 213, 216, 227-229, 232, 252, 256, 272, 273, 285, 297, 308,
312, 316, 326, 328, 334
D, Frontal views with smile before and after retreatment including dental rehabilitation. E, Occlusal views
before and after retreatment including dental rehabilitation.
• Figure 17-4, cont’d 
• Adequate bone contact between the proximal and
distal segments, without compression or torquing
• Appropriate alignment of the proximal and distal
segments to limit the rotation or torquing of each
proximal segment.
4. With the release of IMF, the mandible is put through
the range of motion to confirm the adequate stability
of the skeletal fixation across the ramus osteotomy site
on each side.
5. The occlusion is then checked for any centric relation–
centric occlusion discrepancies or other causes of mal­
occlusion. If a discrepancy is seen, each proximal
segment must be released of its fixation and then
again repositioned until the planned, stable, and
reproducible occlusion is achieved (i.e., Steps 1
through 5 are repeated, as needed).
Late Malocclusion after Sagittal Split
Ramus Osteotomies
Malocclusion after the successful initial healing of sagittal
split ramus osteotomies is the result of either skeletal or
dental causes.* Skeletal causes may include condylar
resorption (see Chapter 36); remodeling or malunion (i.e.,
relapse) at the osteotomy site; or continued mandibular
growth; these conditions are all described in more detail
later in this chapter. Dental causes of malocclusion after
sagittal split ramus osteotomies are often not appreciated

556 SECTION 2  Planning, Surgical Technique, & Complications
of lower jaw growth in individuals with true mandibular
excess may occur later than it does in average individuals
(Figs. 17-6 and 17-7) (see Chapter 20); this is especially
true for individuals with asymmetric mandibular excess
growth anomalies (see Chapter 22). Alternatively, the indi­
vidual with a typical Class II long face growth pattern (i.e.,
vertical maxillary excess combined with mandibular defi­
ciency) can be assumed to have a normal mandibular growth
vector without a tendency for late development (see Chapter
21). I believe that, if the long face patient’s chronic nasal
obstruction problem is simultaneously managed at the time
of orthognathic surgery (i.e., septoplasty, inferior turbinate
reduction, the widening of a tight nasal aperture, and the
lowering of the nasal floor), further pathologic vertical
growth is also likely to be arrested (see Chapter 10).
Ramus Remodeling and Malunion after Sagittal Split
Ramus Osteotomy
With the use of rigid internal fixation (e.g., bicortical screws
or plates and screws), the remodeling and malunion of the
ramus osteotomy site is believed to be an uncommon cause
of relapse.109,115,179,206,236,248,302,324 Although infrequent, infec­
tion that has led to sequestration (e.g., of the buccal shelf
of the proximal segment) and malunion has been reported.
In most clinical settings, there is little evidence to support
the concept of late relapse at the ramus osteotomy site after
satisfactory initial healing has occurred (by approximately
5 weeks). However, limited bone contact or inadequate
fixation of the bony segments may cause initial fibrous
union followed by malunion and resulting malocclusion.
This would be documented as morphologic change in the
mandibular angle (i.e., clockwise rotation of the distal
segment) in the presence of unchanged condylar morphol­
ogy (i.e., no ongoing erosion of the condylar head). There
would also be measurable change in either the mandibular
length (i.e., as measured from the condyle to the pogonion)
or the sella–nasion–B-point angle documented during the
analysis of the serial cephalometric radiographs after surgery.
Proffit and colleagues do make a case for ramus remodel­
ing with relapse after mandibular set-back when managing
a Class III skeletal pattern.248 These authors believe that,
when the orthognathic procedure for the management
of a Class III skeletal pattern is a mandibular set-back
only versus a two-jaw surgery (i.e., with the primary move­
ment being maxillary advancement in combination with
only minor mandibular adjustment), then relapse at the
ramus osteotomy site is a common occurrence. In a recent
clinical study, Proffit and colleagues confirmed that—
despite improvements in surgical fixation techniques (i.e.,
rigid fixation versus intraosseous wires and IMF)—when
mandibular set-back only procedures are carried out for a
Class III malocclusion, skeletal instability is often signifi­
cant. They confirmed better long-term skeletal and occlusal
stability when two-jaw surgery is performed for the manage­
ment of Class III skeletal patterns (i.e., maxillary advance­
ment with limited mandibular set-back).251
until much later, but they are generally related to the unsta­
ble orthodontic positioning of the teeth outside of the
boundaries of the alveolar process before or after surgery;
this is discussed later in this chapter (see also Chapters 5
and 6).208
Condylar Resorption after Orthognathic Surgery
Although it is rare, idiopathic condylar resorption may
present after orthognathic surgery (maxillary or mandibular
osteotomies), routine orthodontic treatment, or routine
dental procedures; it may also occur spontaneously and
not in association with any specific form of treatment
(see Chapter 36).12,117,118,143,144,148,159,202,212,237,278,327 Condylar
resorption is usually bilateral, symmetric, and seen in young
females who are between 15 and 35 years old. Although no
agreed upon etiology has been delineated for idiopathic
condylar resorption, hormonal and autoimmune causes are
suspected (see Chapter 36). Unilateral condylar resorption in
association with compressive forces may also be seen after
the excessive use of elastics in an attempt to overcome
residual malocclusion. The clinical setting may involve
heavy elastic use either as part of an orthodontic camouflage
approach to avoid surgery (Fig. 17-5) or after orthognathic
procedures that did not achieve the desired occlusion. In
either case, heavy compressive forces on the condyle may
result in temporomandibular joint symptoms followed
by condylar resorption with a loss of condylar (posterior
facial) height.
Continued Growth of the Mandible after
Orthognathic Surgery
Under normal conditions, the mandible is the last bone in
the craniofacial skeleton to complete growth. In general,
mandibular growth should be complete between the ages of
14 and 16 years in girls and between the ages of 16 and 18
years in boys. Chronologic and skeletal age will vary from
individual to individual, and mandibular growth in men
may continue beyond the age of 18 years, but this is uncom­
mon. Jaw growth in girls is usually complete within 2 years
after the onset of regular menses. The completion of jaw
growth may be assessed in the following ways: 1) via the
growth-plate analysis of a hand and wrist radiograph 2) via
the analysis of a quantitative condylar head bone scan in
comparison to a lumbar vertebra (L2) 3) via the analysis of
the mandibular length with the use of serial lateral cepha­
lometric radiographs 4) via the analysis of cervical vertebral
maturation with the use of serial lateral cephalometric
radiographs 5) via the assessment of serial dental models in
centric relation or 6) via the assessment of serial occlusal
photographs taken in centric relation.*
Mandibular growth in individuals with micrognathia is
generally complete at an earlier age than it is among normal
“average” mandibular growers. Alternatively, the cessation
*References 26-28, 30, 33-38, 46-48, 68, 81, 92, 94, 119, 129, 130, 201,
214, 215, 218-224, 226, 258, 266, 270, 274-276, 280, 281, 286, 289,
290, 302, 332
Text continued on p. 563

557
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicici Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatata hicicicicic Su
Su
Surg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicick
Or
Orththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicic Su
Surg
r ery
ry; J.C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatata hicicici Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicici k
A
B
• Figure 17-5  A 23-year-old woman was referred for surgical evaluation. During her high school
years, she was recognized as having a malocclusion, and she underwent four bicuspid extractions
and orthodontic treatment to neutralize the occlusion. During her college years, she experienced a
closed lock of her jaw as a result of a dislocated disc within the left temporomandibular joint. After 3
months of conservative management, the patient underwent arthroscopy with lysis of adhesions. With
a recurrence of the closed lock attributed to the disc in the left temporomandibular joint, she underwent
discectomy and fat graft interposition. A review of the patient’s earlier medical records, including dental
models and radiographic analyses, confirmed the primary cause of current malocclusion to be a
longstanding developmental jaw deformity that was initially treated with orthodontics alone. Dental
relapse had occurred, and the patient’s temporomandibular disorder was likely the result of unstable
intercuspation. The relief of the temporomandibular disorder was achieved through an open-joint
procedure but with the additional loss of posterior facial height and mandibular asymmetry. The patient
was referred to this surgeon and agreed to a comprehensive orthodontic and orthognathic approach.
The patient’s procedures included bilateral sagittal split ramus osteotomies (horizontal advancement
and counterclockwise rotation) and osseous genioplasty (horizontal advancement). Facial balance and
satisfactory occlusion were achieved and maintained without the return of temporomandibular disor­
der. A, Frontal views in repose before and after retreatment. B, Frontal views with smile before and
after retreatment.
Continued

558 SECTION 2  Planning, Surgical Technique, & Complications
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
o nicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicic u
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C Pos
o nick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
o nicicicick
C
D
E
Chronic condylar head
erosion prior to surgery
C, Oblique facial views before and after retreatment. D, Profile views before
and after retreatment. E, Panorex radiograph before retreatment. This image indicates a chronic flat­
tening of the left condylar head.
• Figure 17-5, cont’d

559
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Pre surgery with 4 bicuspid extractions as a teenager
After re-treatment
F
G
Mandibular advance
and counterclockwise
rotation
H
F, Occlusal views before retreatment, with orthodontics in progress, and after successful retreatment.
G, Articulated dental casts indicate analytic model planning. H, Lateral cephalometric radiographs before and after successful
retreatment.
• Figure 17-5, cont’d

560 SECTION 2  Planning, Surgical Technique, & Complications
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
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r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 17-6  An 18-year-old man with malocclusion and a lifelong history of obstructed nasal breathing was
referred for the surgical evaluation. The pattern of deformity was maxillary deficiency in combination with relative
mandibular excess, which resulted in a severe Class III negative overjet anterior open bite. He had previously
undergone growth modification and camouflage orthodontics including lower bicuspid extractions, without
success. After a thorough evaluation, he underwent 12 months of orthodontic decompensation followed by
jaw and intranasal surgery. The patient’s surgery included Le Fort I osteotomy in segments (horizontal advance­
ment, clockwise rotation, transverse widening, and correction of the arch form) with interpositional grafting;
sagittal split ramus osteotomy (minimal counterclockwise rotation); osseous genioplasty (bone burring and
recontouring); and septoplasty and inferior turbinate reduction. These procedures were followed by finishing
orthodontics. The occlusion achieved during the operation and maintained at the patient’s debracketing 6 months
later was ideal. By 2 years after surgery, however, a symmetric Class III negative overjet malocclusion had
recurred. A, Frontal views before and 2 years after reconstruction. B, Frontal views with smile before and 2 years
after reconstruction.

561
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
A review of the 2-year postoperative dental models indicated stable maintenance of the
arch width and of the correction of the curve of Spee. The models could be articulated into a similar occlusion
as had been achieved at the time of operation. Therefore, the cause of change in occlusion could not be attrib­
uted to the segmental osteotomies or dental relapse. The cause of the recurrent malocclusion was felt to be
either ongoing mandibular growth or Le Fort I osteotomy site relapse. An analysis of the postoperative cepha­
lometric radiographs—which showed an increase in the sella–nasion–B-point angle and the maintenance of the
sella–nasion–A-point angle—confirmed maxillary stability. Ongoing mandibular growth was the cause of the
malocclusion. Treatment options included Le Fort I osteotomy (3-mm advancement) versus sagittal split ramus
osteotomies (3-mm set-back). The patient was pleased with the functional improvements (i.e., swallowing,
speech, chewing, lip closure/posture, and breathing) and the enhanced facial aesthetics without temporoman­
dibular disorders. He elected to receive no further treatment. C, Oblique facial views before and 2 years after
reconstruction. D, Profile views before and 2 years after reconstruction.
• Figure 17-6, cont’d 
Continued

562 SECTION 2  Planning, Surgical Technique, & Complications
Prior to retreatment with lower bicuspid extractions
Pre surgery
5 weeks after surgery
2 years after treatment
E
E, Occlusal views before retreatment, immediately before surgery, 5 weeks after surgery, and 2 years after
treatment.
• Figure 17-6, cont’d

563
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Arch expansion
G
F
Maxillary clockwise
rotation
F, Articulated dental casts after analytic model planning. G, Lateral cephalo­
metric radiographs before and after treatment.
• Figure 17-6, cont’d 
Le Fort I Osteotomy: Skeletal Stability
and Relapse
Immediate (Early) Malocclusion after
Le Fort I Osteotomy
Immediate (early) malocclusion that is recognized either
intraoperatively or during the first several days or weeks
after surgery may occur after a Le Fort I osteotomy unless
the following intraoperative conditions are met (see Figs.
17-1 through Fig 17-4)*:
1. After Le Fort I down-fracture osteotomy, full mobi­
lization of the maxilla and the segments (if segmenta­
tion has been carried out) is accomplished before the
placement of fixation.
2. An accurate prefabricated acrylic splint is secured to
the maxillary occlusal surfaces. The splint stabilizes
the new maxillary arch form (i.e., the arch width
and the curve of Spee) when segmental osteotomies
are carried out.
3. After the securing of the splint to the maxillary denti­
tion, IMF is applied to establish the new horizontal
position of the maxilla; the dental midline (yaw ori­
entation); the preferred maxillary plane orientation
(pitch orientation); and any cant correction (roll ori­
entation) required.
4. With the condyles seated in the terminal hinge posi­
tion and IMF established via the prefabricated splint,
the maxillomandibular complex is rotated until the
desired vertical position of the maxilla is achieved.
• Bony prematurities are common with maxillary
impaction. It is easy for the surgeon to overlook
interferences in the posterior region of the lateral
nasal walls just medial to the descending palatine
vessels (see Fig. 15-25, A and B).
*References 22, 26, 52, 53, 79, 82, 87, 128, 134, 145, 147, 178, 187-189,
191, 193, 194, 233, 234, 239, 241, 244, 259, 264, 279, 287, 307, 317

564 SECTION 2  Planning, Surgical Technique, & Complications
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatata hicicic Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicici k
Or
Orththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
g athicic Su
Surg
r ery
ry; J.C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicick
Or
Or
Or
Or
Or
Orthththththththththth
r ogn
gn
gn
gn
g
tatatatatathicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicicick
Or
Or
Or
O thththththth
r ogn
gn
g atatathicic Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicicicick
A
B
• Figure 17-7  A 13-year-old boy born with bilateral cleft lip and palate arrived for surgical evaluation
with a severe cleft jaw deformity. He underwent primary lip and palate repair, a pharyngeal flap pro­
cedure, bone grafting, and a columella lengthening procedure at another institution. He was referred
to this surgeon with severe maxillary hypoplasia that was causing profound effects on his speech
articulation, chewing ability, breathing, and self-esteem. For this reason, early jaw reconstruction was
chosen. He underwent maxillary Le Fort I osteotomy (horizontal advancement and vertical lengthening
with interpositional [iliac] bone grafting). This was carried out with the understanding that further maxil­
lary growth should not be expected, whereas mandibular growth would likely continue and result in
a recurrent Class III. A review of the longitudinal cephalometric radiographs after surgery confirmed
no significant horizontal maxillary relapse but ongoing mandibular growth. A, Frontal views with smile
before and 1 year after surgery just before the removal of the orthodontic appliances. B, Oblique facial
views before and 1 year after surgery.
• Care should be taken to prevent premature con­
tacts across the Le Fort I osteotomy site, which are
followed by a “slide” into maximum bone contact
during further vertical closure of the maxilloman­
dibular complex. This would cause condylar dis­
placement with malocclusion that should be
recognized at the release of the IMF. The maloc­
clusion would typically present as either a
symmetric anterior open bite (if both condyles are
displaced) or as an asymmetric lateral shift in the
bite (if one condyle is displaced).
5. There must be adequate bone contact across the oste­
otomy site after the maxilla is stabilized with plate
and screw fixation into the desired position. If not,
an interpositional graft of sufficient quality should be
placed and secured (see Chapters 15 and 18). Without

565
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
16mm
D
Pre surgery
1 year after treatment
E
C
C, Lateral cephalometric views before and 1 year after surgery. D, Articulated dental casts that indicate analytic
model planning. E, Occlusal views before and 1 year after surgery, just before debanding.
• Figure 17-7, cont’d 
Continued

566 SECTION 2  Planning, Surgical Technique, & Complications
Or
Or
Or
Orthththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
g atatathicici Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
osnicicici k
F
F, Facial and occlusal views from when the patient was 18 years old (i.e., 5 years after Le Fort I
advancement) that indicate recurrent Class III malocclusion as a result of ongoing mandibular growth.
• Figure 17-7, cont’d 
adequate bone contact across the osteotomy site,
fibrous union may occur (see Chapter 16). Another
possibility is that of initial bony union with relapse
(i.e., malunion) occurring as full healing proceeds
during the 6 to 12 months after surgery, thereby
resulting in late malocclusion.
6. Adequate plate and screw stabilization of the maxilla
generally requires the placement of titanium fixation
at each pyriform rim and each zygomatic buttress (see
Fig. 15-26). When interpositional grafts are required,
additional titanium fixation is placed from the supe­
rior maxilla and extended across the graft to the
dentate segment (see Fig. 15-29, A, B, and C). Addi­
tional plate and screw fixation may also be placed
horizontally across any interdental osteotomies, if
needed.
7. With release of the IMF, the occlusion is checked as
the mandible is rotated (opened and closed) with the
condyles seated in the terminal hinge position. The
occlusion must evenly contact and fit passively into
the splint. If not, the plate and screw fixation across
the Le Fort I osteotomy is released. Any bony interfer­
ence is then identified and removed. The maxilla is
again repositioned and the fixation reapplied (i.e.,
repeat Steps 4 through 7) until the planned occlusion
is achieved and confirmed.
Late Malocclusion after Le Fort I Osteotomy
Skeletal causes of a late malocclusion after Le Fort I osteot­
omy may include the following: 1) remodeling (relapse) at
the Le Fort I osteotomy site (as described later in this
chapter) 2) fibrous union at the Le Fort I osteotomy site (as
described later in this chapter) 3) remodeling (relapse) at
the segmental osteotomy sites (as described later in this
chapter) 4) condylar resorption (as described previously in
this chapter and in Chapter 36)143 and 5) continued man­
dibular growth (as described previously in this chapter; see
Figs. 17-6 and 17-7).* Dental causes of malocclusion after
Le Fort I osteotomy are often not realized until much later.
They are related to the unstable orthodontic positioning of
the teeth outside of the boundaries of the alveolar process
before or after surgery (as described later in this chapter and
in Chapters 5 and 6).208
The precise cause of relapse at the Le Fort I osteotomy
site is often difficult to pinpoint , but it is generally related
to the following: 1) inadequate mobilization of the down-
fractured maxilla before the placement of fixation 2) inad­
equate bone contact across the osteotomy site after the
fixation is applied 3) inadequate (non-rigid) plate and screw
fixation across the osteotomy site or 4) excessive occlusal
forces or movement transmitted across the osteotomy site
during initial healing.†
Fibrous union of the maxilla after Le Fort I osteotomy is
an infrequent occurence. When it occurs, expect to find
painless mobility of the upper jaw, with or without maloc­
clusion. Risk factors should be recognized, at which point
surgical techniques and postoperative management can be
adjusted to limit this complication (see Fig. 16-21). The
combination of extensive horizontal advancement and ver­
tical lengthening will result in large osteotomy site defects
*References 27, 28, 30, 33-38, 46-48, 68, 81, 92, 94, 119, 129, 130,
201, 214, 215, 218-224, 226, 258, 266, 270, 274-276, 280, 281, 286,
289, 301, 302
†References 3, 4, 11, 14-16, 18-20, 24, 29, 63, 83, 95, 99, 109, 114, 121,
135, 138, 139, 141, 142, 146, 149, 172, 179, 240, 242, 243, 245, 249,
250, 253, 273, 321, 331, 333, 334

567
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
is generally needed for at least 6 months to retain the
arch form. (This is described later in this chapter.)
Orthodontic Treatment: Dental Stability
and Relapse
The objective of orthodontics in conjunction with jaw
surgery is to align the dentition in each arch by placing the
maxillary and mandibular teeth fully within the basal bone.
When the jaws and jaw segments are then surgically repo­
sitioned, the preferred occlusion is achieved. Following
Andrews’ Six Keys to Normal Occlusion provides the
framework for the accomplishment of the orthodontic
objectives (see Chapters 5 and 6).208
Moen and colleagues carried out a prospective clinical
study to evaluate the short-term occlusion achieved and the
long-term occlusion maintained after bilateral sagittal split
ramus osteotomies with advancement for the treatment of
Class II skeletal deformities.208 Prospectively, 36 patients
with Class II skeletal patterns who were to undergo bilateral
sagittal split ramus osteotomies agreed to participate in the
study. The mean age at operation was 33 years (range, 16
to 59 years). All of the study patients underwent periopera­
tive orthodontics and were followed clinically, with dental
models and radiographs (i.e., lateral cephalometric and
Panorex). These standard records were obtained at 8 weeks,
1 year, and 13 years after surgery. Interestingly, for the
majority of patients, cephalometric analysis confirmed
insignificant skeletal changes during long-term follow up
after successful initial healing had occurred. Long-term
recurrent malocclusion was found to be primarily dental
rather than skeletal in origin.208 To achieve and then main­
tain the ideal occlusion, the importance of the stable ortho­
dontic positioning of the teeth in the alveolus cannot be
overstated (Figs. 17-9 through 17-14).
The lips, tongue, cheeks, soft palate, mandible and peri­
odontal ligaments function dynamically with the stationary
(immobile) maxilla and the teeth to achieve chewing, swal­
lowing, breathing, speech, and lip closure. Parafunctional
habits of these structures (e.g., posturing of the tongue, lips,
and jaw) may influence the position of the teeth and the
supporting skeletal structures. Dental compensations are
expected biologic responses when a jaw disharmony is
present at birth or when it occurs during growth. The orth­
odontic mechanical removal of dental compensations
should position the teeth within the alveolar process to then
maximize the surgical correction and also to provide a
framework for long-term occlusal stability and periodontal
health.*
Extraction Therapy to Eliminate Crowding
Dental extractions may be necessary when there is inade­
quate alveolar bone to eliminate the dental crowding and
with limited bone contact. Failure to form adequate bony
bridges at the healing sites is likely to result in delayed
healing, fibrous union, or late relapse. Negative influences
on bone healing at the Le Fort I osteotomy site may include
the following: (1) injury to flap circulation (2) thin osteo­
porotic bone at the zygomatic buttress and the pyriform
rims, with inadequate fixation and (3) the decision to not
place interpositional grafts when the bone gaps are of criti­
cal size. Additional postoperative healing risk factors include
the following: (1) infection or wound dehiscence after
surgery (2) the presence of a heavy occlusion (e.g., grinding,
clenching) (3) too rapid of a return to normal chewing
forces (4) excessive mouth opening against intermaxillary
elastics and (5) the breakage (stress fracture) of the fixation
plates. Systemic conditions that are known risk factors for
poor bone healing include the following: (1) diabetes (2)
collagen disease (3) vascular disease (4) osteoporosis or
bisphosphonate use (5) nicotine abuse (6) poor nutritional
status; and (7) previous radiation treatment.
Relapse across the segmental maxillary osteotomy
sites after palatal widening is generally related to the follow­
ing: (1) inadequate mobilization of the segments (2) inad­
equate surgical splinting of the new arch shape during initial
healing (i.e., the first 5 weeks) (3) inadequate or unstable
interdigitating occlusion between the maxillary and man­
dibular teeth after the splint is removed or (4) inadequate
medium-term orthodontic maintenance (i.e., lasting
approximately 6 months) with an appropriate appliance
after the surgical splint is removed (see Figs. 17-3 and 17-8).
Transverse relapse after the removal of the surgical splint
may also occur as a result of the use of counterproductive
intermaxillary elastic forces. For example, the use of vertical
elastics placed on the buccal brackets of the upper and lower
molars in an attempt to close posterior open bites may result
in the simultaneous unintended collapse of the arch width.
Frequent technical errors that can occur when complet­
ing Le Fort I segmental arch expansion and that may result
in malocclusion include the following:
1. Inadequate skeletal mobilization. When significant
widening of the posterior maxilla is required, bilateral
(rather than unilateral) parasagittal osteotomies will
assist with the tension-free placement of the segments
into the splint (see Chapter 15).
2. Inadequate splint strength. The use of a non-flexible
splint (e.g., a reinforced U-shaped acrylic splint,
transpalatal support) is essential to maintain the arch
width during initial healing (see Chapter 13).
3. Inadequate soft-tissue mobilization. After the comple­
tion of segmental osteotomies, the stretching of the
palatal soft tissues through the down-fracture (i.e.,
the use of a spreader forceps) improves the tension-
free placement of the segments into the splint.
4. Inadequate postsurgical care. After the splint is removed
(i.e., 5 weeks after surgery), the seamless transfer of
responsibility from the surgeon to the orthodontist
for ongoing maxillary arch form maintenance is
essential. The effective use of orthodontic mechanics
*References 2, 7, 55, 61, 71, 77, 78, 80, 93, 100, 103, 157, 186, 190,
205, 217, 247, 246, 267, 288, 330, 335, 336

Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 17-8  A 15-year-old high school student was referred by her orthodontist for surgical evaluation of a long-standing developmental jaw
deformity with malocclusion and a lifelong history of obstructed nasal breathing. The pattern of growth disturbance was maxillary deficiency in
combination with relative mandibular excess, and this resulted in a Class III negative overjet anterior open bite malocclusion. The patient had
undergone growth modification and camouflage orthodontics, without success. Referral to this surgeon was followed by orthodontic decompensa­
tion in conjunction with jaw and intranasal surgery and then finishing orthodontics. The patient’s surgery included maxillary Le Fort I osteotomy in
two segments (horizontal advancement, transverse widening, and vertical lengthening); sagittal split ramus osteotomies (counterclockwise rotation
and minimal horizontal advancement); and septoplasty and inferior turbinate reduction. The surgical occlusion that was initially achieved at operation
and then maintained during the early phase of healing was stable. By 6 to 12 months after surgery, a degree of posterior crossbite had recurred.
A, Frontal views with smile before and after reconstruction. B, Oblique facial views before and after reconstruction.

569
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Pre surgery
2 years after treatment
D
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
A review of the postoperative dental models indicated intermolar transverse constriction as compared with what was surgi­
cally planned, executed, and achieved at 5 weeks after surgery, when the prefabricated splint was removed. A review of the dental models confirmed
a combination of skeletal and dental relapse that resulted in maxillary arch constriction. In retrospect, the postoperative orthodontic mechanics of
the labial arch wire to maintain the surgically achieved arch width were not adequate. The use of a transpalatal wire or an acrylic palatal plate
maintained for 6 months after surgery may have prevented maxillary arch form relapse after the surgical splint was removed (i.e., 5 weeks after
surgery). Treatment options for the residual malocclusion include redo Le Fort I segmental osteotomies with expansion versus surgically assisted
rapid palatal expansion. The patient was pleased with the improvements (i.e., chewing, speech articulation, lip closure/posture, and breathing) and
the enhanced facial aesthetics. She was left with a functional occlusion without centric relation–centric occlusion discrepancies or temporoman­
dibular disorder. She elected to receive no further treatment. C, Profile views before and after reconstruction. D, Occlusal views with orthodontic
decompensation in progress and 3 years after treatment. The positive overjet overbite is maintained but with recurrent maxillary transverse
constriction.
• Figure 17-8, cont’d 
Continued

570 SECTION 2  Planning, Surgical Technique, & Complications
Arch expansion
F
E
Mandibular counter-
clockwise rotation
E, Articulated dental casts that indicate analytic model planning.
F, Lateral cephalometric radiographs before and after reconstruction.
• Figure 17-8, cont’d 
to remove compensations without displacing the roots
outside of alveolar housing. Opinions regarding the indica­
tions for extractions have changed remarkably over the past
150 years since the beginning of “modern” orthodontics.
During the 1880s, Edward Angle joined other progres­
sive restorative dentists of his time in their opposition to a
casual attitude toward the extraction of teeth (see Chapter
2). Angle’s belief was that, through diligent effort, the orth­
odontic alignment of the full complement of teeth was
possible. He felt that the orthodontist’s ultimate objective
was for every person to have the potential for an ideal rela­
tionship of all 32 natural teeth.
Dr. Angle believed that the cause of most Class II or
Class III problems was often the result of abnormal stresses
on the jaws. Through the orthodontist’s active application
of controlled pressure on the teeth (i.e., arch expansion) and
occasionally directly on the bone (i.e., chin cup and head­
gear), Dr. Angle believed (at least early during his career)
that the clinician could change jaw growth and overcome
the presenting Class II or Class III deformity.
Angle also taught that proper jaw and dental function
on the part of the individual should maintain the teeth in
their orthodontically corrected position. He believed—or at
least hoped—that, after the teeth were placed in proper
occlusion, the natural forces transmitted to the teeth would
cause alveolar bone to generate around them.
Through trial and error, he realized that simply tipping
the teeth into a new position was often inadequate. He
developed the Ribbon Arch appliance and then the Edgewise
appliance to “bodily” move the teeth. These were the first
clearly described and reliably designed orthodontic appli­
ances that were capable of controlling root position. At this
time, Dr. Angle claimed that these were “bone-growing
appliances.”10 For Angle, this work was simply an extension
of Wolff’s law of bone, which states that the internal archi­
tecture of a bone represents the stress pattern that is placed
on it.
Angle’s treatment philosophy involved arch expansion
with the use of vectored rubber bands and other appliances,
as needed, to bring the teeth into occlusion. To Angle, at
least early during his career, the term relapse as it applied
after orthodontic expansion that had been carried out to
uncrowd and correct overjet or overbite simply meant that
the achieved occlusion was inadequate or technically incor­
rect. According to Angle, “If a correct occlusion had been
produced [by the orthodontist] the result would be stable.”10
Therefore, he felt, “if the orthodontic result was not stable,
the fault was either that of the orthodontist or poor compli­
ance by the treated patient, not the theory.”10
For the most part, Angle believed that, for each indi­
vidual, ideal facial aesthetics would result when the teeth
were placed in ideal occlusion. Whether the patient agreed
or not, by divine definition, the best facial appearance for
that patient would be achieved when the dental arches had
been expanded so that all of the teeth were in ideal occlu­
sion. Angle adamantly believed that extractions were not
indicated.
Text continued on p. 592

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• Figure 17-9  A female high-school student was referred by her orthodontist for surgical evaluation. Since her mid childhood years, the patient
was known to have a long face growth pattern, and she had a lifelong history of obstructed nasal breathing. She had undergone attempted growth
modification followed by orthodontic camouflage, without success. At the time of referral, the patient’s concerns included lip incompetence, gummy
smile, weak profile, malocclusion, and nasal obstruction. She agreed to a surgical correction. The orthodontic treatment plan then changed in
preparation for orthognathic surgery. Extractions were not carried out to correct the maxillary and mandibular arch forms. The patient then under­
went maxillary Le Fort I osteotomy (horizontal advancement and vertical intrusion); bilateral sagittal split ramus osteotomies (minimal horizontal
advancement and counterclockwise rotation); osseous genioplasty (vertical reduction and horizontal advancement); and septoplasty, inferior turbi­
nate reduction, and recontouring of the nasal floor. Successful initial surgical healing was achieved. The occlusion maintained at splint removal (i.e.,
5 weeks after surgery) was as planned. The orthodontic appliances were removed 6 months after surgery, with ideal occlusion and orthodontic
retention continued. The patient returned 3 years after surgery with complaints of recurrent anterior open-bite malocclusion. A, Frontal views in
repose before and 3 years after surgery. B, Frontal views with smile before and 3 years after surgery.
Continued

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D
An analysis was carried out that included the review of lateral cephalometric and Panorex radiographs taken before surgery,
5 weeks after surgery, and 3 years after surgery. The patient had no temporomandibular disorder, and there was no evidence of condylar resorp­
tion. Therefore, idiopathic condylar resorption was ruled out. Cephalometric analysis of the presurgical, early postoperative, and late postoperative
cephalometric radiographs revealed satisfactory initial repositioning and healing of the jaws without skeletal relapse at 3 years. A comparison of
the 5-week postoperative and 3-year postoperative sella–nasion–A-point and sella–nasion–B-point angles and facial heights confirmed skeletal
stability. A review of the arch form (i.e., the dental models) suggested orthodontic relapse that included transverse maxillary constriction and incisor
intrusion. The mandibular arch form also indicated dental relapse. Treatment options included redo Le Fort I osteotomy in three segments for the
correction of the arch form versus surgically assisted rapid palatal expansion. Orthodontics would also be required. The advantages of four bicuspid
extractions as part of dental decompensation were also discussed. The patient was pleased with the enhanced facial aesthetics (i.e., a less gummy
smile, an improved profile, and lip closure) and the improved breathing that was achieved. She also did not have any temporomandibular disorder.
She elected to receive no further treatment. C, Oblique facial views before and 3 years after surgery. D, Profile facial views before and 3 years after
surgery.
• Figure 17-9, cont’d

573
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Prior to retreatment
Pre surgery
5 weeks after surgery
3 years after treatement
E
E, Occlusal views before the orthodontic retreatment, immediately before surgery, 5 weeks after surgery, and
3 years after surgery.
• Figure 17-9, cont’d 
Continued

574 SECTION 2  Planning, Surgical Technique, & Complications
F
G
Mandibular counter-
clockwise rotation
Maxillary counter-
clockwise rotation
Pre ortho
5 weeks after surgery
3 years after surgery
H
Pre surgery
5 weeks after surgery
3 years after surgery
F, Articulated dental
casts that indicate analytic model planning.
G, Serial lateral cephalometric views before
orthodontic retreatment, 5 weeks after
surgery, and 3 years after surgery. H, Serial
Panorex views of the left condyle–ramus
before surgery, 5 weeks after surgery, and 3
years after surgery. I, Serial Panorex views of
the right condyle–ramus before surgery, 5
weeks after surgery, and 3 years after.
• Figure 17-9, cont’d 
Pre surgery
I
5 weeks after surgery
3 years after surgery

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B
• Figure 17-10  A 14-year-old girl was referred by her orthodontist for surgical evaluation. She presented with a long face Class II growth pattern
and a lifelong history of obstructed nasal breathing. She underwent non-extraction orthodontics, including mechanics to correct the maxillary arch
form. The patient’s surgery included maxillary Le Fort I osteotomy (vertical intrusion, horizontal advancement, and counterclockwise rotation); sagittal
split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical reduction and horizontal advance­
ment); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. Healing occurred without complications. The occlusion that was
initially achieved and maintained at 5 weeks after surgery was as planned. Unfortunately, the patient refused continued postoperative orthodontics
and the appliances be removed 3 months after surgery. She was also not compliant with retainer use. By 1 year after surgery, there was a recur­
rence of the anterior open bite. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.
Continued

576 SECTION 2  Planning, Surgical Technique, & Complications
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C
D
A review of the dental models confirmed dental relapse with a recurrent accentuated curve of Spee and arch constriction
of the maxilla. In retrospect, segmental orthodontic mechanics followed by segmental maxillary surgery would likely have prevented this problem.
At this time, treatment options include segmental orthodontic mechanics and redo Le Fort I osteotomy in segments. The patient and her family
were pleased with the improvements in lip closure/posture, a diminished gummy smile, improved profile aesthetics, and better breathing during
the day and night. The patient did not have temporomandibular disorder, and she elected to received no further treatment. C, Oblique facial views
before and after treatment. D, Profile views before and after treatment.
• Figure 17-10, cont’d

577
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Prior to treatment
Pre surgery
5 weeks after surgery
1 year after treatment
E
E, Occlusal views in mixed dentition before treatment, with preoperative orthodontics complete, with initial
surgical occlusion achieved (i.e., 5 weeks after surgery), and 1 year after treatment. Note: Discoloration of right maxillary central incisor
crown suggests pulpal pathology.
• Figure 17-10, cont’d 
Continued

578 SECTION 2  Planning, Surgical Technique, & Complications
Mandibular counter-
clockwise rotation
Maxillary counter-
clockwise rotation
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric views before and after
treatment.
• Figure 17-10, cont’d

579
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
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B
• Figure 17-11  A 17-year-old boy was referred by his orthodontist for the surgical evaluation of a long-standing developmental jaw deformity with
malocclusion and a lifelong history of obstructed nasal breathing. The patient had undergone both growth modification and camouflage orthodontics,
without success. Examination confirmed a Class III long face growth pattern with an anterior open bite. He then underwent orthodontic mechanics
in preparation for jaw surgery. The maxillary arch was leveled with orthodontic mechanics. The patient’s surgery included maxillary Le Fort I oste­
otomy (horizontal advancement, vertical shortening, and clockwise rotation); bilateral sagittal split osteotomies of the mandible (minimal set-back
and clockwise rotation); and septoplasty, inferior turbinate reduction, and nasal base recontouring. An osseous genioplasty with horizontal advance­
ment would have further enhanced the patient’s facial aesthetics but was refused. The surgery was followed by finishing orthodontics. The patient’s
occlusion at 5 weeks after surgery was excellent, and it remained so at the time of the debracketing 6 months after surgery. By 1 year after surgery,
a slight Class III tendency with posterior constriction was evident. A, Frontal views in repose before and after surgery. B, Frontal views with smile
before and after surgery.
Continued

580 SECTION 2  Planning, Surgical Technique, & Complications
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C
D
By 2 years after surgery, the anterior occlusion was edge to edge, and the maxillary arch form was irregular. The cause
of the recurrent malocclusion was felt to be either ongoing mandibular growth or a loss of maxillary arch form as a result of dental relapse. A review
of the cephalometric data suggested stability of the mandible (i.e., the sella–nasion–A-point and sella–nasion–B-point angles were unchanged at
intervals after surgery). A review of the dental models confirmed dental relapse with a change in the maxillary arch form (i.e., constriction in the
arch width and an accentuated curve of Spee). Treatment options include maxillary Le Fort I osteotomy in segments for the correction of the arch
form versus surgically assisted rapid palatal expansion. An osseous genioplasty was also offered to improve the patient’s profile aesthetics. The
patient was pleased with the functional improvements (i.e., chewing and speech articulation), and he did not have temporomandibular disorder;
he also appreciated the enhanced facial aesthetics. He elected to receive no further treatment. C, Oblique facial views before and after surgery.
D, Profile views before and after surgery.
• Figure 17-11, cont’d

581
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Pre surgery
1 year after surgery
2 years after treatment
E
Mandibular counter
clockwise rotation
Maxillary clockwise
rotation
F
G
E, Occlusal views immediately
before surgery and at 1 year and 2 years after surgery.
F, Articulated dental casts that indicate analytic model
planning. G, Lateral cephalometric radiographs before and
after surgery.
• Figure 17-11, cont’d

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B
• Figure 17-12  A 20-year-old female college student was referred for surgical evaluation. During the mixed dentition, she was noted to
have a long face growth pattern with an anterior open bite. She was treated from the time that she was 11 to 15 years old with growth-
modification followed by a four-bicuspid orthodontic camouflage approach, without success. She presented for surgical evaluation with
complaints of chronic obstructed nasal breathing; an anterior open bite that caused difficulty with chewing and with speech articulation;
wide lip separation with lip strain at closure; and a retrusive profile appearance. There was generalized root resorption and early anterior
mandibular labial bone loss and gingival recession. A comprehensive evaluation also confirmed septal deviation and inferior turbinate
hypertrophy with increased nasal airway resistance. The patient agreed to an orthodontic and orthognathic/intranasal surgical approach.
Her surgery included maxillary Le Fort I osteotomy in segments (arch form correction, horizontal advancement, vertical shortening, and
counterclockwise rotation); bilateral sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous
genioplasty (horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose
before and after treatment. B, Frontal views with smile before and after treatment.

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D
The occlusion that was initially achieved and maintained at 5 weeks after surgery was as planned. Postoperative
orthodontic appointments were complicated by the patient’s attendance at an out-of-state college. At the time of appliance removal (i.e.,
10 months after the operation), there was partial recurrence of the anterior open bite. The occlusion then remained stable at the 18-month
postoperative interval. There was no popping, clicking, or pain in either temporomandibular joint. There was mild masticatory muscle
discomfort, which was relieved with an effective night guard. An analysis of the postoperative cephalometric radiographs, which were taken
at 1 month and 18 months after surgery, confirmed a stable SNB angle. The condyle-to-gonion measurement also remained stable. A
review of the condyle morphology on the Panorex radiograph revealed no significant change. A review of the dental models (i.e., the surgi­
cal planning models and those from 16 months after surgery) suggested a degree of dental relapse in the form of recurrent curve of Spee
issues in the maxilla and the mandible. The patient elected to undergo no further treatment. C, Oblique facial views before and after treat­
ment. D, Profile views before and after treatment.
• Figure 17-12, cont’d 
Continued

584 SECTION 2  Planning, Surgical Technique, & Complications
Prior to retreatment with 4 bicuspid extractions
1½ years after treatment
Pre surgery
E
Mandibular counter-
clockwise rotation
Maxillary counter-
clockwise rotation
Curve of Spee
F
G
F
E, Occlusal views before retreatment, with orthodontics in progress, and at 16 months after surgery.
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and 16 months after
surgery.
• Figure 17-12, cont’d

585
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
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B
• Figure 17-13  A 25-year-old man presented with a long face anterior open-bite growth pattern. He had undergone four bicuspid extrac­
tions and a surgically assisted rapid palatal expansion procedure to reduce crowding and to expand the maxillary arch width at another
institution. He was referred to this surgeon with residual maxillofacial problems, including jaw discrepancy, residual malocclusion, and chronic
obstructed nasal breathing. The patient agreed to additional orthodontic mechanics and surgery, including Le Fort I osteotomy in two seg­
ments (vertical shortening, horizontal advancement, and arch narrowing); sagittal ramus osteotomies (horizontal advancement and coun­
terclockwise rotation); septoplasty; the reduction of the inferior turbinates; and osseous genioplasty (vertical shortening and horizontal
advancement). He is shown before and after the completion of his final phase of treatment. A, Frontal views in repose before and after
retreatment. B, Frontal views with smile before and after retreatment.
Continued

586 SECTION 2  Planning, Surgical Technique, & Complications
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C
D
C, Oblique facial views before and after retreatment. D, Profile views before and after retreatment.
• Figure 17-13, cont’d

587
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Prior to retreatment with 4 bicuspid extractions
Prior to orthognathic surgery
After SARPE
After treatment
E
E, Occlusal views after earlier orthodontic treatment including four bicuspid extractions, after surgically
assisted rapid palatal expansion (SARPE), just before orthognathic surgery, and after retreatment.
• Figure 17-13, cont’d 
Continued

588 SECTION 2  Planning, Surgical Technique, & Complications
G
Mandibular counter-
clockwise rotation
Arch narrowing
F
Maxillo-mandibular advancement and vertical shortening
H
I
Fenestrations in maxillary walls after SARPE
F, Articulated dental casts that indicate analytic model planning.
G, Lateral cephalometric views before and after retreatment. H, Panorex radiograph before retreat­
ment. I, Intraoperative view of the anterior maxilla after the surgically assisted rapid palatal expan­
sion (SARPE) procedure and just before Le Fort I osteotomy.
• Figure 17-13, cont’d

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A
B
• Figure 17-14  A young man born with a unilateral cleft lip and palate had been treated by other surgeons. His treatments had included
primary cleft lip repair; primary cleft palate repair; two cleft lip revisions; three cleft palate revisions; the placement of a superiorly based
pharyngeal flap; iliac grafting for a cleft defect; cleft rhinoplasty; and suboptimal Le Fort I osteotomy with an external RED distraction
osteogenesis (DO) device. The patient was referred to this surgeon when he was 17 years old with residual cleft deformities, including the
following:
• Nasopharyngeal stenosis with obstructive sleep apnea (apnea–hypopnea index of 11.4 events, with desaturation to 89%)
• Persistent oronasal fistula and alveolar cleft
• Residual cleft jaw deformity with maxillary hypoplasia and Class III malocclusion
• Chronic nasal obstruction as a result of septal deviation and enlarged inferior turbinates
• Residual cleft nasal deformity
• Cleft lip deformity with a lack of continuity of the orbicularis–oris muscle
A, Frontal views before and after reconstruction. B, Frontal views with smile before and after reconstruction.
Continued