Orthognathic Surgery

691
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
• Figure 20-2  A 26-year-old man arrived for surgical evaluation. Since the mixed dentition, he had been recognized
as having a developmental jaw deformity characterized by maxillary deficiency in combination with relative mandibu­
lar excess. Camouflage orthodontic treatment that included four bicuspid extractions was carried out when the
patient was between 12 and 16 years old. A residual Class III negative overjet with an anterior open-bite malocclu­
sion remains. The patient has never been able to breathe well through the nose as a result of septal deviation and
inferior turbinate enlargement. Secondary occlusal trauma resulted in the need for root canal therapy and crowns
in all four posterior quadrants. There is labial bone loss and gingival recession associated with the anterior mandibular
teeth. A comprehensive dental rehabilitative and reconstructive approach will require periodontal evaluation and
treatment followed by orthodontic decompensation and then by jaw and intranasal surgery. A, Frontal facial and
occlusal views before retreatment. B, Profile facial view and lateral cephalometric radiograph before retreatment.
C, Panorex radiograph before retreatment.
©Elsevier Inc.
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692 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
• Figure 20-3  A 30-year-old man arrived for the evaluation of a longstanding jaw deformity with malocclusion, chronic
obstructive nasal breathing, and an awareness of periodontal issues. Since his early childhood years, he was known to
have a jaw deformity with malocclusion, including an anterior open bite. When he was between 8 and 12 years old, he
underwent orthodontic camouflage treatment in an attempt to close the open bite; this included full bracketing and the
use of heavy anterior elastics. By the time that he graduated from high school, he was conscious of a significant recurrent
anterior open bite with dental crowding. Throughout his college years, he was aware of gingival recession on the labial
aspect of many of the anterior teeth of the maxilla more so than the mandible. He was sent by his general dentist for
an orthodontic evaluation and then to this surgeon for an opinion. The patient was referred for periodontal evaluation
with confirmation of significant labial bone loss of the anterior dentition (more so on the maxilla than the mandible) and
gingival recession. A comprehensive approach was recommended; this would include gingival grafting and four bicuspid
extractions, with orthodontic retraction of the anterior dentition into the solid alveolar bone. This would be followed by
jaw reconstruction, finishing orthodontics, and periodontal surveillance. A, Frontal facial and occlusal views before retreat­
ment. B, Profile facial view and lateral cephalometric radiograph before retreatment. C, Panorex radiograph before
retreatment.
B
C
©Elsevier Inc.
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©Elsevier Inc.
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693
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
• Figure 20-4  A 29-year-old man arrived for the evaluation of a longstanding developmental jaw deformity character­
ized by maxillary deficiency with relative mandibular excess. There is malocclusion and chronic obstructive nasal
breathing. By the time he was 13 years old, he was referred by his pediatric dentist to an orthodontist for the evalu­
ation of a Class III negative overjet malocclusion. He then underwent a 2-year course of compensatory orthodontics
in an attempt to neutralize the occlusion. He was left with an Angle Class III negative overjet and early signs of gingival
recession. The patient also has a history of stress-induced asthma and chronic obstructed nasal breathing. He uses
Flonase, Singulair, and other medications in an effort to open the nasal airway, and he is also being seen by an aller­
gist. For his gingival recession, he was referred to a periodontist, and connective tissue grafting was carried out for
the lower anterior dentition on several of the maxillary posterior teeth. An orthodontic consultation confirmed crowding,
the proclination of the maxillary anterior dentition, and uprighted mandibular anterior teeth. Evaluation of the upper
airway documented a deviated septum and hypertrophic inferior turbinates. An orthodontic and surgical approach
was recommended to limit further secondary dental trauma, to stabilize the periodontium, and to correct the occlusion.
A, Frontal facial and occlusal views before retreatment. B, Profile facial and lateral cephalometric radiographs before
retreatment. C, Panorex radiograph before re-treatment.
B
C
©Elsevier Inc.
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A

694 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
management.8,14,16,22,71,88,95,114 If the curve of Spee is exces­
sive as a result of vertical skeletal dysplasia, then leveling is
also done in segments in preparation for surgical correction
(see Chapter 17).
In the presence of maxillary deficiency, limited space to
uncrowd the upper teeth may leave the roots tipped outside
of the solid alveolar housing. In this circumstance, maxillary
first bicuspid extractions with space closure before surgery
is preferred. With only borderline crowding, extractions are
often not carried out. Limited dental space deficiency can
often be managed through the judicious use of interproxi­
mal reduction. In addition, the aesthetic consequences of
mildly proclined incisors (i.e., A-point to B-point discrep­
ancy in profile) can be improved via the clockwise rotation
of the maxillomandibular complex at the time of surgery
(see Chapters 12 and 13).
Immediate Presurgical Planning
The immediate presurgical planning takes into account
collaborative clinical efforts between the orthodontist,
the surgeon, the patient, and the patient’s family that
will have been ongoing since the initial consultation
visits.32,74,75,84,93,98 Depending on the condition of the
dentition and the supporting structures, the restorative
dentist and the periodontist may also have been intricately
involved.
Patient-specific medical and dental records are reviewed,
including radiographs (e.g., computed tomography scans;
panoramic, lateral, and posteroanterior cephalometric and
periapical radiographs); photographs (e.g., facial, occlusal);
and dental models.
Immediate presurgical records (i.e., within 2 to 6 weeks
of surgery) will most importantly include facial measure­
ments taken during direct visual examination; alginate
impressions of the maxilla and the mandible; a centric rela­
tion bite registration; and a face-bow registration.
First, broad-stroke clinical decisions are made involving
the preferred vector changes for each jaw; only then are the
precise millimeter distances and angular changes required
for each jaw to achieve the desired results determined (see
Chapter 12). Analytic model planning is carried out on the
articulated dental casts with use of the Erickson Model
Table. Splints are constructed to assist with the achievement
of the precise occlusion and the preferred facial aesthetics
in the operating room (see Chapter 13).
During surgical planning, consideration should be given
to the following eight aspects (see Chapter 12):
1. Assess the degree of horizontal advancement required in
the midface as measured at the maxillary incisal edge.
A nose that appears to be excessively large in a
patient with a skeletal Class III condition favors the
horizontal advancement of the maxilla. Repositioning
and projecting the upper jaw forward will diminish
the apparent size of the nose. An obtuse nasolabial
angle with a hypotonic upper lip also favors maxillary
• Assess the current level of oral hygiene and the need for
a home care program.
• Assess for the effects of occlusal trauma and malocclusion
on the periodontium.
• Assess the level of attached gingiva and the need for
augmentation.
• Confirm the adequacy of the alveolar bone and the need
to create space with the use of extractions.
• Assess the need for restorations to remove decay, to
replace deficient enamel, and to achieve a healthy gingi­
val interface.
Orthodontic Preparation for Orthognathic
Surgery
1. Before orthodontic decompensation, assess the level
of attached gingiva, the position of the labial and
lingual plates, and the alveolar crest heights. Consider
the effects of any planned orthodontic maneuvers on the
periodontium.
2. Make decisions about the tooth (root) size to alveolar
volume discrepancies in each arch and the need for
extractions to establish and preserve periodontal health.
3. Create a plan (i.e., separate surgical and orthodontic
objectives) to achieve preferred anteroposterior and ver­
tical incisor positions in the maxilla and the mandible.
4. Understand how the orthodontic objectives become
more limited when they are combined with the planned
surgical procedures (e.g., maxillary segmentation, bimax­
illary osteotomies) to then achieve the final desired arch
form, midline positioning, occlusion, and facial sym­
metry and proportions.
5. Make decisions about orthodontic mechanics and
anchorage requirements to achieve the chosen
objectives.
6. At the end of the presurgical orthodontic phase (i.e., 4
to 6 weeks before surgery), full-dimensional stabilizing
(i.e., passive) arch wires should be in place. The place­
ment of surgical hooks can be done just before surgery.
Leveling the Mandibular Arch
When an accentuated curve of Spee is present in the lower
arch of a patient with Class III malocclusion, it is managed
through a combination of intrusion of the incisors and
extrusion of the premolars or molars.20,49 In preparation for
surgery, repositioning the lower incisors forward is generally
advantageous for the Class III skeletal pattern. Therefore,
lower arch extractions are rarely indicated. If limited labial
bone is present, a periodontal evaluation is recommended
before the incisors are orthodontically moved forward. If
gingival recession has occurred or if the gingiva is genetically
inadequate, augmentation grafting procedures are indicated
(see Chapter 6).
Leveling of the Maxillary Arch
If the upper arch is narrow, then orthodontic leveling
is performed in segments in anticipation of surgical

695
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Basic Surgical Approach
Regardless of the cause of the Class III skeletal pattern, the
common aesthetic impression in profile is of a flat or
concave midface with a long and forward-projecting chin.89
The classic dentofacial deformity of maxillary deficiency
with relative mandibular excess will require at a minimum
a Le Fort I osteotomy with horizontal advance­
ment.30,31,38,62,85,86,112 The need for additional vector changes
in the maxilla should always be considered (e.g., transverse
widening, vertical adjustment, maxillary midline to facial
midline correction, cant correction, clockwise maxillary
plane rotation).121
The Le Fort I osteotomy (often performed in segments)
with three-dimensional repositioning is generally com­
bined with sagittal split ramus osteotomies to place the
distal mandible into ideal occlusion at the new maxillary
location.9-12,50-52,63-66,70,87,94,110,113 In most cases, the full
overjet deficiency is corrected in the maxilla. Clockwise
rotation of the maxilla and the mandible will generally leave
the mandibular incisor unchanged in the sagittal (i.e., hori­
zontal) plane. However, the pogonion will have moved
posteriorly.
An osteotomy of the chin with horizontal or vertical
change is also frequently desirable.36 If chronic nasal obstruc­
tion is present, then procedures to improve the airway in
accordance with the physical examination (i.e., septoplasty,
inferior turbinate reduction) may be simultaneously accom­
plished (Figs. 20-5 through Fig. 20-20).73,75
In general, well thought out maxillary surgical maneu­
vers (i.e., horizontal advancement, clockwise rotation) will
also correct the presenting negative vector relationship
between the ocular globe and the lower eyelid. In doing so,
the overlying cheek and periorbital soft tissues are immedi­
ately enhanced. This also limits the unattractive eyelid and
midface aging effects that would otherwise occur (i.e., soft-
tissue descent, rounding of the palpebral fissure, lengthen­
ing of the lower lid, loss of cheek region soft-tissue
prominence; see Chapter 25).
When limiting the surgery to one jaw (either through
mandibular set-back or Le Fort I advancement), the imme­
diate correction of the occlusion may be possible, but a
suboptimal outcome is likely. A one-jaw approach is rarely
preferred from the overall perspective of facial aesthetics,
occlusal stability, and upper airway management. A Le Fort
I osteotomy in combination with mandibular ramus oste­
otomies that incorporates clockwise rotation of the maxil­
lomandibular complex is generally needed to achieve
midface fullness, to improve the projection of the nasal tip
and, to enhance the upper lip to tooth aesthetics (see Figs.
20-5 through 20-20).
Demetriades and colleagues confirmed the clinical
importance of considering the airway when formulating a
treatment plan for the correction of a skeletal Class III
pattern.26 They reported on 26 patients who presented
with developmental dentofacial deformities that were
horizontal advancement; doing so will improve the
nasolabial angle and provide fullness to the upper lip.
A constricted nasal aperture and a depressed base of
the nose also benefit from maxillary advancement. A
fully projected midface fills out the pyriform rims and
provides needed width to the alar base. For these same
reasons, the individual who appears to have flat upper
cheeks with pulled-down lower eyelids (i.e., scleral
show) benefits from Le Fort I osteotomy with
advancement and clockwise rotation.
2. Assess the degree of vertical change required in the
midface as measured at the maxillary incisal edge.
Individuals with maxillary deficiency and relative
mandibular excess generally present with varying
degrees of either vertical midface excess or deficiency.
A decision regarding the preferred aesthetic vertical
position of the maxillary incisors should be made.
Anterior vertical lengthening and clockwise rotation
are frequent preferred vector changes used to achieve
enhanced midface aesthetics in the patient with a
Class III growth pattern.
3. Assess the potential advantages of clockwise rotation of
the maxillary plane to achieve preferred A-point to
B-point positioning (i.e., pitch orientation).
Clockwise rotation of the maxillomandibular
complex is generally required to enhance a positive
vector relationship between the ocular globe and the
lower eyelid.
4. Clarify any maxillary midline to facial midline
discrepancies and their planned correction (i.e. yaw
orientation).
When doing so, consideration is given to the max­
illary yaw orientation and the anticipated yaw effects
on facial symmetry.
5. Identify any canting (i.e., roll orientation) of the maxilla
and its planned correction.
If more than 4 degrees of cant are present, this will
be noticeable to even the untrained eye at conversa­
tional distance (see Chapter 12).
6. Identify the advantages of segmentation of the upper
jaw to achieve the preferred maxillary arch form and
occlusion.
Determine the preferred location of the interden­
tal osteotomies to best achieve the patient’s objectives.
This will have been discussed with the treating ortho­
dontist before the initiation of treatment.
7. Assess the baseline chin morphology.
Anticipate the location of the pogonion after jaw
repositioning. Consider the advantages of osseous
genioplasty and the preferred ultimate horizontal and
vertical position of chin.
8. Assess the baseline pyriform rim, floor of nose, and ante­
rior nasal spine morphology.
Anticipate the location of these structures
after maxillary repositioning and the advantages
of recontouring them to achieve the ultimate
objectives.
Text continued on p. 753

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-5  A 17-year-old high school student was referred by his orthodontist for surgical evaluation. A non-extraction orthodontic approach
had previously been carried out, without success. The Class III negative overjet anterior open-bite malocclusion required redo orthodontics and
jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings (i.e. septal deviation and inferior turbinate
hypertrophy), intranasal procedures were also planned. When orthodontic decompensation was complete, the patient’s surgery included maxillary
Le Fort I osteotomy in segments (arch expansion, horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus oste­
otomies (limited corrections); osseous genioplasty (vertical reduction and minimal horizontal advancement); and septoplasty and inferior turbinate
reduction. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.

697
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-5, cont’d 
Continued

698 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Prior to retreatment
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and then after the completion of
treatment.
• Figure 20-5, cont’d

699
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
F
G
Mandibular
straightening
Maxillary advancement
and clockwise rotation
Arch expansion
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 20-5, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-6  A 17-year-old high school student was referred by his orthodontist for surgical evaluation. The patient’s Class III negative overjet
anterior open-bite malocclusion required redo orthodontics, including maxillary bicuspid extractions and jaw surgery. Because the patient had a
lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also required. When orthodontic decompensation
was complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch expansion, clockwise rotation, horizontal advance­
ment, and vertical lengthening); sagittal split ramus osteotomies (limited corrections); osseous genioplasty (vertical reduction and minimal horizontal
advancement); and septoplasty and inferior turbinate reduction. A, Frontal views in repose before and after treatment. B, Frontal views with smile
before and after treatment.

701
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-6, cont’d 
Continued

702 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Prior to retreatment after maxillary biscupid extraction
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and then after the completion of treat­
ment. The patient required gingival grafting on the labial aspect of the right maxillary canine.
• Figure 20-6, cont’d

703
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
F
G
Mandibular adjustment
Clockwise advancement
and rotation
Correction of arch form
F
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric
radiographs before and after treatment.
• Figure 20-6, cont’d

704 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-7  A 16-year-old high school student was referred by his orthodontist for surgical evaluation. He had previously undergone orthodontics,
including four bicuspid extractions. The residual Class III negative overjet malocclusion required further orthodontics in combination with jaw recon­
struction. Because the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also required.
When the orthodontic decompensation was complete, the patient’s surgery included maxillary Le Fort I osteotomy (horizontal advancement); sagittal
split ramus osteotomies (horizontal advancement); osseous genioplasty (vertical reduction and horizontal advancement); and septoplasty and inferior
turbinate reduction. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.

705
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-7, cont’d 
Continued

706 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
E
Pre surgery after four bicuspid extractions
After treatment
E, Occlusal views with redo orthodontics in progress and after the completion of treatment. F, Articulated
dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment. Note the gingival
recession on the labial aspect of the mandibular canines as a result of the orthodontic mechanics.
• Figure 20-7, cont’d

707
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-8  A 20-year-old college student was referred by his orthodontist for surgical evaluation. His Class III negative overjet anterior open-
bite malocclusion required jaw surgery. Orthodontic decompensation was carried out without maxillary extractions, which left the incisors moderately
procumbent. The patient’s surgery included maxillary Le Fort I osteotomy in segments (arch expansion, horizontal advancement, vertical lengthen­
ing, and clockwise rotation) and sagittal split ramus osteotomies (clockwise rotation). Note the aesthetic advantage of the maxillomandibular
clockwise rotation as part of the correction. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment.
Continued

708 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-8, cont’d

709
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
E
Prior to treatment
Pre surgery
After treatment
E, Occlusal views before treatment, with orthodontics in progress, and then after the completion of
treatment.
• Figure 20-8, cont’d 
Continued

710 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary advancement
and clockwise rotation
Mandibular clockwise rotation
Arch expansion
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and
after treatment.
• Figure 20-8, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-9  A 22-year-old man was referred by his orthodontist for surgical evaluation. A non-extraction orthodontic approach had previously
been carried out, without success. The patient’s Class III negative overjet anterior open-bite malocclusion required redo orthodontics and jaw
surgery. Because he had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also needed. When
preoperative orthodontics were complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch expansion, horizontal
advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (limited corrections); osseous genioplasty (minimal
horizontal advancement); and septoplasty and inferior turbinate reduction. Note the aesthetic advantage of the maxillary clockwise rotation in the
presence of baseline incisor procumbancy. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment.
Continued

712 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-9, cont’d

713
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Arch expansion
Mandibular
straightening
Maxillary advancement
and clockwise rotation
F
G
Pre surgery
After treatment
E
E, Occlusal views with orthodontics in progress and after the completion of treatment. F, Articu­
lated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 20-9, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-10  A 17-year-old high school student was referred by his orthodontist, who requested surgical evaluation for a Le Fort III advance­
ment. The Class III negative overjet malocclusion with maxillary deficiency gave the impression of flat cheekbones and infraorbital rims. Evaluation
confirmed that the patient’s deformity was limited to the maxilla and the mandible. Because the patient had a lifelong history of nasal obstruction
and consistent physical findings, intranasal procedures were also required. When preparatory orthodontics were complete, the patient’s surgery
included maxillary Le Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (set-
back and clockwise rotation); osseous genioplasty (vertical reduction); and septoplasty and inferior turbinate reduction. Note the aesthetic advantage
of the maxillomandibular clockwise rotation in the presence of baseline incisor procumbancy. This rotation projects the pyriform rims forward and
sets back the pogonion. The orthodontic over-retraction of the lower incisors resulted in labial bone loss and gingival recession. A, Frontal views
in repose before and after treatment. B, Frontal views with smile before and after treatment.

715
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
C
D
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-10, cont’d

716 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Mandibular clockwise
rotation
Maxillary advancement
and clockwise rotation
G
E
©Elsevier Inc.
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gn
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gn
gn
gn
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gn
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gn
gn
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gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rgery
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
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os
os
os
os
os
os
os
os
os
os
os
os
os
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©Elsevier Inc.
Or
Or
Orththogn
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 atatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rgery
ry
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
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os
os
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F
E, Worm’s-eye views before and after reconstruction. F, Occlusal views with ortho­
dontics in progress and after the completion of treatment. Note the mild gingival recession on the labial
aspect of the mandibular anterior teeth as a result of orthodontic mechanics. G, Articulated dental casts that
indicate analytic model planning.
• Figure 20-10, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-11  A 25-year-old man was referred for surgical evaluation. A non-extraction orthodontic camouflage approach had previously been
carried out, without success. He previously underwent a cosmetic rhinoplasty in an attempt to reduce the size of the nose. The Class III negative
overjet malocclusion required redo orthodontics and jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent
physical findings, intranasal procedures were also required. When the presurgical orthodontics were complete, the patient’s surgery included maxil­
lary Le Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (clockwise rotation);
osseous genioplasty (vertical reduction and minimal horizontal advancement); and septoplasty and inferior turbinate reduction. Note the aesthetic
advantage of the maxillomandibular clockwise rotation in the presence of baseline incisor procumbancy. A, Frontal views in repose before and after
treatment. B, Frontal views with smile before and after treatment.
Continued

718 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-11, cont’d

719
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of treatment.
Note the gingival recession on the labial aspect of the mandibular and maxillary anterior dentition as a result of the dental roots being
crowded into limited available alveolar bone.
• Figure 20-11, cont’d 
Continued

720 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary advancement
and clockwise rotation
Mandibular
adjustment
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 20-11, cont’d

721
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-12  An 18-year-old high school student was referred by his orthodontist for surgical evaluation. A non-extraction orthodontic approach
had previously been carried out, without success. The Class III negative overjet anterior open-bite malocclusion required redo orthodontics and
jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also benefi­
cial. When orthodontic decompensation was complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch expansion,
correction of curve of Spee, horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (counterclockwise
rotation); osseous genioplasty (vertical reduction and horizontal advancement); and septoplasty and inferior turbinate reduction. Note the aesthetic
advantage of the maxillary clockwise rotation and the mandibular counterclockwise rotation. A, Frontal views in repose before and after treatment.
B, Frontal views with smile before and after treatment.
Continued

722 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-12, cont’d

723
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of
treatment.
• Figure 20-12, cont’d 
Continued

724 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Arch adjustment
Counterclockwise rotation
of mandible
Clockwise advancement and
rotation of maxilla
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before
and after treatment.
• Figure 20-12, cont’d

725
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-13  A 20-year-old college student was referred for surgical evaluation. The Class III negative overjet deep-bite malocclusion required
orthodontics and jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures
were also beneficial. Orthodontics was carried out without extraction. A degree of maxillary incisor procumbency remained. The patient’s surgery
included maxillary Le Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies
(clockwise rotation); osseous genioplasty (vertical reduction and minimal horizontal advancement); and septoplasty and inferior turbinate reduction.
Note the aesthetic advantage of the maxillomandibular clockwise rotation in the presence of baseline incisor procumbancy. A, Frontal views in
repose before and after treatment. B, Frontal views with smile before and after treatment.
Continued

726 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-13, cont’d

727
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Prior to treatment
After treatment
E
Mandibular clockwise
rotation
Mandibular
adjustment
Maxillary advancement
and clockwise rotation
F
G
E, Occlusal views before retreatment and after the completion of treatment. F, Articulated dental
casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment.
• Figure 20-13, cont’d

728 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-14  A 19-year-old college freshman was referred for evaluation. He had a maxillary deficiency with a relative mandibular excess growth
pattern and a Class III negative overjet anterior open-bite malocclusion. During the mixed dentition, the patient was treated with growth-modification
techniques and rapid palatal expansion. When he was 18 years old, orthodontic mechanics were reinitiated; in preparation for jaw reconstruction.
The maxillary and mandibular second molars were poorly developed and required removal. The patient had a lifelong history of nasal obstruction;
physical examination confirmed a deviated septum, enlarged inferior turbinates, and a constricted nasal aperture. When orthodontic decompensa­
tion was complete, the patient’s surgery included maxillary Le Fort I osteotomy (+12 mm horizontal advancement, +2 mm vertical lengthening,
2.5 mm midline correction) and interpositional iliac bone graft; sagittal split ramus osteotomies (horizontal advancement and counterclockwise
rotation); osseous genioplasty (vertical shortening); and septoplasty, inferior turbinate reduction, and pyriform rim recontouring. A, Frontal views in
repose before and after treatment. B, Frontal views with smile before and after treatment.

729
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-14, cont’d 
Continued

730 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Pre surgery
After treatment
E
Mandibular advancement and
counterclockwise rotation
Maxillary advancement and
vertical shortening
F
G
E, Occlusal views with orthodontics in progress and then 4 years after the completion of treatment. F, Articulated dental
casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment.
• Figure 20-14, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-15  A 27-year-old woman was referred by her orthodontist for surgical evaluation. A non-extraction orthodontic approach had been
carried out during her high school years, without success. Her Class III negative overjet anterior open-bite malocclusion required redo orthodontics
and jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also
beneficial. After the orthodontic decompensation was complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch
expansion, horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (counterclockwise rotation);
osseous genioplasty (vertical reduction); and septoplasty and inferior turbinate reduction. Note the aesthetic advantage of the mandibular counter­
clockwise rotation. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.
Continued

732 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-15, cont’d

733
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of
treatment.
• Figure 20-15, cont’d 
Continued

734 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary advancement
and clockwise rotation
Mandibular counter-
clockwise rotation
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 20-15, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
A
B
• Figure 20-16  A 16-year-old high school student was referred by her orthodontist for surgical evaluation. A non-extraction orthodontic approach
had previously been carried out, without success. The Class III negative overjet anterior open-bite malocclusion required redo orthodontics and
jaw surgery. Because the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also benefi­
cial. Presurgical orthodontics were carried out without extractions, and the maxillary anterior procumbancy remained. The patient’s surgery included
maxillary Le Fort I osteotomy in segments (arch expansion, horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus
osteotomies (minimal clockwise rotation); osseous genioplasty (vertical reduction and minimal horizontal advancement); and septoplasty and inferior
turbinate reduction. Note the aesthetic advantage of the maxillary plane clockwise rotation in the presence of baseline incisor procumbency.
A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.
Continued

736 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 20-16, cont’d

737
CHAPTER 20  Maxillary Deficiency with Relative Mandibular Excess Growth Patterns
E
Prior to retreatment
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of
treatment.
• Figure 20-16, cont’d 
Continued

738 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary advancement
and clockwise rotation
Arch expansion
Mandibular
clockwise rotation
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after treatment.
• Figure 20-16, cont’d

Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
Orthognathic Surgery; J.C. Posnick
B
A
• Figure 20-17  A 15-year-old high school student was referred by her orthodontist for surgical evaluation. A non-extraction orthodontic approach
had previously been carried out, without success. The Class III negative overjet malocclusion required redo orthodontics and jaw surgery. Because
the patient had a lifelong history of nasal obstruction and consistent physical findings, intranasal procedures were also beneficial. Presurgical
orthodontics were carried out without extractions, and the maxillary incisor procumbency remained. The patient’s surgery included maxillary Le
Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (clockwise rotation); osseous
genioplasty (vertical reduction and minimal horizontal advancement); and septoplasty and inferior turbinate reduction. Note the aesthetic advantage
of the maxillomandibular clockwise rotation in the presence of baseline incisor procumbency. A, Frontal views in repose before and after treatment.
B, Frontal views with smile before and after treatment.
Continued