Orthognathic Surgery

791
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
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
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-8, cont’d 
Continued

792 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to treatment
After treatment
Pre surgery with four bicuspid extractions
E
E, Occlusal views before treatment, with orthodontic decompensation including four bicuspid extractions in
progress, and after the completion of treatment.
• Figure 21-8, cont’d

793
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and
after surgery.
• Figure 21-8, cont’d

794 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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 21-9  A young woman arrived for surgical evaluation. Her history and physical examination confirmed lifelong nasal obstruction, lip incom­
petence, difficulty chewing, and frequent speech articulation errors. The facial aesthetic concerns included an awareness of a weak chin, a gummy
smile, lip strain, and the impression of having a larger nose. The patient had experienced secondary occlusal trauma with a need for root canal
therapy and crowns on multiple posterior teeth. Further investigations were carried out by a speech pathologist and an otolaryngologist, and a
fresh look was taken at the patient’s requirements for the achievement of a satisfactory occlusion. Orthodontic decompensation including four
bicuspid extractions in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures carried out included Le
Fort I osteotomy (horizontal advancement, vertical shortening, and counterclockwise rotation); sagittal split ramus osteotomies (horizontal advance­
ment and counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); and septoplasty, inferior turbinate
reduction, and nasal floor recontouring. A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after
reconstruction.

795
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
Continued
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
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-9, cont’d

796 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to treatment
After treatment
Orthodontics in progress with 4 bicuspid extractions
E
E, Occlusal views before retreatment, with orthodontics in progress including four bicuspid extractions in
progress, and after the completion of treatment.
• Figure 21-9, cont’d

797
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
F
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
surgery.
• Figure 21-9, cont’d

798 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
A
B
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
• Figure 21-10  A 17-year-old boy arrived with his parents for surgical evaluation. His history and physical examination confirmed lifelong nasal
obstruction, heavy snoring, difficulty chewing, and frequent speech articulation errors. The facial aesthetic concerns include an awareness of a
gummy smile, lip strain, and a weak profile. Earlier during his life, he had undergone orthodontics that included rapid palatal expansion and full
bracketing, without success. An anterior open bite and constricted arch-width malocclusion remained. Further evaluations were carried out by a
speech pathologist and an otolaryngologist, and a fresh look was taken at the patient’s orthodontic needs. Orthodontic decompensation in com­
bination with orthognathic and intranasal surgery was chosen. The simultaneous procedures carried out included Le Fort I osteotomy in segments
(horizontal advancement, vertical shortening, counterclockwise rotation, arch expansion, and the correction of the curve of Spee); sagittal split
ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement);
and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and after reconstruction. B, Frontal
views with smile before and after reconstruction.

799
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
C
D
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, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 21-10, cont’d 
Continued

800 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
After treatment
Pre surgery
E
F
Mandibular counter-
clockwise rotation
Arch expansion
G
E, Occlusal views with orthodontic decompensation in progress and after the completion of treatment.
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after surgery.
• Figure 21-10, cont’d

801
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
rims, and the anterior nasal spine region with a bur on a
rotary drill is also an important surgical maneuver to achieve
preferred upper lip and nasal aesthetics as well as to ensure
maximum improvements in upper airway function (see
Chapters 10 and 15).
These maxillary surgical maneuvers will also improve the
negative vector ocular globe to lower eyelid relationship that
was present preoperatively (see Chapter 25). In the teenager
and young adult, this will stabilize the midface and perior­
bital soft tissues and limit the negative effects that would
otherwise likely occur with age (e.g., soft-tissue descent,
rounding of the palpebral fissure, lengthening of the lower
lid, loss of cheek region soft-tissue prominence).
Surgical Planning Pitfalls
The Need for Two-Jaw Surgery
It is better to accept the need for bimaxillary and chin
osteotomies in combination with intranasal procedures to
obtain a favorable result rather than to compromise facial
aesthetics and airway improvements in an attempt to keep
the surgery within one jaw. For the patient with a long face,
bimaxillary surgery is almost always beneficial to achieve
the desired midface (maxillary) projection; to achieve the
desired lower face (mandibular) projection; and to achieve
the preferred profile line (i.e., via the control of A-point to
B-point positioning through the use of counterclockwise
rotation).
Maxillomandibular Counterclockwise
Rotation
The achievement of a preferred A-point to B-point relation­
ship (i.e., pitch orientation) when the patient is in the
natural head position is essential for enhanced facial aesthet­
ics. For a patient with a long face growth pattern, counter­
clockwise rotation of the mandibular plane is typically
carried out. The maxillary plane may also require counter­
clockwise rotation with intrusion of the anterior maxilla
(thus lessening the gummy smile) in combination with
either neutral or, to a lesser extent, intrusion of the posterior
maxilla. The achievement of an actual numerical plane
angle is not in itself an objective. The maxillomandibular
complex is counterclockwise rotated as needed to achieve
the preferred profile aesthetics. Although it has been much
discussed, the use of sagittal split ramus osteotomies of the
mandible prevents the lengthening of the posterior facial
height during these maneuvers. The proximal segment of
the mandible (i.e., the condyle and ramus section) remains
essentially neutral, regardless of clockwise or counterclock­
wise rotation of the distal aspect of the lower jaw.
Managing Incisor Inclination
When the maxillomandibular complex is counterclockwise
rotated to improve the pitch orientation, effects on both
the base of the nose and the relative maxillary incisor
relationship and pogonion projection when viewing the
patient’s profile in the natural head position. The immediate
pre­surgical models will confirm details of the planned seg­
mentation of the maxilla and the need for any occlusal
equilibration to achieve the preferred occlusion in the oper­
ating room.
Linear (millimeter) and angular (degree) decisions
regarding the preferred repositioning of the maxilla specifi­
cally incorporate the following:
• The desired vertical positioning of the maxillary
incisor crown
• The desired horizontal positioning of the maxillary
incisor crown
• The need to reposition the maxillary dental midline
to match the facial midline (i.e., yaw orientation)
• The need to alter or correct any maxillary cant (i.e.,
roll orientation)
• The need to vertically adjust the posterior maxillary
height to establish a preferred A-point to B-point
relationship of the jaws (i.e., pitch orientation); coun­
terclockwise rotation of the maxillary plane is a fre­
quent maneuver
• The need to or benefit of segmenting the maxilla to
alter the arch width or the curve of Spee
Immediate presurgical planning will confirm the antici­
pated functional and aesthetic advantages of sagittal split
ramus osteotomies to reposition the mandible into oc­
clusion with the new maxillary position versus accepting
the limitations of mandibular autorotation (i.e., one-jaw
surgery). The baseline anterior projection of the maxilla in
a patient with a long face is generally deficient and requires
horizontal advancement at the level of the maxillary inci­
sors. Horizontal advancement in combination with vertical
intrusion and pyriform rim recontouring will limit the
undesirable widening of the nose that would otherwise
occur with a “straight-up” intrusion of the maxilla and
autorotation of the mandible. Simultaneous sagittal split
ramus osteotomies of the mandible (i.e., two-jaw surgery) are
required to achieve these objectives in almost all cases.118-121 It
is also likely that an oblique osteotomy of the chin with
vertical shortening and limited horizontal advancement will
be advantageous.
The clinician should confirm or refute a lifelong history
of chronic obstructive nasal breathing in the patient (see
Chapter 10). During the physical examination, intranasal
findings that are consistent with increased nasal airway resis­
tance are likely to include septal deviations and inferior
turbinate hypertrophy. If the history and physical findings
warrant, then septoplasty and inferior turbinate reduction
should be carried out to improve nasal breathing. The
baseline presence of excess vertical height in the anterior
maxilla (i.e., a high nasal floor) with lip incompetence
and a constricted nasal width (i.e., a tight nasal aperture) is
also typical and will benefit from midface intrusion, arch
expansion through segmental osteotomies, and horizontal
advancement. Recontouring of the nasal floor, the pyriform

802 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
by preoperatively banding the first molars with lingual
attachments. The transpalatal appliance can be constructed
in advance from the maxillary cast of the model planning.
It is often tempting for the orthodontist to rapidly finish
treatment and remove the brackets, but this is almost always
a mistake. The dentoalveolar segments are generally not
fully stable for approximately 6 months. If the maxillary
posterior segments relapse after surgery, not only will there
be a return of posterior crossbites, but the occlusion also
tends to open anteriorly (see Chapter 16).
Complications, Informed Consent,
and Patient Education
The orthodontist and the surgeon are asked to evaluate the
individual with a long face and then to attempt to alter
nature’s events. With a sound understanding of the natural
progression of the uncorrected dentofacial deformity and
with knowledge of how specific interventions will affect
function and facial aesthetics, predictable results are gener­
ally expected. The potential risks as compared with the
anticipated benefits of each procedure and the review of
alternative approaches to manage each problem are taken
into account, because complications (i.e., unfavorable out­
comes) will always occur in a small percentage of patients.
The patient’s willingness to make an informed decision and
then to accept responsibility for that choice is an integral
aspect of the patient–doctor interaction (see Chapter 17).115
Malocclusion after Orthodontics and
Orthognathic Surgery
There are inherent biologic challenges to the orthodontic
movement of the teeth within the alveolar process and the
surgical repositioning of the jaws and jaw segments in the
individual with a long face.* This includes the technical
aspects of the repositioning; the initial healing require­
ments; and the difficulties associated with the long-term
maintenance of the mechanically relocated teeth, jaws, and
jaw segments. When following sound aesthetic and biome­
chanical principles, clinicians are able to carry out ortho­
dontic treatment and surgical procedures in the individual
with a long face to safely and reliably achieve the desired
results in most cases. Potential intraoperative technical dif­
ficulties associated with sagittal split ramus osteotomies of
the mandible and the maxillary Le Fort I osteotomy that
can result in an immediate (early) malocclusion are prevent­
able in most cases (see Chapter 17). Timing the surgical
procedures to limit the risk of ongoing jaw growth after
surgery is generally possible. The orthodontic removal of
dental compensations with the use of bicuspid extractions
as needed to place the teeth solidly in the alveolar housing
inclination above and the pogonion and the relative man­
dibular incisor inclination below are to be expected. The
extent of baseline deformities and the need for pitch orien­
tation correction will influence the extent of recontouring
required at the pyriform rims above and chin repositioning
below to enhance facial aesthetics.
Treating the Gummy Smile
When considering the enhancement of the relationship of
the upper lip to the maxillary upper incisors, it is important
to avoid the planning pitfall of treating the gummy smile
as an isolated feature. The clinician should make decisions
about the degree of excessive anterior maxillary height and
the extent of planned intrusion primarily on the basis of the
anticipated upper lip position in repose and not on its posi­
tion during a smile (see Fig. 21-8). In the patient with a
long face, surgical alteration of the upper lip to tooth rela­
tionship will occur for a variety of reasons, including vertical
maxillary intrusion; horizontal maxillary advancement; arch
expansion; closure of the open bite; shortening of the chin;
recontouring the pyriform rims; and recontouring and low­
ering of the nasal floor. The dynamic lip function and the
static lip position after healing cannot be entirely predicted
from the combination of skeletal changes that are generally
carried out. No accurate quantitative mathematic formula
for predicting the postoperative hard tissue to soft tissue
changes with this condition is currently available. Keep in
mind that as much as 4 mm of incisor crown exposure at
rest is fine; a few millimeters of lip incompetence is accept­
able, and it is better to show more teeth than less.
Postsurgical Orthodontic Maintenance
and Maintenance
In general, the maintenance of the new arch form is the
most challenging aspect of the postsurgical orthodontic
phase of treatment. With segmentation of the maxilla, a
rigid acrylic occlusal splint is prefabricated and secured to
the maxillary dentition in the operating room (see Chapter
13). The splint remains in place during the initial bone-
healing phase, (approximately 5 weeks). Intermittent inter­
maxillary elastics are used during this time to retrain the
masticatory muscles, to provide motion in the temporo­
mandibular joints, to increase patient comfort, and to
confirm the stability of the occlusion. When the splint is
removed, the patient should immediately (ideally within 24
hours) return to the orthodontist for the placement of a
continuous maxillary arch wire. The surgically expanded
arch width and the corrected curve of Spee must be actively
orthodontically maintained throughout occlusal finishing
(see Chapter 17). In accordance with the orthodontist’s
clinical judgment, this is accomplished via some combina­
tion of a rigid labial wire, a transpalatal appliance, and a
palatal acrylic plate. The placement of a transpalatal appli­
ance at the time of splint removal is facilitated
*References 8, 35, 42, 45, 49, 50, 81, 90, 91, 104, 106, 113, 126, 131,
136, 137

803
CHAPTER 21  Long Face Growth Patterns: Maxillary Vertical Excess with Mandibular Deformity
masticatory muscles. The presence of an anterior open-bite
malocclusion is often claimed to be a factor in temporo­
mandibular disorder. The successful correction of the Long
Face dentofacial deformity through orthodontics and
orthognathic surgery has been documented to improve the
pretreatment symptoms of many individuals, but it may
accentuate symptoms in others (see Chapter 9).3,103
Conclusions
The long face growth pattern represents a frequent presenta­
tion of dentofacial deformity for which many individuals
request treatment. The opportunities for the treating clini­
cians to effectively improve the presenting head and neck
dysfunctions (e.g., mastication, speech articulation, swal­
lowing, breathing, lip closure/posture) and also to achieve
enhanced facial aesthetics are significant. A coordinated
approach and a well-informed patient and family generally
result in orthodontic and surgical treatment being a life-
changing event.
will best ensure stable long-term occlusion and periodontal
health (see Chapter 17).
Temporomandibular Disorders:
Effects of Orthodontics and
Orthognathic Surgery
It is estimated that an average of 32% of the population
reports at least one symptom of temporomandibular disor­
der, whereas an average of 55% demonstrate at least one
clinical sign. Temporomandibular disorders include various
symptoms and signs of the temporomandibular joints, the
masticatory muscles, and the related structures. The symp­
toms and signs may include a spectrum of referred head and
neck discomforts; joint noise (e.g., popping, clicking, crepi­
tus); reduced or altered mandibular movements as a result
of muscle spasm or disc displacement, with or without
reduction; condylar head erosion; and pain on direct
palpation of either temporomandibular joint or of the
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807

22
Asymmetric Mandibular Excess
Growth Patterns
JEFFREY C. POSNICK, DMD, MD
• Hemimandibular Hyperplasia: Type I
Condylar Hyperactivity
• Hemimandibular Elongation: Type II Condylar
Hyperactivity
• Assessing Jaw Growth Maturity
• High Partial Condylectomy Procedure for
Active Condylar Hyperactivity
• Presurgical Orthodontic Treatment
• Surgical Approach
• Complications, Informed Consent, and
Patient Education
• Malocclusion after Orthodontics and
Orthognathic Surgery
• Temporomandibular Disorders: The Effects of
Orthodontics and Orthognathic Surgery
• Conclusions
are dependent on multiple factors, including the intensity
of the mandibular hyperactivity; the patient’s age when
the abnormal bone growth begins; any underlying heredi­
tary dentofacial deformity tendency; and the treatment
that was previously rendered (i.e., orthodontic, dental, or
surgical) before the patient’s arrival to the surgeon for evalu­
ation. These asymmetric mandibular excess growth patterns
may be confused with other causes of maxillomandibular
asymmetry (i.e., hemifacial hyperplasia, hemifacial micro­
somia, growth disturbance after a condyle injury during
childhood).10,27,48,49,55,93,94,124 Most misdiagnosis are easily
clarified by taking an accurate history, completing a physical
examination, and reviewing the patient’s radiographs
(Fig. 22-1).
Obwegeser believes that this dentofacial deformity is
caused by two different growth regulators.23-25,68-91 The first
is a more rare form, and it is clinically characterized by an
increase in volume of all parts of the affected side of the
mandible, without a lateral shift of the chin to the opposite
side. Its primary effects end near the midline at the symphy­
sis (Figs. 22-2 through 22-5). The second and more common
form of this dentofacial deformity is characterized by an
elongation of the affected side of the mandible, often with
widening of the gonial angle and with clear displacement
(i.e. lateral shift) of the midline of the chin and the man­
dibular dental midline to the opposite side of the face (Figs.
22-6 through 22-14).
Obwegeser also stated that these two pure forms of den­
tofacial deformity may present as a spectrum.23-25,68-91 He
called these two pure dentofacial deformities Type I or hemi­
mandibular hyperplasia and Type II or hemimandibular elon­
gation. Obwegeser hypothesized that the steering mechanism
for the growth of these two distinct mandibular anomalies
is located entirely within the cartilaginous zone of the con­
dylar head. This was proven to him by the fact that, when­
ever a very rapidly developing mandibular overgrowth
(either Type I or Type II) was encountered, he was able to
arrest the growth and prevent further deformity by complet­
ing a high condylar resection.
A specific pattern of dentofacial deformity that occurs after
birth and that primarily affects the mandible may be referred
to as an asymmetric mandibular excess growth anomaly.* This
is a useful term for name recognition, but it falls short of
explaining the causes and effects of this common pattern of
jaw deformity. This condition typically results in an uneven
Angle Class III malocclusion, and it has been referred to by
a variety of terms, including deviated mandibular progna­
thism, condylar hyperplasia, mandibular lateral gnathism,
osteochondroma of the mandibular condyle, and asymmetric
Class III dentofacial deformity. The overall effect on maxil­
lofacial morphology also includes the secondary deformities
that occur to the maxilla, the nose, the chin region, the
position of the teeth, and the distortions that are visually
observed in the overlying soft-tissue envelope. These effects
*References 1, 2, 4, 6, 7, 9, 11-16, 22, 28, 36, 38, 41, 47, 50, 58, 60,
62, 65-67, 100, 106, 112-114, 117, 120, 123, 125
Text continued on p. 853

808 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
• Figure 22-1  Asymmetric man­
dibular excess growth patterns are
often confused with other causes of
maxillomandibular asymmetry. Most
misdiagnoses are easily clarified by
taking an accurate patient history,
completing a physical examination,
and reviewing the patient’s radio­
graphs. A, A teenage girl with hemi­
facial hyperplasia of the right side is
shown. This anomaly involves the
overgrowth of both the soft and
hard tissues on one side of the
face. There is an asymmetric Class
III malocclusion with a shift of the
mandibular dental midline to the
opposite side. B, Hemifacial micro­
somia results in the deficiency of
tissues within the first and second
brachial arches on one side of the
face. The intraoral examination is
usually consistent with an asymmet­
ric Class II excess overjet malocclu­
sion. This 15-year-old girl with
hemifacial microsomia of the right
side demonstrates these findings.
There is a shift of the mandibular
dental midline toward the ipsilateral
side. C, A 12-year-old boy in the
permanent dentition sustained a
right condyle fracture of the mandi­
ble earlier during his life with result­
ing ipsilateral (right side) mandibular
hypoplasia and secondary deformi­
ties of the maxilla. He presented
with an asymmetric Class II deep-
bite malocclusion. There is a shift
of the mandibular dental midline
toward the ipsilateral side. The over­
lying soft-tissue envelope is dis­
torted but not malformed.
A
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809
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
• Figure 22-2  A teenage girl with right side
hemimandibular hyperplasia. She demon­
strates a typical phenotype as described
within the chapter. A, Frontal facial and com­
puted tomography (CT) scan views without
intervention. B, Left facial oblique and CT
scan views without intervention. C, Left profile
and CT scan views without intervention.
A
B
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Continued

810 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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os
o nicicicicick
D, Right facial oblique and
CT scan views without intervention. E, Right
profile and CT scan views without intervention.
F, Frontal and submental vertex CT scan views
without intervention.
• Figure 22-2, cont’d

811
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gnatata hicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry; J.C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicicicici k
A
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththth
r ogn
gn
gn
gn
g atatatathicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
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
os
os
os
os
os
osnicicicicicicicicicicicicicici k
B
• Figure 22-3  A woman in her early 20s with left side hemimandibular hyperplasia. She demonstrates a typical phenotype as described
within the chapter. A, Frontal facial and occlusal views without intervention. B, Facial and posteroanterior cephalometric views without
intervention.
Continued

812 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
C
Inferior border asymmetry
D
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C, Right profile and lateral cephalometric views without intervention. D, Asymmetry of the mandibular inferior
borders is demonstrated in the left and right facial oblique views without intervention.
• Figure 22-3, cont’d

813
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
B
Increased
ramus height
But with shift of dental
midline to the right
Condylar
hyperplasia
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
• Figure 22-4  A man in his mid 20s with an atypical hybrid form of an asymmetric mandibular excess growth pattern on the right is shown
without treatment intervention. A, Frontal facial view in repose. Occlusal views are also shown. The mandibular dental midline is tipped to the right.
B, Frontal facial view with smile. A posteroanterior cephalometric radiograph is also shown.
Continued

814 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
C
D
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C, Left facial oblique and CT scan views without intervention. D, Left profile and CT scan views without intervention.
• Figure 22-4, cont’d

815
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
E
F
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
E, Right facial oblique and CT scan views without intervention. F, Right profile and CT scan views without intervention.
• Figure 22-4, cont’d

A
B
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
• Figure 22-5  A 17-year-old female with hemimandibular hyperplasia of the left side and the typical facial and occlusal phenotype. She also has
a lifelong history of obstructed nasal breathing. She underwent a comprehensive orthodontic and orthognathic surgical approach. Her procedures
included maxillary Le Fort I osteotomy in segments (minimal advancement, cant correction, and arch expansion); bilateral sagittal split ramus
osteotomies (cant correction and minimal horizontal advancement); left mandibular inferior border recontouring; osseous genioplasty (asymmetry
correction); and septoplasty and inferior turbinate reduction. Note that asymmetry is present at the inferior borders before surgery and that there
is much improvement afterward. A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after
reconstruction.

817
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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, Left facial oblique views before and after reconstruction. D, Right facial oblique views before and after reconstruction.
• Figure 22-5, cont’d 
Continued

818 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Pre surgery
2 years after surgery
E
Planned segmental osteotomy
Location of segmental osteotomy
Arch expansion
Cant correction
G
F
Correction of roll orientation
E, Occlusal views before surgery and after reconstruction. F, Articulated dental models that indicate analytic
surgical planning. G, Lateral cephalometric radiographs before and after reconstruction.
• Figure 22-5, cont’d

• Figure 22-6  This is a 15-year-old girl who had been evaluated for routine orthodontic care when she was 12½ years old. At that
time, she had not yet begun her menses or undergone a pubertal growth spurt. Routine orthodontics were initiated. By the time she
was 15 years old (i.e., 2 years after menarche and a pubertal growth spurt), she developed an obvious asymmetric mandibular
excess growth pattern due to right condylar overgrowth (Type II Hemimandibular Elongation). This resulted in both facial asymmetry
and an asymmetric Angle Class III negative overjet with a posterior crossbite malocclusion. The mandibular dental midline and chin
are shifted to the contralateral side. A, Facial and occlusal views when the patient was 12 years old. B, Facial and occlusal views
when the patient was 15 years old. C, Panorex radiographs when the patient was 12 and 15 years old, respectively.
B
C
Condylar
hyperplasia
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
g atatatathicicic Su
Su
Surg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
osnicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththth
r ogn
gn
gn
gn
gnatata hicicicic Su
Su
Surg
r ery
ry; J.C.
C Pos
os
os
os
os
osnicicicicicicick
A

820 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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
A
B
• Figure 22-7  A 17-year-old boy with a diagnosis of left hemimandibular elongation is shown. This condition affects his chewing and speech
articulation. The patient has a lifelong history of the obstruction of his nasal breathing. During his early teenage years, the patient underwent an
initial phase of orthodontics, without success. He was referred for surgical evaluation and then underwent a combined redo orthodontic and surgical
approach. With the relief of dental compensation, the patient’s surgery included maxillary Le Fort I osteotomy in segments (horizontal advancement,
cant correction, arch expansion, and clockwise rotation); bilateral sagittal split ramus osteotomies (cant correction and mandibular straightening);
septoplasty and inferior turbinate reduction; and osseous genioplasty (straightening). A, Frontal views in repose before and after reconstruction.
B, Frontal views with smile before and after reconstruction.

821
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 22-7, cont’d 
Continued

822 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontic decompensation, and 4 years after treatment.
• Figure 22-7, cont’d

823
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Cant
correction
Maxillary
clockwise
rotation
Mandibular
straightening
Roll Orientation Correction
Arch expansion
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 22-7, cont’d

824 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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
A
B
• Figure 22-8  A 17-year-old male high school student was referred by his orthodontist for surgical evaluation. His asymmetric Class III negative
overjet anterior open-bite malocclusion was consistent with hemimandibular elongation. He required redo orthodontics and jaw surgery with a
non-extraction approach. The patient had a lifelong history of nasal obstruction and consistent physical findings, so intranasal procedures were
also required. With orthodontic decompensation complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch expan­
sion, horizontal advancement, vertical lengthening, and clockwise rotation); sagittal split ramus osteotomies (minimal set-back); osseous genioplasty
(vertical reduction); and septoplasty and inferior turbinate reduction. A, Frontal views in repose before and after treatment. B, Frontal views with
smile before and after treatment.

825
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 22-8, cont’d 
Continued

826 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontics in progress, and after the completion of treatment.
• Figure 22-8, cont’d

827
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Clockwise
rotation
Arch widening
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after treatment. Note the improved A-point to B-point relationship that has been achieved through maxillary clockwise
rotation.
• Figure 22-8, cont’d

828 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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
A
B
• Figure 22-9  A 20-year-old man with left side hemimandibular elongation is shown. During his teenage years, he underwent attempted growth
modification and orthodontic camouflage that included the removal of three bicuspids, without success. He had a lifelong history of obstructed
nasal breathing. He was referred to this surgeon for evaluation and agreed to a comprehensive redo orthodontic and orthognathic approach. With
the relief of dental compensation, his surgery included maxillary Le Fort I osteotomy in segments (minimal advancement, vertical adjustment, cant
correction, arch expansion, and the correction of the curve of Spee); bilateral sagittal split ramus osteotomies (mandibular straightening and asym­
metric correction); osseous genioplasty (asymmetry improvement); and septoplasty and inferior turbinate reduction. A, Frontal views in repose
before and after reconstruction. B, Frontal views with smile before and after reconstruction.

829
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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, Left oblique facial views before and after reconstruction. D, Left profile views before and after reconstruction.
• Figure 22-9, cont’d 
Continued

830 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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
E
F
E, Right oblique facial views before and after reconstruction. F, Right profile views before and after reconstruction.
• Figure 22-9, cont’d

831
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Prior to retreatment with 3 bicuspid extractions carried out as a teenager
Pre surgery
After treatment
G
G, Occlusal views before retreatment, after orthodontic decompensation, and after treatment. Note that the
left mandibular second molar and the right maxillary second molar are unopposed; this is a result of the orthodontic extraction pattern.
• Figure 22-9, cont’d 
Continued

832 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
J
Three quadrant bicuspid extractions were previously carried out
Cant
correction
Mandibular
straightening
Arch expansion
Curve of Spee
Roll Orientation Correction
H
I
Condylar
hyperplasia
H, Articulated dental casts that indicate analytic model planning. I, Panorex radiograph taken before retreatment
that indicates left condyle hyperplasia and missing bicuspids in three quadrants. J, Lateral cephalometric radiographs before and after
reconstruction.
• Figure 22-9, cont’d

833
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Or
Or
Or
Or
Or
Or
Orththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatathicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
o nicicicicicicicicick
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatathicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
osnicicicicicicicicicick
A
• Figure 22-10  A teenaged boy with right side hemimandibular elongation. When he was between 10 and 14 years old, he was treated with
growth modification attempts and then orthodontic camouflage. His overjet improved at the expense of the dental compensation, and the facial
deformity remained. He was referred to this surgeon, who recommended stopping active treatment until the patient was skeletally mature. When
he was 17 years old, he underwent redo orthodontics and an orthognathic approach. The orthodontics were carried out without extractions, which
left the maxillary incisors procumbent. Clockwise rotation of the maxillomandibular complex as part of the orthognathic correction was helpful to
overcome the facial disharmony. The patient’s surgical procedures included maxillary Le Fort I osteotomy in segments (cant correction, horizontal
advancement, clockwise rotation, arch expansion, and vertical lengthening); bilateral sagittal split ramus osteotomies (mandibular straightening and
clockwise rotation); and septoplasty and inferior turbinate reduction. A, Facial and occlusal views when the patient was 14 years old, after failed
growth modification and orthodontic camouflage.
Continued

834 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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
O ththththththththththththththththththththththththththththththththththththththth
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
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Sur
u g
r ery
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
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicick
Or
Orthth
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
g atatata hicic Su
Sur
u g
r ery; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicici k
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
O ththththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S r
u g
r ery
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.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicicicicicicicicicicicicicicick
Or
Orthth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatata hicicicicic Su
Su
S r
u g
r ery
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicick
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
O thththththththththththththththththththththththththththththththththththth
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
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic 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 r
u g
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
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.
C.
C Pos
os
os
os
os
os
os
os
os
os
osnicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Sur
u g
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
o nicicick
C
D
B, Facial views
in repose before and after reconstruction.
C, Frontal views with smile before and
after reconstruction. D, Profile views
before and after reconstruction.
• Figure 22-10, cont’d

835
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Prior to redo orthodontics
Pre surgery
After treatment
E
E, Occlusal views when the patient was 14 years old just after the removal of orthodontics appliances, with
retreatment in preparation for surgery, and after reconstruction.
• Figure 22-10, cont’d 
Continued

836 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Cant correction
Maxillary
clockwise
rotation
Arch expansion
Roll Orientation Correction
F
Mandibular
clockwise
rotation
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after reconstruction. Clockwise rotation of the maxillomandibular complex was helpful to improve the A-point to B-point
relationship, despite maxillary incisor procumbancy.
• Figure 22-10, cont’d

837
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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
A
B
• Figure 22-11  A 17-year-old girl with right side hemimandibular elongation. When she was between 10 and 14 years old, she was treated with
growth modification and orthodontic camouflage techniques. She was referred to this surgeon when she was 17 years old to address her facial
asymmetry and malocclusion. She underwent redo orthodontics to decompensate the arches as well as an orthognathic approach. Her surgical
procedures included maxillary Le Fort I osteotomy (horizontal advancement and clockwise rotation); bilateral sagittal split ramus osteotomies (man­
dibular straightening); osseous genioplasty (horizontal advancement); and septoplasty and inferior turbinate reduction. A, Frontal views in repose
before and after reconstruction. B, Frontal views with smile before and after reconstruction.
Continued

838 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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C
D
C, Left oblique facial views before and after treatment. D, Left profile views before and after reconstruction.
• Figure 22-11, cont’d

839
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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E
F
E, Right oblique views before and after reconstruction. F, Right profile views before and after reconstruction.
• Figure 22-11, cont’d 
Continued