Orthognathic Surgery

841
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
H
Mandibular
straightening
Maxillary
clockwise
rotation
I
H, Articulated dental casts that indicate analytic model planning. I, Lateral cephalometric radiographs before and after
reconstruction.
• Figure 22-11, cont’d

Orth
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A
B
• Figure 22-12  A 25-year-old woman with left side hemimandibular elongation. She was treated with growth modification and then orthodontic
camouflage earlier in life, without success. She was referred to this surgeon and underwent redo orthodontics to decompensate the arches as well
as an orthognathic approach. Lifelong nasal obstruction and intranasal examination confirmed the need for septoplasty and inferior turbinate reduc­
tion. The orthodontics were carried out without extractions, which left the maxillary incisors procumbent. Clockwise rotation of the maxilla as part
of the orthognathic correction was helpful to overcome this problem and to improve the A-point to B-point relationship. Her surgical procedures
included maxillary Le Fort I osteotomy in segments (cant correction, horizontal advancement, clockwise rotation, and arch expansion); bilateral
sagittal split ramus osteotomies (mandibular straightening); osseous genioplasty (horizontal advancement); and septoplasty and inferior turbinate
reduction. A, Facial views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.

843
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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D
C, Oblique facial views before and after reconstruction D, Profile views before and after reconstruction.
• Figure 22-12, cont’d 
Continued

844 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, in preparation for surgery, and after reconstruction.
• Figure 22-12, cont’d

845
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
F
Arch expansion
Maxillary clockwise
rotation
Mandibular
adjustment
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before
and after reconstruction.
• Figure 22-12, cont’d

846 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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A
B
• Figure 22-13  A 20-year-old woman with right side hemimandibular elongation. She was treated with orthodontic camouflage techniques, without
success. She was referred to this surgeon and underwent an orthognathic and redo orthodontic approach. Her surgical procedures included
maxillary Le Fort I osteotomy in segments (horizontal advancement, clockwise rotation, and arch expansion); bilateral sagittal split ramus osteotomies
(straightening and asymmetric correction); and septoplasty and inferior turbinate reduction. A, Facial views in repose before and after reconstruc­
tion. B, Frontal views with smile before and after reconstruction.

847
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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D
C, Left oblique views before and after reconstruction. D, Left profile views before and after reconstruction.
• Figure 22-13, cont’d 
Continued

848 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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F
E, Right oblique views before and after reconstruction. F, Right profile views before and after reconstruction.
• Figure 22-13, cont’d

849
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
Pre surgery
After treatment
G
I
Arch expansion
Maxillary clockwise
rotation
Roll Orientation Correction
Cant correction
Mandibular counter
clockwise rotation
H
G, Occlusal views in preparation for surgery and after reconstruction. H, Articulated dental casts that indicate
analytic model planning. I, Lateral cephalometric radiographs before and after reconstruction. Clockwise rotation of the maxilla was
helpful to improve the A-point to B-point relationship.
• Figure 22-13, cont’d

850 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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A
B
• Figure 22-14  A 17-year-old girl with left side hemimandibular elongation. Earlier in her life, she was treated with growth modification and orth­
odontic camouflage techniques, without success. She also has a lifelong history of nasal obstruction. She was referred to this surgeon and under­
went redo orthodontics and an orthognathic approach. Her surgical procedures included maxillary Le Fort I osteotomy (cant correction and horizontal
advancement); bilateral sagittal split ramus osteotomies (mandibular straightening); osseous genioplasty (minimal horizontal advancement); and
septoplasty and inferior turbinate reduction. A, Facial views in repose before and after reconstruction. B, Frontal views with smile before and after
reconstruction.

851
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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• Figure 22-14, cont’d 
Continued

852 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment
Pre surgery
After treatment
F
F, Occlusal views before retreatment, in preparation for surgery, and after reconstruction. Note that the
maxillary and mandible dental midlines are improved but not fully corrected.
• Figure 22-14, cont’d

853
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
proliferative layer; the transitional layer; and the hypertro­
phic cartilage layer.
Villanueva-Alcojol and colleagues attempted to corre­
late demographic and clinical presentations of condylar
hyperplasia with the described histopathologic features and
then with the associated scintigraphic and clinical findings
after treatment with high condylectomy during the active
phase.122 Interestingly, the authors were unable to find a
correlation between the histologic type (as described by
Slootweg and Muller116) and the uptake of the affected
condyle on bone single photon emission computed tomog­
raphy or between the patient’s age and his or her histologic
type.
The preferred treatment to correct the dysmorphology
for all forms of condylar hyperplasia is surgical including
the repositioning and recontouring of the bones in combi­
nation with orthodontics to align the teeth.* The extent of
Raijmakers and colleagues carried out a meta-analysis
to determine gender differences when it came to the diag­
nosis of asymmetric mandibular excess.101 Ten studies were
reviewed, and these included a total of 275 affected patients.
The meta-analysis showed a clear predominance of female
patients in the study populations. The male and female
patients had an equal distribution of left- and right-sided
condylar overgrowth. The authors postulate that hormonal
variations—especially of estrogen in women—may explain
these differences. An alternative explanation put forth for
this apparent female predilection is a difference in motiva­
tion between the sexes to seek the correction of their facial
asymmetry (see Fig. 22-6).
Slootweg and Muller described four histologically dif­
ferent types of mandibular condylar hyperplasia.116 They
proposed a classification system that is based on histologic
criteria, and they divided hyperplastic condyles into four
types, depending on the arrangement and morphology of
the various layers of the condyle. These condylar layers were
the fibrous articular layer; the undifferentiated mesenchyme
Roll Orientation Correction
Mandibular counter
clockwise rotation
G
H
G, Articulated dental casts that indicate analytic model planning. H, Lateral cephalometric
radiographs before and after reconstruction.
• Figure 22-14, cont’d 
*References 8, 17, 26, 31, 33, 37, 39, 52-54, 56, 59, 61, 96, 99, 102,
103, 111, 115, 118, 119, 121, 126

854 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
treatment depends on the presenting dysmorphology and
the status of condylar growth. If ongoing condylar growth
is documented, then a form of high condylectomy should
be considered to arrest progressive dysmorphology.20,21,40,42
High condylectomy (i.e., the removal of 4 mm to 5 mm of
the condyle) and condylar shaving procedures (i.e., the
removal of only 2 mm to 3 mm of the condyle) are options
that are discussed in the literature. The documentation of
cartilage islands that extend into the cancellous bone sug­
gests that the pathology is not limited to the apparent
cartilage surface. For this reason, some clinicians prefer the
high condylectomy procedure, because it will also remove
subcondylar bone; in theory, it will also more fully eliminate
the potential of the growth center.
Hemimandibular Hyperplasia: Type I
Condylar Hyperactivity
Type I hemimandibular hyperplasia is a dentofacial defor­
mity that results in excessive growth in volume of the
whole hemimandible. With this condition, there is three-
dimensional enlargement of one side of the mandible, and
this includes all aspects: the condyle, the condylar neck, the
ramus, the body, and the symphysis. The anomaly termi­
nates exactly at the symphysis of the mandible. In its pure
form, this condition does not result in a significant shifting
of the midline of the chin or of the mandibular dental
midline to the contralateral side. The occlusion is rotated,
but there is minimal to no crossbite. There is an increase in
vertical height, but it does not involve widening of the
affected side of the face. This three-dimensional enlarge­
ment of the mandible results in a notable asymmetric
rotation of the face. There is visually apparent ipsilateral
downward and medial projection of the ramus as well as of
the angle and body of the mandible.
When the anomalous process begins before puberty,
there will be more severe and characteristic secondary defor­
mities of the maxilla, the contralateral mandible, and the
positioning of the teeth. The secondary maxillary deformi­
ties follow the downward and medial growth of the ipsilat­
eral mandible, and the occlusal plane becomes canted. The
ipsilateral increase in vertical height on the affected side
leads to an apparent decrease in facial height on the “normal”
(contralateral) side. To the uninitiated, the facial appearance
may be confused with Hemifacial Microsomia.
The natural history of this pure form of hemimandibular
hyperplasia (Type I) is to progress and result in three-
dimensional disproportion and asymmetry on both sides of
the maxilla, the mandible, and the chin region. Fortunately,
this form of asymmetric mandibular excess is rare as com­
pared with hemimandibular elongation (Type II), which
results in a less severe three-dimensional clinical deformity.
When hemimandibular hyperplasia is recognized in its
active and progressive state, Obwegeser recommends a con­
dylar shave to arrest the disease process and to prevent
further progression.23-25,68-91 Another reason why some clini­
cians prefer the partial condylectomy procedure is that it
can be used as a method to shorten the posterior facial
height. When the phenotype is characterized by primary
vertical overgrowth with minimal to no horizontal deviation
of the mandible, it can simultaneously be an effective way
to restore the morphology. If the deformity remains active
and is allowed to reach its endpoint, then the restoration of
ideal facial aesthetics is problematic. The objectives of the
condylar shave procedure are to arrest any further abnormal
growth on the affected side; to prevent continued secondary
deformities of the maxilla, the nose, and the contralateral
side of the mandible; and to arrest any additional malposi­
tioning of the teeth. The problem with this approach is that
secondary procedures to correct the facial skeleton are still
required in most cases. It remains unclear just how much of
a deformity will be aborted by an open-joint procedure.
Practically speaking, however, a condylar procedure (e.g.,
condylar shave, high condylectomy) is not generally
required, because growth has usually ceased by the time of
diagnosis and surgical referral. This can be surmised by a
review of the patient’s previous records (e.g., radiographs,
facial and occlusal photographs, dental models), or it can
be confirmed by a bone scan. Definitive treatment of the
dentofacial deformity through orthognathic and recontour­
ing surgery is the usual approach once growth maturity and
condylar arrest have occurred.
Functional Aspects
• Articulation errors in speech may result if a significant
malocclusion is present (see Chapter 8).
• Predictable chewing and swallowing difficulties will
result if a significant posterior open-bite malocclusion is
present (see Chapter 8).
• The ability to comfortably close the lips together
and their position at rest may be negatively affected
depending on the extent of jaw malposition and dental
malocclusion.
• Depending on the extent of deformity, the individual
with asymmetric mandibular excess is likely to experi­
ence self-esteem and body-image issues (see Chapter 7).
• Nasal airway obstruction as a result of a deviated septum
and turbinate enlargement with increased nasal airway
resistance may be present and should be ruled out (see
Chapter 10).
• Detrimental long-term effects on the dentition and the
periodontium caused by traumatic malocclusion, the
displacement of teeth outside of the alveolar housing, or
previous camouflage orthodontic treatment may occur
(see Chapter 6).
• A higher-than-average incidence of TMD has been
reported in this form of dentofacial deformity (see
Chapter 9).
Clinical Characteristics
• This deformity should not be confused with hemifacial
microsomia, because the soft-tissue envelope (including

855
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
the external ear) is not hypoplastic on the affected side
of the face.
• There is increased vertical height of the affected (ipsilat­
eral) side of the face.
• The medial and downward shift of the ipsilateral man­
dible is most notable at the angle.
• There is a relative lateral and upward position of the
contralateral mandible.
• The overall face has a “rotated” appearance.
• Mouth opening is without restriction.
• The ipsilateral corner of mouth is inferior but not pos­
teriorly positioned.
• The cheek appears flat on the ipsilateral side.
• The width of the face on the ipsilateral side appears to
be decreased.
• The maxilla is generally canted down on the ipsilateral
side.
Dental Findings
• The crowns of the teeth on the contralateral side of
the mandible tilt toward the ipsilateral side. They do
so as a dental compensation to maintain occlusion
with the opposing maxillary teeth, thereby avoiding
crossbite.
• Lingual tilting of the mandibular alveolar ridge on the
contralateral side is a secondary deformation as the (con­
tralateral) lower jaw shifts lateral and assumes a superior
position.
• The dental arches appear “twisted” by the slow process
of three-dimensional growth distortion of the ipsilateral
mandibular and the secondary deformations that occur
in the contralateral side of the mandible and whole
maxilla.
• If the ipsilateral excess mandibular growth is rapid, then
the maxilla cannot respond at the same rate; this results
in an ipsilateral posterior open bite.
• If the rate of ipsilateral excess mandibular growth is rela­
tively slow, then maxillary dental hypereruption with
secondary canting and the maintenance of occlusion are
more likely.
• In most cases, the maxillary and mandibular dental mid­
lines will closely match.
Radiographic Findings
• There is three-dimensional enlargement of the ipsilateral
mandible, which terminates at the symphysis. The
enlarged (ipsilateral) condyle also becomes “classically”
deformed.
• The overall height of the body of the mandible is greater
on the ipsilateral side.
• The inferior border and angle of the mandible are
rounded on the ipsilateral side.
• Increased
alveolar
height
between
the
inferior
border and the root apices on the ipsilateral side is
expected.
• The mandibular canal will be displaced downward on the
ipsilateral side, often in close proximity to the inferior
border.
Hemimandibular Elongation:
Type II Condylar Hyperactivity
The dentofacial deformity called Type II hemimandibular
elongation results in excessive growth on one side of the
mandible without an overall three-dimensional increase in
the volume of the whole affected side as seen with a Type I
condition (i.e., hemimandibular hyperplasia; see Figs. 22-6
through 22-15). At the same time, hemimandibular elonga­
tion is not limited to just one aspect of the mandible. It
results in a relative elongation (i.e. lateral shift) of all com­
ponents of the ipsilateral lower jaw, including the condyle,
the condylar neck, the ascending ramus, and the body. The
condylar neck will be elongated and narrow, but the con­
dylar head (i.e., the articulation of the temporomandibular
joint [TMJ]) appears to be relatively normal in size and
shape.
Obwegeser recognizes two distinct variations within the
Type II hemimandibular elongation form of condylar
hyperactivity.23,24,25,68-91 In the first subgroup (i.e., the
“slender type”), there is an elongated hemimandible on
the affected side as well as a morphologic “stretching” of the
angle of the mandible. The distinguishing morphologic
feature is an obtuse gonial angle as compared with the
contralateral side. The second subgroup (i.e., the “non-
slender type”) has an angle of the mandible that looks very
much like the “normal” contralateral side and yet the whole
(ipsilateral) mandible is clearly elongated.
The clinical features that are always present with Type
II hemimandibular elongation—and therefore useful find­
ings that differentiate it from Type I hemimandibular
hyperplasia—include a visual lateral shift of the chin mid­
line and the mandibular dental midline to the contralateral
side; a posterior crossbite on the contralateral side; and no
significant increase in the posterior facial height from side
to side. The most striking features of Type II hemimandibu­
lar elongation include the deviation of the chin and the
mandibular dental midline to the opposite side with a pos­
terior crossbite on the contralateral side and a class III molar
relationship on the ipsilateral side. As stated, there will be
no significant difference in the posterior facial height
between the two sides of the face, but canting that has been
recognized in the maxilla and mandible is likely to be
present and will benefit from surgical correction.
To review, hemimandibular elongation is the preferred
term for what has classically been referred to as “asymmetric
mandibular excess.” Interestingly, the deformity has usually
progressed and done its damage by the time of clinical
presentation to the surgeon. For this reason, a condylar
shave is rarely warranted. In general, these deformities can
be reliably managed with standard orthognathic techniques
carried out at skeletal maturity in conjunction with effective

856 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
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A
B
• Figure 22-15  A 21-year-old woman with a diagnosis of left hemimandibular elongation; this affects her chewing and speech articulation. She
also has a lifelong history of obstructed nasal breathing. During her early teenage years, the patient underwent an initial phase of orthodontics,
without success. She 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.

857
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 22-15, cont’d 
Continued

858 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 after treatment.
• Figure 22-15, cont’d

859
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
directly related to the presenting facial asymmetry (see
Chapter 7).
• Nasal airway obstruction as a result of a deviated septum
and enlarged inferior turbinates with increased nasal
airway resistance is likely present and should be ruled
out (see Chapter 10).
• Detrimental long-term effects on the dentition and peri­
odontium as a result of traumatic malocclusion, the dis­
placement of the teeth outside of the alveolar housing,
or previous camouflage orthodontic treatment may occur
(see chapter 5 & 6).
• A higher-than-average incidence of temporomandibu­
lar disorder (TMD) has been reported with this anoma­
lous pattern of dentofacial growth. Joint noise and
orthodontics to improve head and neck function and to
enhance facial aesthetics (Fig. 22-6 through Fig. 22-14).
Functional Aspects
• Articulation errors in speech may result if a significant
malocclusion is present (see Chapter 8).
• Chewing and swallowing difficulties resulting from the
presenting malocclusion are typical (see Chapter 8).
• The ability to comfortably close the lips together and
their position at rest will be negatively affected by the
extent of jaw malposition and dental malocclusion.
• The individual with this jaw growth pattern is
likely to experience self-esteem and body image issues
Arch expansion
Maxillary clockwise
rotation
F
G
Roll Orientation Correction
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before
and after treatment. Note that the clockwise rotation of the maxilla was helpful to improve the A-point to B-point relationship as
viewed in profile.
• Figure 22-15, cont’d

860 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
• The ipsilateral condylar neck will be long, but the diam­
eter is typically not increased.
• When viewed on a posteroanterior cephalometric radio­
graph, canting of the maxillary occlusal plane may be
seen (i.e., downward and forward on the ipsilateral
side).
• When viewed on a posteroanterior cephalometric radio­
graph, canting of mandibular plane is typically seen (i.e.,
downward and forward on the ipsilateral side).
Assessing Jaw Growth Maturity
Skeletal scintigraphy with a technetium bone scan is a
useful method for the assessment of difficult growth-
related
diagnostic
problems
of
the
mandibular
condyle.3,29,34,35,57,63,92,95,104 For patients with asymmetric
mandibular excess, the state of residual growth may be clari­
fied by the unequal ratio of uptake of technetium in each
condylar head. Alternatively, an equal ratio of uptake shows
that asymmetric growth has likely ceased. In difficult diag­
nostic cases, normal versus abnormal condylar growth can
be further assessed by comparing the ratio of the uptake
with the tabulated normative standards developed by Kaban
and colleagues.18,19,43-46 The cessation of mandibular growth
can be more or less predicted when the uptake ratios
approach 0.70, which is the adult norm. Skeletal scintigra­
phy (i.e., bone scan) may be useful during the making of
decisions that involve the timing and extent of treatment
when residual condylar growth remains uncertain. After the
cessation of growth, there will be no advantage to an open-
joint procedure. In this case, the correction of the dentofa­
cial deformity with the use of standard orthognathic
techniques is indicated.5,107-109
High Partial Condylectomy Procedure
for Active Condylar Hyperactivity
The successful treatment of asymmetric mandibular excess
requires the cessation of growth before definitive surgical
correction. Knowledge of whether the condition is still
active is assessed at the condylar site.5,107-109 For the patient
with hemimandibular elongation, the deformity has usually
progressed and done its damage by the time of clinical
presentation to the surgeon. In general, the presenting jaw
deformities are best managed with standard orthognathic
techniques that are carried out at skeletal maturity to
improve both head and neck function and to enhance facial
aesthetics. Alternatively, the hemimandibular hyperplasia
deformity may be more gradual in its progression. In this
case, if the condition is allowed to reach its endpoint, it may
not be possible to achieve an ideal symmetric facial aesthetic
result. A condylar shave procedure may be beneficial for the
subgroup of patients with Type I hemimandibular hyper­
plasia to arrest ongoing abnormal growth on the affected
discomfort on the ipsilateral side are not infrequent (see
Chapter 9).
Clinical Characteristics
• The pogonion of the mandible and soft-tissue chin
prominence are shifted to the contralateral side.
• The lower lip is in front of (i.e., anterior to) the upper
lip; this is the reverse of normal.
• Vertical mouth opening is usually undisturbed.
• The ipsilateral corner of the mouth is usually lower and
more anterior than the contralateral side (i.e., canting is
present).
• The profile line may be harmonious, but it more likely
gives the impression of mandibular prognathism.
• The soft-tissue cheek region appears fuller on the contra­
lateral side.
• The prominence of the cheekbone appears to be deficient
on the ipsilateral side.
• There is no apparent vertical height difference between
the two sides of the face.
Dental Findings
• The ipsilateral molars are in Class III malocclusion.
• The contralateral molars may be in Class I or Class II
malocclusion.
• A posterior crossbite on the contralateral side is
typical.
• The mandibular dental midline is shifted to the contra­
lateral side.
• Tilting of the lower anterior teeth with the incisal sur­
faces toward the ipsilateral side is typical.
• Retroinclination of the lower incisors is generally seen.
• Lingual inclination of the contralateral mandibular pos­
terior teeth is typical.
• The maxilla is often canted downward and forward on
the ipsilateral side.
Radiographic Findings
• Ascending ramus asymmetry from side to side is
frequent.
• A thick cortical plate along the inferior border of the
mandible on the ipsilateral side is frequent.
• The ipsilateral mandibular canal may appear to be lower
positioned (i.e., closer to the inferior border), better
defined (i.e., encased in cortical bone), and in close prox­
imity to the roots of the teeth as compared with the
contralateral side.
• The overall visual appearance and the measurable length
of the mandible indicate elongation on the ipsilateral
side.
• The ipsilateral angle of the mandible may be more obtuse
(i.e., slender) as compared with the normal (contralat­
eral) side.

861
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
tried with the hope of neutralizing the occlusion and avoid­
ing surgery. These camouflage orthodontic mechanics
hamper the preferred surgical positioning of the jaws to
achieve maximum facial harmony, and they will also leave
the occlusion prone to late relapse and the dentition suscep­
tible to long-term periodontal breakdown (see Chapter 5).
In preparation for an orthognathic correction, the ortho­
dontic treatment of each jaw should achieve the correct
positioning of the teeth within the respective alveolar
process (see Chapter 5). If this is accomplished, the clini­
cians can best achieve maximum mirror-image skeletal sym­
metry, Euclidian facial proportions, and a long-term stable
occlusion with periodontal health (see Chapter 6).
Surgical Approach
The Influence of Chin Asymmetry on
Perceived Facial Attractiveness
Naini and colleagues undertook an investigation with the
objective of assessing how severe an asymmetry at the
chin point would have to be to influence perceived attrac­
tiveness.64 Idealized two-dimensional frontal facial views
were created with the use of computer software in which
the chin point was altered from side to side in 5-mm incre­
ments from 0 mm to 25 mm. These images were then rated
on a seven-point Likert scale by a preselected group of
observers that included orthognathic patients before treat­
ment, clinicians, and laypeople (n = 185 observers). The
study confirmed that, in the frontal view, chin asymmetries
of 10 mm or greater are perceived as being significant,
whereas those of 5 mm or less largely go unnoticed. The
greater the degree of asymmetry (i.e., >10 mm), the more
noticed it will be by an observer and the greater the patient’s
desire for correction. Both clinician and patient ratings were
similar and found to be more critical than the ratings given
by laypeople. The images that were considered the most
attractive showed perfect bilateral symmetry of the chin
region. The lowest-rated images showed the highest degrees
of asymmetry of the chin. Combined vertical and horizontal
asymmetries were rated slightly worse than horizontal asym­
metry alone.
Hemimandibular Hyperplasia (Type I)
If the hemimandibular hyperplasia deformity remains active
and is allowed to progress to its endpoint, it may not be
possible to achieve an ideal symmetric facial aesthetic result.
For this reason, a high condylar shave to arrest further
abnormal growth on the affected side and to prevent
ongoing secondary deformities (i.e., of the maxilla, nose,
and contralateral side of the mandible; malpositioning of
the teeth) should be considered if condylar hyperactivity
remains, as described previously.20,21,40,42
Details of the definitive maxillofacial reconstruction will
depend on the patient-specific morphologic findings (see
side; to prevent further secondary deformities of the maxilla,
the nose, and the contralateral side of the mandible; and to
arrest the malpositioning of the teeth.20,21,40,42
Some surgeons are relatively quick to suggest a high
condylectomy or a condylar shave, because they feel that
little harm will be done and that such a procedure has the
potential to limit the extent of orthognathic surgery that
will be required. Most surgeons remain hesitant when it
comes to performing a direct condylar procedure, because
they recognize the law of unintended consequences and
the potential for the deterioration of TMJ function. In
general, I agree with this conservative approach when con­
sidering an open condylar procedure.
Lippold and colleagues as well as other researchers have
suggested that minimal harm occurs from a “high condylar
shave.”51 Until recently, critical reviews of an invasive TMJ
approach have not been forthcoming. Saridin and col­
leagues completed an evaluation of temporomandibular
function after high partial condylectomy in a consecutive
series of individuals with unilateral condylar hyperplasia
(N = 33).110 The study group included individuals with
unilateral condylar hyperplasia whose conditions were con­
sidered to be active; in other words, the mandibular asym­
metry appeared to be clinically progressive, and the bone
scan was positive. The subjects then underwent high con­
dylectomies (N = 33). The patients were compared with
a control group that was matched for age and gender (N
= 31). All patients and all members of the control group
filled out a history questionnaire and underwent a clinical
examination in accordance with the research diagnostic
criteria for temporomandibular disorders. The patients were
studied for an average of 4.3 years after the condylectomy
was carried out (range, 0.6 to 13.3 years). The results of
the study indicate that patients with unilateral condylar
hyperplasia who undergo condylectomy in an attempt to
arrest progressive mandibular asymmetry will have more
joint-related temporomandibular problems and a higher
persistence of long-term pain as compared with age- and
gender-matched controls.
Presurgical Orthodontic Treatment
Among patients who are affected by these mandibular excess
growth patterns, orthodontic maneuvers that were carried
out earlier during their lives to modify growth or as camou­
flage approaches to neutralize the occlusion should be
overcome with further orthodontic mechanics before
orthognathic surgery. Frequently seen scenarios include the
following: (1) orthodontic overexpansion of the maxillary
arch to correct crossbites; (2) hypereruption of the molars
on one side and intrusion on the other side to correct
canting; (3) lingual tipping of the mandibular molar or
premolar crowns on the contralateral side and buccal tipping
of the molar or premolar crowns on the ipsilateral side; and
(4) retroclining of the lower anterior teeth to correct the
overbite. All of these orthodontic techniques may have been

862 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
shared responsibility for the treatment result is more likely
(see Chapter 16).
Malocclusion after Orthodontics
and Orthognathic Surgery
There are inherent biologic challenges to the orthodontic
movement of the teeth within the alveolar process and to
the surgical repositioning of the jaws or jaw segments in the
individual with an asymmetric mandibular excess growth
anomaly. This includes the technical aspects of the reposi­
tioning, the initial healing requirements, and the difficulties
associated with the long-term maintenance of the mechani­
cally relocated teeth, jaws, and jaw segments. When follow­
ing sound biomechanical and aesthetic principles, clinicians
carry out orthodontic treatments and surgical procedures;
in most cases, the results are effectively maintained. Poten­
tial intraoperative technical difficulties associated with sagit­
tal split ramus osteotomies of the mandible and maxillary
Le Fort I osteotomy can result in immediate early maloc­
clusion, but these problems are generally preventable (see
Chapter 17). In the teenager, timing surgery to limit concern
about ongoing mandibular growth afterward is more prob­
lematic with asymmetric mandibular excess than with most
other patterns of dentofacial deformity; this is discussed in
more detail earlier in this chapter. All of these factors must
be taken into account to achieve and then maintain the
desired results.
Temporomandibular Disorders:
The Effects of Orthodontics and
Orthognathic Surgery
It is estimated that an average of 32% of the population
report at least one symptom of TMD, whereas an average
of 55% demonstrate at least one clinical sign. TMD includes
various symptoms and signs of the TMJs, the masticatory
muscles, and the related structures. The symptoms and signs
may include a spectrum of referred head and neck pain;
joint noise (e.g., popping, clicking, crepitus); reduced or
altered mandibular movements caused by muscle spasm or
disc displacement with or without reduction; condylar head
erosion; and pain on direct palpation of either of the TMJs
or the masticatory muscles. Occlusal factors (i.e., degrees of
malocclusion) are often claimed to be associated with TMD.
Asymmetric mandibular excess is associated with TMD
more frequently than many other dentofacial deformities.
The correction of the presenting jaw deformity and maloc­
clusion through effective orthodontics and orthognathic
surgery may relieve symptoms and signs of TMD in some
patients, but this is not predictable for each individual
patient. As stated earlier in this chapter, Saridin and col­
leagues found that the completion of a partial condylec­
tomy on the ipsilateral side was associated with a higher
incidence of TMD (see Chapter 9).110 This should give the
Figs. 22-2 through 22-5).30,32,97,98,105 A wide spectrum of
three-dimensional maxillofacial distortions caused by the
primary anomaly and the secondary deformities is expected.
In addition to standard techniques (i.e., Le Fort I osteotomy
in segments, sagittal split ramus osteotomies of the man­
dible, osteotomy of the chin), mandibular inferior border
recontouring will often be beneficial (see Chapter 12). The
recontouring includes inferior border resection and rotary
drill bur modification from the angle of the mandible to
the chin on the ipsilateral side, as indicated. Inferior border
augmentation on the contralateral side is not usually recom­
mended because, over time, visible irregularities on the
grafted side can easily occur after partial graft resorption.
Segmentation of the maxilla (i.e., into two or three pieces)
is also generally required to correct the cant and the arch
form.
Hemimandibular Elongation (Type II)
The deformities of hemimandibular elongation are best
managed with standard orthognathic techniques carried
out at skeletal maturity to improve both head and neck
function and to enhance facial aesthetics (see Figs. 22-6
through 22-14). This will include, at a minimum, sagittal
split ramus osteotomies of the mandible. If the maxilla is
secondarily deformed (i.e., canted, with a shift of the dental
midline and an altered arch form), a Le Fort I osteotomy
with three-dimensional repositioning is also required. An
oblique osteotomy of the chin will likely further improve
facial symmetry and proportions (see Chapter 12). The
need for a high condylar shave to arrest growth remains
limited, and this procedure is only considered in the pres­
ence of documented progressive active disease at the time
of diagnosis.
Complications, Informed Consent, and
Patient Education
Orthodontists and surgeons are frequently asked to evaluate
jaw disharmonies and malpositioned teeth and then to
attempt to alter nature’s events. With an understanding of
the natural progression of the uncorrected asymmetric man­
dibular excess growth anomaly and with knowledge of
how specific interventions will affect head and neck func­
tion and facial aesthetics, predictable results are generally
achieved. Complications and patient dissatisfaction will
always occur in a small percentage of individuals. In the
setting of asymmetric mandibular excess, obtaining the
desired occlusion is more or less predictable. The expected
outcome is an improvement in the facial asymmetry with
persistent minor discrepancies. The clinician’s ability to
com­municate the potential risks, complications, alternative
approaches, and expected results of the recommended treat­
ment to the patient and the patient’s family is essential to
the achievement of a favorable outcome. When the patient,
the family, and all treating clinicians are fully informed,

863
CHAPTER 22  Asymmetric Mandibular Excess Growth Patterns
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Conclusions
Obwegeser believes that asymmetric mandibular excess growth
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76. Obwegeser HL: Die bewegung des unteren
alveolarforstatzes zur korrektur von
kieferstellungsanomalien: Part 1. Dtsch Z
Zeitschrift 23:1075–1084, 1968.
77. Obwegeser HL: Operative Behandlung der
zahnlosen progenie ohne intermaxillare
fixation. Schweiz Monatschr Zahnhlkd
78:416–425, 1968.
78. Obwegeser HL: Die bewegung des unteren
alveolarforstatzes zur korrektur von
kieferstellungsanomalien: Part 2. Dtsch Z
Zeitschrift 24:5–15, 1969.
79. Obwegeser HL: Forstchritte und
schwerpunkte der orthopadischen kiefer-
und gesichtschirurgie. In Schuchardt K,
Pfeifer G, editors: Fortschritte der kiefer-u
gesichtschirurgie, Vol 21, Stuttgart, 1971,
Thieme, pp 54–60.
80. Obwegeser HL: Mandibular surgery. Br J
Oral Surg 10:251–253, 1973.
81. Obwegeser HL: Kieferstellungskorrekturen
beim erwachsenen spaltpatienten. Dtsch Z
Zeitschrift 28:688–694, 1973.
82. Obwegeser HL: Grundsatzliches zur
korrekturplanung von kiefer- und
gesichtsanomalien aus chirurgischer sicht. In
Schuchardt K, Schwenzer N, editors: Fortschr
kiefer gesichtschir, Vol 26, Stuttgart, 1981,
Thieme, pp 9–12.
83. Obwegeser HL, Farmand M: Unsere
behandlung der kiefergelenksankylose.
Schweiz Monatschr Zahnhlkd 92:569–580,
1982.
84. Obwegeser HL, Maked MS:
Hemimandibular hyperplasia/
hemimandibular elongation. J Maxillofac
Surg 14:183, 1986.
85. Obwegeser HL, Makek M: Hemimandibulare
hyperplasie-hemimandibulare elongation.
Zahnnarztl Med Schrifttum, Munchen
18:273–313, 1986.
86. Obwegeser HL, Marentette L: Profile
planning based on alterations in the position
of the bases of the facial thirds. J Oral
Maxillofac Surg 44:302–311, 1986.
87. Obwegeser HL, Mekek M: Hemimandibular
hyperplasia-hemimandibular elongation.
J Maxillofac Surg 14:183–208, 1986.
88. Obwegeser HL: Chirurgische
behandlungsmoglichkeiten von
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Fortschr Kieferorthop 49:272–296, 1988.
89. Obwegeser JA: Eine neue operationsmethode
zur osteotomie des gesamten

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unterkiefer-alveolarfortsatzes. Osterr Z Stomal
85:35–46, 1988.
90. Obwegeser HL: Descriptive terminology for
jaw anomalies. Oral Surg Oral Med Oral
Pathol 75:138–140, 1993.
91. Obwegeser HL: Mandibular growth
anomalies: Terminology-aetiology-diagnosis-
treatment, Berlin, Heidelberg, New York,
2001, Springer-Verlag.
92. Paulus G, Hirschfelder U, Festel H:
Computergestutzte quantitative
skelettszintigraphie bei der therapieplanung
der condylaren hyperplasie. Forstchr Kiefer
Gesichtschir 32:180–181, 1987.
93. Perko M: Hipertrofija masetera. J Chir
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94. Persson M: Mandibular asymmetry of
hereditary origin. Am J Orthod 63:1–11,
1973.
95. Pogrel MA: Quantitative assessment of
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Oral Med Oral Pathol 60:15–17, 1985.
96. Posnick JC: Asymmetic mandibular
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Craniofacial and maxillofacial surgery in
children and young adults, Vol 40,
Philadelphia, 2000, WB Saunders Co,
pp 1057–1080.
97. Posnick JC, Fantuzzo J, Orchin J: Deliberate
operative rotation of the maxillo-mandibular
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J Oral Maxillofac Surg 64:1687–1695,
2006.
98. Posnick JC, Fantuzzo JJ, Troost, T:
Simultaneous intranasal procedures to
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2281, 2007.
99. Posnick JC, Agnihotri N: Managing chronic
nasal airway obstruction at the time of
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100. Proffit WR, Fields HW, Moray LJ:
Prevalence of malocclusion and orthodontic
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101. Raijmakers PG, Karssemakers LHE, Tuinzing
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1990.
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Osteochondroma of the mandibular
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866

23
Short Face Growth Patterns:
Maxillomandibular Deficiency
JEFFREY C. POSNICK, DMD, MD
• Functional Aspects
• Clinical Characteristics
• Dental Findings
• Radiographic Findings
• Treatment Indications and Objectives
• The Role of Growth Modification in the
Preadolescent Patient
• Definitive Reconstruction
• Postsurgical Orthodontic Maintenance and
Detailing
• Complications, Informed Consent, and
Patient Education
• Malocclusion after Orthodontics and
Orthognathic Surgery
• Temporomandibular Disorders: The Effects of
Orthodontics and Orthognathic Surgery
• Conclusions
disproportionate facial width-to-height ratio; and either a
prominent pogonion (more frequent with a Class I deep
bite) or a weak chin (more common with a Class II excess
overjet).3,10,11,20,21,35,39,40 Normally, there is a 1 : 2 relationship
between the distance from the base of the nose to the upper
lip and the distance from the lower lip to the chin. In the
individual with a short face growth pattern, the relationship
is closer to 1 : 1.15,42,43,56 The labiomental sulcus is deep and
the lower lip is everted, thereby further confirming the
degree of mandibular deficiency. The maxillary incisors are
often completely covered by the upper lip, which creates an
edentulous appearance in repose and an unfavorable “no
gingiva” smile. With the teeth in occlusion, the oral aperture
appears closed and the upper lip projects forward, often in
front of procumbent incisors. Individuals are frequently
described as having a sad or unhappy look in repose as a
result of the downturned oral commissures and the closed
aperture. The reduced lower facial height causes the everted
and prominent lips that would otherwise have appropriate
shape and volume if the facial height and horizontal projec­
tion of the jaws were restored. In the profile view, the nose
appears long and prominent. There is often a lateral flaring
of the nostrils with a “hanging columella.”
Classically, there is a deep bite with either marked ante­
rior crowding or excessive flaring with less dental crowd­
ing.34 There may be a Class II malocclusion with greater
than average overjet.50,51 If so, the mandible has greater
deficiency than the maxilla, and the pogonion will lack
prominence. Individuals with Class I deep bite without
excess overjet are more likely to have a retropositioned
A-point as compared with the B-point (i.e., a counterclock­
wise rotated maxillomandibular complex) and a prominent
pogonion. The maxillary and mandibular planes are often
nearly horizontal, which results in a “square jaw” facial
appearance.
Functional Aspects
• Articulation errors in speech and altered swallowing
mechanisms that result from the small jaws, the Class II
A frequently seen pattern of facial disharmony has the
common denominator of a significant degree of vertical
and horizontal (sagittal) deficiency in the maxilla and man­
dible. Measuring the ratio of the lower facial height (i.e.,
the subnasion to the menton) to the upper facial height
(i.e., the glabella to the subnasion) will confirm that the
lower height is diminished. The height of the alveolar
process in both jaws is reduced.23 The visual presentation of
the face includes an apparent redundancy of the soft-tissue
envelope of the lower face, thereby creating “chubby cheeks”
in the adolescent and a prematurely aged look by early
adulthood.
Clinical examination of the individual with a short face
growth pattern will generally confirm a pseudoprominence
of the nose; an acute nasolabial angle; a measurable and
visually perceived short lower facial height with a

867
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
deep-bite malocclusion, and the limited intraoral volume
for the tongue are expected (see Chapter 8).
• Difficulties with chewing and with lateral and protrusive
mandibular movements as a result of the Class II deep-
bite malocclusion are expected (see Chapter 8).
• A spectrum of upper airway sites of obstruction often
exists with the short face growth pattern. This includes
obstructions at the intranasal, palatopharyngeal (retro­
palatal), and glossopharyngeal (retroglossal) locations.
The incidence of obstructive sleep apnea is increased in
this patient population and should be ruled out (see
Chapter 10 & 26).
• Detrimental long-term effects on the dentition and the
periodontium as a result of any traumatic malocclusion,
the crowding of the teeth in the limited alveolar housing,
and previous camouflage orthodontic treatment may be
seen (see Chapter 5 & 6).
• A higher incidence of temporomandibular disorders in
the form of masticatory muscle discomfort as a result of
the short facial height and the deep-bite malocclusion
has been reported (see Chapter 9).
Clinical Characteristics
• Absence of maxillary tooth show beneath a relaxed
upper lip
• Limited tooth and no gingiva show with broad smile
• Acute nasolabial angle
• Depressed pyriform rims
• An apparent fullness of the cheeks and a squareness of
the overall face
• An apparent prominent and elongated nose when viewed
in profile
• Procumbent everted lips, turned down corners of the
mouth, and a closed aperture
• An excessively deepened and elongated labiomental fold
• Soft-tissue bunching that eventually results in perioral
creases (i.e., marionette lines)
• Early and deep jowl formation by middle age
• Premature loss of any semblance of an attractive neck–
jaw angle
Dental Findings
• Class II excess overjet malocclusion is common, but a
Class I deep bite is also frequent.
• A deep impinging bite with palatal irritation is a frequent
finding.
• Dental crowding with flaring of the incisors in each arch
is also a frequent finding.
Radiographic Findings
• The total anterior facial height is decreased (i.e., from the
nasion to the menton).
• The lower anterior facial height is short (i.e., from the
subnasion to the menton).
• Horizontal retrusion is measurable at the A-point and
the B-point in both jaws.
• Disproportion in the ratio of the facial width to the facial
height is measurable on an anteroposterior cephalomet­
ric radiograph or a computed tomography scan.
• Excessive procumbency of the maxillary and mandibular
incisors is frequently measurable.
• Excessive flattening (i.e., counterclockwise rotation) of
the maxillary and mandibular planes is frequently
measurable.
• Decreased alveolar bone height associated with the max­
illary incisors is measurable (i.e., the distance from the
floor of the nose to the incisal edge).
• Decreased alveolar bone height associated with the man­
dibular incisors is measurable (i.e., the distance from the
short menton to the incisal edge).
Treatment Indications and Objectives
The indications for treatment in a patient with a short face
growth pattern may be to improve function (e.g., occlusion,
chewing, swallowing, speech, breathing, lip posture), but
another compelling aspect is typically the enhancement of
facial aesthetics. The visually aesthetic advantages of the
surgical lengthening and projection of the short and retru­
sive lower face toward Euclidian proportions are immedi­
ately apparent and do not require quantification.32,33,58
To restore facial proportions and preferred facial aesthet­
ics, there must be both vertical and horizontal expansion of
the maxillomandibular complex.54 Accomplishing these
objectives will eliminate cheek and lip region bunching and
distortion and restore a pleasing soft-tissue envelope. When
this is done, a youthful oral aperture is restored. The corners
of the mouth are no longer downturned, and the lips will
be separated when they are at rest. The upper vermillion
increases in volume, and the labiomental fold flattens. The
maxillary incisors can be seen in repose, and the gingiva is
visible with smile. The nose no longer appears excessively
prominent, and the nasolabial angle improves. The jowls
diminish, and the length-to-width ratio of the face is
restored. The shape of the face changes from square to oval
with the restoration of the natural contours and attractive
ogee curves. The overall facial aesthetic changes from sad
and older appearing to younger looking and more attractive
(Figs. 23-1 through 23-7).
The Role of Growth Modification in the
Preadolescent Patient
Individuals with lower anterior facial height deficiency can
frequently be identified at an early age. They tend to have
an acute (flat) mandibular plane angle with a deep bite.25
This is accompanied by an upward (counterclockwise)
rotated anterior mandible that results in a prominent-
appearing pogonion.
Text continued on p. 892

868 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 23-1  A 28-year-old woman arrived for a third surgical opinion regarding a reduction rhinoplasty and reduction genioplasty. The diagnosis
of a short face growth pattern was made. Maxillomandibular advancement and vertical lengthening were recommended. The patient agreed to a
surgical approach with perioperative orthodontics. Her surgery included maxillary Le Fort I osteotomy in segments (vertical lengthening, horizontal
advancement, arch expansion and clockwise rotation) with interpositional grafting; sagittal split ramus osteotomies (horizontal advancement and
clockwise rotation); and osseous genioplasty (vertical lengthening) with interpositional grafting. A, Frontal views in repose before and after recon­
struction. B, Frontal views with smile before and after reconstruction.

869
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
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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 23-1, cont’d 
Continued

870 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary
clockwise
rotation
Mandibular
clockwise
rotation
E
E, Occlusal views before and after treatment. Only minimal change in the occlusion was required. F, Articulated dental
casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment.
• Figure 23-1, cont’d

871
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
Orth
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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 23-2  A 16-year-old girl arrived with her parents for surgical evaluation. She requested a reduction rhinoplasty and a chin implant. A
diagnosis of maxillomandibular deficiency with a Class II excess overjet malocclusion was made. She agreed to a surgical and (redo) orthodontic
approach. No extractions were carried out, and a degree of incisor proclination was tolerated. The patient’s surgery included maxillary Le Fort I
osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation) with interpositional grafting; sagittal split ramus osteotomies (hori­
zontal advancement and clockwise rotation); and osseous genioplasty (vertical lengthening) with interpositional grafting. A, Frontal views in repose
before and after treatment. B, Frontal views with smile before and after treatment.
Continued

872 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
C
D
C, Oblique facial views before and after treatment. D, Profile views before and after treatment.
• Figure 23-2, cont’d

873
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
E
G
Maxillary
clockwise
rotation
Mandibular
clockwise
rotation
F
E, Occlusal views before and after treatment. Only minimal change in the occlusion was required. F, Articulated dental
casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment.
• Figure 23-2, cont’d

874 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 23-3  A 24-year-old woman arrived for evaluation. She had previously undergone four bicuspid extractions and orthodontics to neutralize
her occlusion during her high school years. Analysis confirmed a short face growth pattern that accounted for the apparent large nose, weak profile,
obtuse neck–chin angle, and edentulous look. She agreed to a combined (redo) orthodontic and surgical approach. The patient’s surgery included
maxillary Le Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation) with interpositional grafting; sagittal split ramus
osteotomies (horizontal advancement and clockwise rotation); and osseous genioplasty (vertical lengthening and minimal horizontal advancement)
with interpositional grafting. Minimal change in the occlusion was required. A, Frontal views in repose before and after treatment. B, Frontal views
with smile before and after treatment.

875
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
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 23-3, cont’d 
Continued

876 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
C
E
Prior to retreatment after four bicusbid extractions
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and after reconstruction.
• Figure 23-3, cont’d

877
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
F
G
Maxillary
clockwise
rotation
Mandibular
clockwise
rotation
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 23-3, cont’d

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 23-4  A woman in her late 20s arrived for the evaluation of her edentulous look. She had previously undergone orthodontic neutralization
of her occlusion during her high school years. Analysis suggested a short face growth pattern that accounted for her apparent large nose, protrusive
chin, and edentulous look. The patient also complained of nasal obstruction, restless sleeping, and daytime fatigue. Examination confirmed septal
deviation and enlarged inferior turbinates, and an attended polysomnograph documented mild obstructive sleep apnea. She underwent a combined
(redo) ortho­dontic and surgical approach. The patient’s surgery included maxillary Le Fort I osteotomy in segments (horizontal advancement, vertical
lengthening, arch expansion and clockwise rotation) with interpositional grafting sagittal split ramus osteotomies (horizontal advancement and
clockwise rotation); osseous genioplasty (vertical lengthening and minimal horizontal advancement) with interpositional grafting; and septoplasty
and inferior turbinate reduction. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.

879
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
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 23-4, cont’d 
Continued

880 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 1 year after reconstruction. Minimal
change in the occlusion was required.
• Figure 23-4, cont’d

881
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
F
G
Arch expansion
Mandibular clockwise rotation
Maxillary clockwise rotation
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 23-4, cont’d

882 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 23-5  A 16-year-old girl was referred by her orthodontist, primarily for the evaluation of malocclusion. She underwent attempts at growth
modification and then orthodontic treatment when she was between 10 and 12 years old. The examination confirmed maxillomandibular deficiency
with a Class II excess overjet malocclusion. She had chronic nasal obstruction, and she was also found to have a deviated septum and hypertrophic
inferior turbinates. A surgical and (redo) orthodontic approach was recommended. The patient’s surgery included maxillary Le Fort I osteotomy in
segments (horizontal advancement, vertical lengthening, and arch expansion) with interpositional grafting; sagittal split ramus osteotomies (horizontal
advancement) osseous genioplasty (vertical lengthening) with interpositional grafting; and septoplasty and inferior turbinate reduction. A, Frontal
views in repose before and after treatment. B, Frontal views with smile before and after treatment.

883
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
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 23-5, cont’d 
Continued

884 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 treatment.
• Figure 23-5, cont’d

885
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
F
Arch expansion
G
F, Articulated dental casts that indicate model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 23-5, cont’d

886 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 23-6  A man in his mid 20s arrived for the surgical evaluation of an edentulous look and difficulty breathing. He was found to have a
short face growth pattern, nasal obstruction, and mild obstructive sleep apnea. A surgical approach with (redo) orthodontics was recommended.
The patient’s surgery included maxillary Le Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation) with interpositional
grafting; sagittal split ramus osteotomies (horizontal advancement and clockwise rotation); osseous genioplasty (vertical lengthening) with interpo­
sitional grafting; and septoplasty and inferior turbinate reduction. A, Frontal views in repose before and after treatment. B, Frontal views with smile
before and after treatment.

887
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
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 23-6, cont’d 
Continued

888 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
E
Prior to surgery
After treatment
E, Occlusal views before and after treatment. F, Articulated dental casts that indicate analytic model planning.
G, Lateral cephalometric radiographs before and after treatment.
• Figure 23-6, cont’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
A
B
• Figure 23-7  A 26-year-old woman with a short face growth pattern arrived to discuss her maxillofacial issues. During her early teenage years,
she underwent a full course of orthodontics. Her maxillary lateral incisors were congenitally absent, and the spaces were orthodontically closed,
partially by tipping the canines forward. The maxillary incisor root resorption was significant. There was crowding in the mandibular arch with a
degree of procumbency. The patient had an interest in improving her weak profile and her edentulous look. The patient’s history confirmed heavy
snoring, restless sleeping, and daytime fatigue. Examination confirmed a deviated septum and hypertrophic inferior turbinates. Maxillary retrusion
resulted in the close proximity of the soft palate to the pharyngeal wall. A retrusive mandible resulted in the close proximity of the tongue to the
posterior pharyngeal wall. An attended polysomnogram confirmed mild obstructive sleep apnea. Evaluation by a periodontist and an orthodontist
confirmed the advantage of a comprehensive approach to improve the airway, to achieve a more balanced facial appearance, and to improve
long-term periodontal health. A trial of continuous positive airway pressure improved daytime alertness, but the patient’s feelings of claustrophobia
prevented its use. Periodontal evaluation with gingival grafting and maintenance was carried out. Ortho­dontic appliances were placed with limited
dental repositioning of the maxillary incisors as a result of baseline root resorption. The patient’s surgery included maxillary Le Fort I osteotomy in
segments (horizontal advancement, vertical lengthening, arch form correction, and clockwise rotation) with interpositional graft; bilateral sagittal split
ramus osteotomies (horizontal advancement); and osseous genioplasty (vertical lengthening) and limited horizontal advancement) with interpositional
bonegraft. As a result of treatment, the patient has had a relief of her snoring, more restful sleeping, and improved alertness during the day.
A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.
Continued