Orthognathic Surgery

891
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
E
Prior to retreatment with congenital missing lateral incisors and dental gap closure
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and 1 year after reconstruction. Minimal
change in occlusion was required.
• Figure 23-7, cont’d 
Continued

892 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
lengthening of the maxilla with a face mask apparatus.6 The
best data indicate that use of the Delaire mask to increase
maxillary projection is only effective for young children
who are less than 8 to 10 years old, when the sutures remain
open.48,49 Unfortunately, with the short face growth pattern,
Delaire face mask therapy is simultaneously counterproduc­
tive on the baseline deficient mandible, even if it effectively
projects the maxilla.
Definitive Reconstruction
Timing of Orthognathic Surgery
The best evidence available indicates that, when orthogna­
thic surgery is performed on a patient with a short face
growth pattern (i.e., maxillomandibular deficiency) as early
as the completion of the adolescent growth spurt, the result
will be stable from a growth perspective. Further sagittal
growth of either the maxilla or the mandible almost never
occurs.45 Vertical growth in both the mandible and the
maxilla is also not likely to continue, but, if it does, it should
be proportionate. Therefore, proceeding with orthognathic
Orthodontic growth modification treatment during pre­
adolescence attempts to increase the eruption of the poste­
rior teeth.19,31,44 If this is successful, while lengthening the
anterior facial height, this will cause the mandible to rotate
clockwise, thereby resulting in a downward and backward
shift at the pogonion. Unfortunately, this backward rotation
of the mandible is not favorable to the profile unless it is
also accompanied by horizontal advancement. For the pre­
adolescent with a Class II excess overjet and a short face
growth pattern, cervical headgear has been used to apply
extrusion forces to the posterior maxillary dentition;
however, this tends to simultaneously “set back” the already
retrusive maxilla. As an alternative, functional intraoral
appliances have also been tried in an attempt to erupt the
posterior dentition. These orthopedic maneuvers, when fol­
lowed by orthodontic mechanics, may achieve a neutralized
occlusion in the child with maxillomandibular deficiency.
However, this treatment cannot achieve the vertical height
and the horizontal projection required to normalize the
facial proportions and improve the airway.4,7,22,52,59
Since the late 1970s, Delaire and colleagues have
attempted to achieve horizontal advancement and vertical
F
G
Maxillary clockwise rotation
Arch correction
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 23-7, cont’d

893
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
is to bond metal or ceramic “bite turbos” to the lingual
surfaces of the maxillary incisors. This provides an anterior
bite plane to open the bite without molar extrusion.
Anticipating the advantages of the surgical segmenting
of the maxilla to level the curve of Spee and to correct arch-
width discrepancies is often helpful. The postsurgical final
leveling of the curve in the mandibular arch is generally
both efficient and effective.
Basic Surgical Approach
By definition, for the patient with a moderate to severe
short face growth pattern, there will be a need to simultane­
ously surgically reposition the maxilla, the mandible, and
the chin region if the normalization of both the facial height
and the facial projection is desired.1,2,5,8,9,27-30,36-41,53,58 For the
patient with a Class I short face growth pattern, simply
lengthening the maxilla to improve the upper lip to tooth
relationship through Le Fort I osteotomy with maintenance
of the occlusion will cause an undesirable backward rotation
of the mandible. This “single jaw” approach prevents the
necessary horizontal advancement of the maxilloman­
dibular complex. Unfortunately, the inability to achieve
adequate sagittal (horizontal) projection of the maxilloman­
dibular complex is likely to result in aesthetic disappoint­
ment. For this reason, bimaxillary surgery (i.e., Le Fort I
and bilateral sagittal split ramus osteotomies) is required for
the correction of a short face growth pattern. In borderline
cases, a limited camouflage approach involving an osseous
genioplasty with significant vertical lengthening and a
degree of horizontal advancement may at least provide some
aesthetic enhancement without introducing surgical defor­
mity (see Chapters 37 and 40).
Orthognathic planning begins with the making of deci­
sions about the magnitude of vertical lengthening, horizon­
tal advancement, and clockwise rotation required in the
maxilla. These decisions are primarily based on aesthetic
judgments that are made when examining the patient in the
natural head position (see Chapter 12). A common mistake
is to err on the side of insufficient lengthening of the
midface out of a belief that the short upper lip will not
accommodate the skeletal lengthening. Experience has
shown that the hypotonic (short) upper lip will stretch and
gain function when the maxilla is surgically expanded (i.e.,
horizontal advancement and vertical lengthening). In addi­
tion, as the maxilla is surgically lengthened and simultane­
ously advanced and clockwise rotated, the pyriform rims
and the anterior nasal spine are thrust forward and inferi­
orly, thus further stretching and filling out the soft tissues
of the lower aspect of the nose and the upper lip. When the
anterior floor of the nose (i.e., the alveolar bone height
above the incisors) is short, consideration should also be
given to graft augmentation of the anterior floor at the rim
just above the incisors to further improve nasal base aesthet­
ics. The need for this should be definitively reassessed during
the operation, after the maxilla is stabilized with plate and
screw fixation in its new location. In addition to maxillary
surgery in the individual with maxillomandibular deficiency
as early as the age of 13 or 14 years—but only after the
eruption and orthodontic alignment of the teeth—is gener­
ally safe from a growth perspective.
Orthodontic Preparation for Orthognathic
Surgery
Class II, Division I
The basic presurgical orthodontic goals for the individual
with Class II, Division I malocclusion include the follow­
ing: 1) aligning each dental arch independently; 2) placing
the incisors in their preferred anteroposterior and vertical
plane position; 3) anticipating a stable arch compatibility
after surgery; and 4) considering segmental maxillary oste­
otomies to accomplish these goals.
Extractions from the maxillary arch are generally not
indicated. There is often an excessive curve of Spee in the
mandible, and the full leveling of the curve after surgery is
generally preferred. This is rapidly accomplished via the
extrusion of the premolars after surgery with the use of
vertical elastics. The alternative to preoperative leveling
involves incisor intrusion. Less clockwise rotation of the
mandible at operation should be expected when incisor
intrusion has been carried out to flatten the curve of Spee.
The establishment of eventual arch compatibility through
orthodontics and surgery requires the following:
• Compatible intercanine widths either through ortho­
dontics alone or with the help of maxillary segmental
osteotomies
• Bonding or banding and leveling of the first and
second molars
• Anticipating similar maxillary and mandibular arch
forms either through orthodontics alone or with the
help of maxillary segmental osteotomies
Postsurgical orthodontics will maintain the arch form
and bring the teeth into final occlusion. The full leveling of
the curve of Spee and closure of the extraction spaces in the
mandible is usually accomplished during the detailing phase
after surgery.
Class II, Division II
The basic presurgical orthodontic goals for the Class II,
Division II malocclusion include the following: 1) the need
for the proper vertical and anteroposterior positioning of
the maxillary and mandibular incisors; 2) the need to level
the curve of Spee; and 3) the need to anticipate coordinated
dental arches after surgery, 4) which may include or require
segmental maxillary osteotomies.
In general, the maxillary incisors will require labial
tipping to correct the inclination. For severe deep-bite cases,
it is advisable to fully level the curve of Spee in the man­
dibular arch after surgery. Preoperative glass ionomer bite
planes cemented to the mandibular molars may be helpful,
but unwanted molar intrusion can occur. Another option

894 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
desired result be determined (see Chapter 12). Analytic
model planning is carried out on the articulated dental casts
with use of the Erickson Model Table. Splints are con­
structed to assist with the achievement of the precise occlu­
sion and preferred facial aesthetics in the operating room
(see Chapter 13).
Postsurgical Orthodontic Maintenance
and Detailing
If the Class II excess overjet patient has a presurgical habit
of posturing the mandible forward (i.e., a dual bite), there
may also be a tendency to do so during the immediate
postoperative healing phase, thereby producing a pseudo­
anterior crossbite. Intermittent intermaxillary elastics are
used during this time to retrain the masticatory muscles, to
provide motion in the temporomandibular joints, to
increase patient comfort, and to confirm the stability of the
occlusion. If a splint is used, when it is removed (e.g., 5
weeks after surgery), the patient should immediately (ideally
within 24 hours) return to the orthodontist for the place­
ment of a continuous maxillary arch wire. In general, the
maintenance of the new arch form after segmental surgery
is the most challenging aspect of the postsurgical orthodon­
tic phase of treatment.
The postsurgical orthodontic objectives should be to
maintain the surgical result and to bring the teeth into ideal
occlusion. In the patient in whom the curve of Spee is to
be fully leveled postoperatively, the use of vertical elastics to
close the mid arch open bites will also be a priority.
Complications, Informed Consent, and
Patient Education
The orthodontist and the surgeon are asked to evaluate the
individual with maxillomandibular deficiency and to then
attempt to alter nature’s events. By understanding the
expected effects of the uncorrected short face growth pattern
(i.e., airway, aesthetics, long-term dental health) and with
knowledge of how specific orthodontic and orthognathic
interventions will alter head and neck function and enhance
facial aesthetics, a successful outcome is expected in most
cases. An understanding of the potential risks in comparison
with the anticipated benefits of each intervention is taken
into account, because complications and dissatisfaction
will always occur in a small percentage of individuals. The
clinician’s ability to communicate the potential risks, com­
plications, alternative approaches, and benefits of the rec­
ommended treatment to the patient and their family is
essential. The patient’s informed decision to proceed pro­
vides the basis for shared responsibility of the expected
convalescence and long-term outcome (see Chapter 16).
Malocclusion after Orthodontics and
Orthognathic Surgery
There are inherent biologic challenges to the orthodontic
movement of teeth within the alveolar process and the
reconstruction, the mandible requires horizontal advance­
ment and often clockwise rotation. This is accomplished
through sagittal split ramus osteotomies. In most cases, an
osseous genioplasty provides access to vertically lengthen
the deficient anterior mandibular alveolar height and inter­
positional grafting is required. Horizontal advancement of
the chin is not generally beneficial.
The previous line of thinking was that vertical lengthen­
ing, especially in combination with horizontal advancement
of the maxilla, is unstable and inadvisable.5,13,14,17,18,24,46,57
We now know that, with full mobilization of the down-
fractured maxilla, lengthening and advancement can be
carried out with occlusal stability and the routine achieve­
ment of improved facial aesthetics. This requires the follow­
ing: 1) well-designed and executed osteotomies; 2) the full
mobilization of the down-fractured maxilla; 3) rigid plate
and screw fixation; 4) the placement of an interpositional
graft (e.g., autogenous or allogenic corticocancellous iliac
bloc graft) into the gaps between the zygomatic buttress
and the pyriform rim on each side; 5) additional rigid
plate and screw fixation to secure each graft; and 6) appro­
priate postoperative management to control bite forces
during the early healing phase at the Le Fort I osteotomy
sites (see Chapter 15). Kretschmer and colleagues studied
the incidence of relapse after Le Fort I osteotomy with
vertical lengthening with both single piece and segmental
Le Fort I osteotomies (see Chapter 17).16 The authors’
data confirms that, when significant advancement and
lengthening at the Le Fort I osteotomy site are carried
out, key factors to achieve postoperative stability include
the interpositional bone grafting of defects and rigid
plate and screw fixation. Interestingly, the researchers did
not find segmentation of the maxilla during bimaxillary
procedures to be a significant cause of either skeletal
or dental relapse.
Immediate Presurgical Planning
The immediate presurgical planning takes into account col­
laborative clinical efforts among the orthodontist, the
surgeon, the patient, and the patient’s family that will have
been ongoing since the initial consultation visits. Depend­
ing on the condition of the dentition and its supporting
structures, the restorative dentist and the periodontist may
also have been intricately involved.
The patient’s specific medical and dental records are
reviewed, including radiographs (e.g., computed tomogra­
phy scans; panoramic, lateral, and posteroanterior cephalo­
metric radiographs; periapical images); photographs (facial
and occlusal); and dental models. Immediate presurgical
records (i.e., within 2 to 6 weeks of surgery) will most
importantly include facial measurements obtained from
direct visual examination; alginate impressions of the
maxilla and mandible; an accurate centric relation bite reg­
istration; and face-bow registration. First, broad-stroke
decisions are made regarding the preferred vector changes
for each jaw; only then can the precise millimeter distances
and angular changes required for each jaw to achieve the

895
CHAPTER 23  Short Face Growth Patterns: Maxillomandibular Deficiency
spasm or disc displacement with or without reduction);
condylar head erosion; and pain on direct palpation of
either temporomandibular joint or of the masticatory
muscles. Occlusal factors (i.e., degrees of malocclusion) are
often claimed to be associated with temporomandibular
disorders. Interestingly, patients with maxillomandibular
deficiency (i.e., the short face growth pattern) tend to have
higher maximum biting forces than those with normal or
long vertical facial dimensions.12,26,47,55 This has been docu­
mented to be statistically significant during swallowing,
simulated chewing, and maximum biting.31 Affected
patients often claim to have difficulty chewing through
foods and also experience masseter muscle discomfort. The
individual with a short face growth pattern and a Class II
significant overjet malocclusion is likely to have an uncom­
fortable dual bite, whereas the patient with a Class I deep
bite is more likely to have temporomandibular joint click­
ing; in the latter case, there is no reason to believe that
progressive temporomandibular joint pathology will occur
(see Chapter 9).
Conclusions
The dentofacial disharmony referred to as short face growth
pattern has the common denominator of a significant degree
of vertical and horizontal deficiency in the maxilla and the
mandible. The aesthetic presentation generally includes
an apparent fullness of the cheeks and a deficiency of the
lower face in the adolescent, with a prematurely aged look
present by early adulthood. To achieve Euclidian facial pro­
portions with enhanced facial aesthetics, there must be both
vertical and horizontal expansion of the maxillomandibular
complex. Accomplishing these objectives should success­
fully eliminate soft-tissue bunching, restore a more pleasing
facial appearance, improve the upper airway, and correct
any presenting malocclusion.
surgical repositioning of the jaws or jaw segments after
osteotomies in a patient with a short face growth pattern.
This includes the technical aspects of the repositioning; the
initial healing requirements; and the difficulties associated
with the long-term maintenance of the relocated teeth, jaws,
and jaw segments. When following sound biomechanical
and aesthetic principles, clinicians carry out orthodontic
treatment and surgical procedures that involve correction
and then successful maintenance of the result in most cases.
Potential intraoperative technical difficulties associated with
sagittal split ramus osteotomies of the mandible and with
maxillary Le Fort I osteotomy can result in immediate
(early) malocclusion, but this is preventable in most cases.
Ongoing growth after surgery is rarely an issue with a short
face growth pattern. Although condylar resorption after
orthognathic surgery is not entirely predictable, it is uncom­
mon (see Chapter 36). The orthodontic removal of dental
compensations and the placement of the teeth solidly in the
alveolar housing will best ensure a long-term stable occlu­
sion and periodontal health. All of these factors are taken
into account to achieve and then maintain a favorable result
(see Chapter 17).
Temporomandibular Disorders:
The 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 disorder includes 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 pain; joint noise (e.g., popping, clicking, crepitus);
reduced or altered mandibular movements (i.e., muscle
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897

24
Bimaxillary Dental Protrusive Growth
Patterns with Dentofacial Disharmony
JEFFREY C. POSNICK, DMD, MD
• Functional Aspects
• Clinical Characteristics
• Dental Findings
• Radiographic Findings
• Treatment Pitfalls
• Orthodontic Approach
• Orthognathic and Dentoalveolar Surgical
Approaches
• 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
bilabial (lip) forces.103,104,120 The common physical findings
include flaccid lips, procumbent maxillary and mandibular
incisors, and an anterior open bite.
Drummond compared the facial morphology of Cauca­
sian Americans to that of African Americans.35 He found
that Africans more frequently have a protrusive and strong
tongue with loose, flaccid lips. These altered forces during
growth are known to gradually push the anterior teeth into
a procumbent position. The resulting proclination of the
teeth in combination with the thickness of the lips make
the lower face appear to be more full. Altemus compared
the cephalofacial relationships of Caucasian, African,
Chinese, Japanese, Navajo Indian, and Australian aboriginal
individuals.3 He concluded that the relative straightness of
an individual’s facial profile is very much a reflection of the
underlying skeletal parts. He also found that, although the
upper facial profiles (i.e., the forehead, orbits, and cheek­
bones) of the varied racial groups appeared to be remarkably
similar, the lower facial profiles (i.e., the maxilla, mandible,
and chin region) did not. The position of the anterior teeth
and lips of African children were found to be more protru­
sive as compared with those of Caucasians. Sushner studied
100 lateral facial photographs of “attractive” Africans.119 He
used the Steiner, Holdaway, and Ricketts cephalometric
standards to analyze the “attractive” African facial photo­
graphs,53,88 and he concluded that the soft-tissue profiles of
the individuals in those photographs were significantly
more protrusive than the accepted Caucasian standards. He
went on to establish African cephalometric norms. Similar
studies completed by Guinn and Connor confirmed that
the African soft-tissue profile is more protrusive and signifi­
cantly different from Caucasian cephalometric norms.5,24,25,50
Peck and Peck set out to determine the public’s concept
of beauty as related to the Caucasian profile.94 The authors
found that the general public admires a more full face as
compared with the accepted cephalometric normative data
and clinical orthodontic standards of the day (e.g., four
bicuspid extractions with orthodontic retraction). These
Bimaxillary dental protrusion can occur in any racial group,
but facial divergence (i.e., convexity) and lip prominence
are strongly influenced by racial and ethnic characteris­
tics.37,67,95,107 Greater degrees of lip and incisor prominence
tend to occur in Asians, Africans, and Latinos as compared
with Caucasians.68,75 In Caucasian populations, dental pro­
trusion is more common among individuals of Mediterra­
nean background than among those from more northern
European regions. The Australian aborigines, who are clas­
sified as Caucasoid, have greater degrees of facial and dental
protrusion. Etiologic factors that favor bimaxillary dental
protrusion with anterior open bite include heredity; para­
oral habits (e.g., thumb sucking); and the presence of strong
protrusive tongue muscle forces in combination with weak

898 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
authors pointed out that the “ultimate source of our aes­
thetic values should be the people [i.e., public opinion], not
just ourselves [i.e., clinicians].” Foster studied facial aes­
thetic preferences among various groups by using profile
silhouettes.44 The evaluators included Africans, Caucasians,
and Chinese individuals; art students; general dentists; and
orthodontists. The results confirmed a common aesthetic
preference for the position of the lips in profile to be within
1 mm to 2 mm of each other. Another finding was that all
groups consistently associated fuller lips with a more youth­
ful appearance. Farrow and colleagues attempted to discover
what African Americans find attractive about their own
profiles.40 The study results found that the preferred aes­
thetic profile involved slight convexity and more protrusion
as compared with standard Caucasian cephalometric norms.
A review of the literature confirms that, as a group, African
Americans differ from Caucasian Americans with regard to
dental, skeletal, and soft-tissue facial parameters.2,31,43,58,122
For both groups, facial convexity is a preferred
feature.28,30,76,77,100 However, the question remains: at what
point does attractive fullness (i.e., convexity) of the profile
become dysmorphic and unattractive?
Distorted vertical and horizontal growth of the maxil­
lomandibular skeleton in association with bimaxillary
dental protrusion will result in both facial and dental dis­
harmony.84 This growth pattern may be associated with
Class I, Class II, and Class III molar relationships, but it
always occurs with mandibular and maxillary incisor pro­
cumbency and anterior open-bite malocclusion.5,47,52,85,113,118
Individuals with bimaxillary dental protrusion will also have
varying degrees of lip incompetence and mentalis strain;
exposure of the anterior teeth in repose and gingival show
with smile; and, typically, a dysmorphic chin in profile. If
these aspects become excessive, then the diagnosis of an
associated dentofacial disharmony is appropriate.109
The generally offered correction of the anterior open-bite
malocclusion associated with bimaxillary dental protrusion
is the extraction of four premolars followed by the ortho­
dontic retraction of the anterior teeth into the edentulous
gaps.6,121,126 This treatment also tends to retract the lips and
to reduce facial convexity.33,34,48,72 To determine which
individuals also have significant dentofacial (jaw) dishar­
mony and thus will benefit from an orthognathic approach
(i.e., the surgical repositioning of the upper and lower jaws),
the clinician should assess pretreatment skeletal, dental, and
soft-tissue parameters. This includes the following:
• An evaluation of the maxillomandibular skeleton (i.e.,
horizontal and vertical dimensions)
• An assessment of the dental condition (i.e., incisor
inclination, spacing and crowding, the curve of Spee,
arch width, overjet, and overbite)
• An evaluation of the soft-tissue static and dynamic
position of the lips (i.e., the lip-to-tooth relationship
in repose and with smile, the interlabial gap, the
degree of mentalis strain with closure, and the naso­
labial and labiomental angles).
Functional Aspects
• Wide lip separation with excessive effort required to
achieve lip seal is present.
• Chronic obstructive nasal breathing as a result of
increased intranasal airway resistance is frequent (see
Chapter 10).
• Classic articulation errors in speech caused by the
anterior open-bite malocclusion are expected (see
Chapter 8).
• Chewing and swallowing difficulties as a result of the
anterior open-bite malocclusion and lip incompetence
are expected (see Chapter 8).
• Detrimental long-term effects on the dentition and the
periodontium caused by traumatic occlusal forces, the
spacing of the teeth in the alveolar housing, or previous
camouflage orthodontic treatment may be seen (see
Chapter 5 and 6).
• Temporomandibular disorder (TMD) should be looked
for but is not generally problematic in these individuals
(see Chapter 9).
Clinical Characteristics
• Separation of the lips at rest of >4 mm
• Excessive dental show with the upper lip at rest and
excessive gingival show with a broad smile
• Flaccid lips with more effort required to bring them into
closure (i.e., mentalis strain and lip incompetence)
• Excessive prominence of the lips with everted vermillion
borders when viewed in profile
• Typically a mouth-breathing habit and an open-mouth
posture with a protrusive tongue
• Convex maxillomandibular profile
• Chin deformity frequently seen in profile
Dental Findings
• Anterior open bite
• Maxillary and mandibular incisor proclination
• Exaggerated curve of Spee in the maxilla and a reverse
curve in the mandible
• Frequently with narrow maxillary arch width
• Frequently with a Class II molar relationship, although
a Class I or Class III malocclusion may be present
• Frequently with interdental spacing in the anterior denti­
tion of the maxilla and mandible
• Despite incisor proclination, presence of adequate peri­
odontal support without gingival recession, labial bone
dehiscence, or fenestration is typical
Radiographic Findings
• Procumbency of the maxillary incisors
• Procumbency of the mandibular incisors
• Lack of chin prominence at the pogonion is generally
notable

899
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
individual, achieving correction of incisor procumbency
and the open bite will have only a limited impact on lip
function and prominence.4,42,90,128
Orthodontic Approach
Historical Perspective
During the early 1900s, the uncompromising non-extraction
orthodontic approach set forth by Angle was the treatment
of the day (see Chapter 2).5 Angle used full-banded appli­
ances to expand the arches as a method of bringing the teeth
into ideal alignment, no matter how much additional pro­
trusion was created in the process. Calvin Case disagreed
with Angle’s treatment concepts for the bimaxillary protru­
sive anterior open-bite problem and stated that “one of the
most dangerous features of the Angle classification is the uni­
versally applied teaching that when the dentures [teeth] are
placed in normal occlusion, the facial outlines will take care of
themselves.”19 For the individual with bimaxillary dental
protrusion, Case proposed bicuspid extraction in all four
quadrants, followed by the placement of full-banded orth­
odontic appliances to retract the procumbent incisors into
the extraction sites. It was not until well after Case’s death
that these techniques for orthodontic management were
popularized by two of Angle’s own students. Charles
Tweed124 in the United States and Raymond Begg10 in
Australia reintroduced extraction treatment into everyday
orthodontic practice. The mainstay of treatment for dento­
alveolar protrusion with anterior open bite continues to
involve the removal of a premolar in each quadrant followed
by orthodontic retraction of the protruded anterior teeth
(see Chapter 17).32,36,60,61,62,73,82
Review of the Literature
There is a definite association between bimaxillary skeletal
(jaw) disharmony and dentoalveolar (dental) protrusion
with open bite. The standard treatment for the dentoalveo­
lar aspects of this condition is four bicuspid extractions and
then the use of maximum anchorage to orthodontically
retract the anterior dentition to achieve space closure; this
will also tend to decrease the chief complaint of lip fullness.
The side effects of this form of treatment may include
root resorption; excess lingual tipping of the anterior
teeth; remodeling with dehiscence and fenestration of
the cortical plate; insufficient retraction as a result of anchor­
age loss; and even more pronounced incisor exposure (i.e.,
gummy smile). Orthodontic technical maneuvers may
also include the use of mini-screws as temporary anchorage
devices (TADs), torque control of the upper and lower
incisors, and alveolar corticotomies followed by more
rapid orthodontic retraction into the bicuspid extraction
sites.7,21,22,55,56,59,69,71,78,83,87,89,92,125,127 These options also run
the risk of the previously mentioned negative sequelae, but
they are believed to shorten overall treatment time.
• Anterior open bite measured at the incisal edges
• Excessive lower anterior facial height (i.e., the distance
measured from nasion to the pogonion)
Treatment Pitfalls
When considering orthognathic surgery for the individual
with bimaxillary dental protrusion, there must be a com­
pelling aesthetic or functional rationale for the shortening
of the anterior vertical dimension of the face and the altera­
tion of the horizontal projection (Figs. 24-1 through
24-11).18,41,46,64,65,80,115 When present, facial aesthetic dishar­
mony in association with bimaxillary dental protrusion is
generally characterized by the following:
• Excessive separation of the lips at rest (i.e., lip incompe­
tence). As a general rule, lip separation at rest should
be less than 4 mm.
• Excessive incisor show with the upper lip at rest. As
a general rule, more than 50% of the vertical height
of the incisor should be seen to be considered
excessive.
• Excessive effort required to bring the lips into closure (i.e.,
mentalis strain).
• Significant vertical and horizontal facial disproportion
when viewed in profile.
All four characteristics are preferred to make the diagno­
sis of a significant dentofacial disharmony in association
with bimaxillary dental protrusion to the extent that the
surgical alteration of the facial height and facial projection
through orthognathic surgery is recommended.
Text continued on p. 939
NOTE: An individual’s degree of soft-tissue lip
prominence may be independent of jaw and tooth
position. The establishment of reasonable skeletal
harmony and dental occlusion is not a guarantee of the
achievement of preferred soft tissue lip shape and
function.
When planning the orthognathic correction, a determi­
nation is made of how much incisor procumbency is too
much.96 Anterior teeth that protrude excessively are likely
to be associated with lips that are prominent, everted, and
separated at rest by more than 3 mm to 4 mm (i.e., lip
incompetence). This will cause the individual to strain in
an attempt to bring the lips together over the protruding
teeth. Retracting (i.e., uprightening) the incisors with the
successful closure of the open bite by whatever means tends
to decrease facial convexity when the face is viewed in
profile.86,93,111,112,116 If the lips are prominent but are able to
comfortably close over the teeth without excessive strain,
then the lip posture (i.e., the position at rest) is largely
independent of the current jaw and tooth position and
more a result of lip muscle tone.16,17,91,101,106,123 For such an

900 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 24-1  A 16-year-old girl was referred by her orthodontist for the evaluation of lip incompetence, anterior open bite, gummy smile, weak
chin, and nasal obstruction. Orthodontics had previously been carried out without extraction therapy. The patient presented with a Class II anterior
open bite dental protrusive malocclusion. A combined orthodontic and surgical approach was recommended. With non-extraction orthodontic
decompensation complete, the patient’s surgery included maxillary Le Fort I osteotomy in segments (arch expansion, correction of the curve of
Spee, vertical intrusion, minimal horizontal advancement and counterclockwise rotation); sagittal split ramus osteotomies (horizontal advancement
and counterclockwise rotation); osseous genioplasty (vertical reduction and horizontal advancement); and septoplasty, inferior turbinate reduction,
and nasal floor recontouring. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.

901
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-1, cont’d 
Continued

902 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
Maxillary counterclockwise rotation
Mandibular counterclockwise rotation
Arch expansion
E
Prior to retreatment
Pre surgery
After treatment
E, Occlusal views before retreatment, with orthodontics in progress, and after treatment. F, Articulated dental
casts that indicate analytic model planning.
• Figure 24-1, cont’d

903
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-2  A 28-year-old woman arrived for the evaluation of malocclusion, gummy smile, lip incompetence, and nasal obstruction. She pre­
sented with a Class III anterior open-bite dental protrusive malocclusion. She underwent a combined orthodontic and surgical approach without
extractions. The patient’s surgery included maxillary Le Fort I osteotomy in segments (transverse expansion, vertical intrusion, minimal advancement,
and clockwise rotation); sagittal split ramus osteotomies (minimal advancement and counterclockwise rotation); osseous genioplasty (vertical reduc­
tion and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal views in repose before and
after treatment. B, Frontal views with smile before and after treatment.
Continued

904 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 24-2, cont’d

905
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
E
Prior to treatment
Pre surgery
After treatment
E, Occlusal views before treatment, with orthodontics in progress, and 3 years after treatment.
• Figure 24-2, cont’d 
Continued

906 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary clockwise rotation
Vertical shortening
Mandibular counter-
clockwise rotation
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 24-2, cont’d

907
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-3  A 24-year-old woman was referred by her orthodontist for surgical evaluation. She presented with a Class III anterior open-bite
dental protrusive malocclusion. She underwent four bicuspid extractions with orthodontic decompensation followed by orthognathic surgery. Her
procedures included maxillary Le Fort I osteotomy in segments (clockwise rotation, horizontal advancement, arch expansion, and vertical shorten­
ing); sagittal split ramus osteotomies (minimal clockwise rotation); osseous genioplasty (horizontal advancement); and septoplasty, inferior turbinate
reduction, and nasal floor recontouring. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment.
Continued

908 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 24-3, cont’d

909
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
F
Maxillary
clockwise
rotation
Mandibular
adjustment
E
Pre surgery after four bicuspid extractions
After treatment
E, Occlusal views with orthodontics in progress and after treatment. F, Articulated dental casts that indicate
analytic model planning.
• Figure 24-3, cont’d

910 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 24-4  A 28-year-old Hispanic woman was referred by her orthodontist for the evaluation of malocclusion and lip incompetence. She was
found to have a Class III anterior open-bite malocclusion and lifelong nasal obstruction. She underwent non-extraction orthodontic decompensation
followed by surgery. Her procedures included maxillary Le Fort I osteotomy in segments (correction of the arch form); sagittal split ramus osteoto­
mies (minimal counterclockwise rotation); osseous genioplasty (horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal
floor recontouring. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.

911
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-4, cont’d 
Continued

912 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Prior to treatment
After treatment
F
G
Maxillary vertical
shortening
Mandibular counter-
clockwise rotation
Arch expansion
E, Occlusal views before orthodontics and after treatment. Note the limited overjet as a result of mild dental
relapse. F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment.
• Figure 24-4, cont’d

913
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-5  An 18-year-old Asian man was referred for surgical evaluation. He presented with a Class III anterior open-bite dental protrusive
malocclusion. Concerns included nasal obstruction, gingivitis, gummy smile, anterior open-bite malocclusion, lip incompetence, and retrusive profile.
Orthodontic decompensation was carried out and included four bicuspid extractions. The patient’s surgery included maxillary Le Fort I osteotomy
in segments (vertical shortening, minimal horizontal advancement, counterclockwise rotation, and transverse widening); sagittal split ramus osteoto­
mies (minimal 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 treatment. B, Frontal views with
smile before and after treatment.
Continued

914 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 24-5, cont’d

915
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
E
Prior to treatment
Pre surgery after four bicusbid extractions
After treatment
X
X
X
X
E, Occlusal views before treatment, before surgery with four bicuspid extractions, and after treatment.
• Figure 24-5, cont’d 
Continued

916 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Maxillary counterclockwise rotation
Mandibular counterclockwise rotation
Arch expansion
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after treatment. Despite the bicuspid extractions, procumbency remains.
• Figure 24-5, cont’d

917
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-6  One of two 15-year-old twin girls who was referred for surgical evaluation. She presented with a Class III anterior open-bite dental
protrusive malocclusion. Orthodontic treatment was carried out without extractions, and maxillary incisor procumbency remained. The patient’s
surgery included maxillary Le Fort I osteotomy in segments (horizontal advancement, vertical shortening, clockwise rotation, and arch expansion);
sagittal split ramus osteotomies (minimal 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
treatment. B, Frontal views with smile before and after treatment.
Continued

918 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 24-6, cont’d

919
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
E
Pre treatment
Pre surgery
After treatment
E, Occlusal views before orthodontics, before surgery, and after treatment.
• Figure 24-6, cont’d 
Continued

920 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Maxillary clockwise rotation
Mandibular counterclockwise rotation
Arch expansion
F
G
F, Articulated dental casts that demonstrate analytic model planning. G, Lateral cephalometric radiographs
before and after treatment.
• Figure 24-6, cont’d

921
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-7  The 15-year-old twin sister of the patient shown in Figure 24-6 was also referred for surgical evaluation. She underwent a combined
orthodontic and surgical approach without extractions. She presented with a Class III anterior open-bite dental protrusive malocclusion. The patient’s
surgery included maxillary Le Fort I osteotomy in segments (horizontal advancement, vertical shortening, clockwise rotation, and arch expansion);
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 treatment.
B, Frontal views with smile before and after treatment.
Continued

922 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 24-7, cont’d

923
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
E
Prior to treatment
Pre surgery
After treatment
E, Occlusal views before treatment, before surgery, and after treatment.
• Figure 24-7, cont’d 
Continued

924 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
G
Maxillary clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric
radiographs before and after treatment.
• Figure 24-7, cont’d

925
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-8  A 28-year-old woman arrived for the evaluation of malocclusion,, lip incompetence, nasal obstruction, and anterior open bite maloc­
clusion. She had previously undergone Phase I orthodontics that included rapid palatal expansion and an attempt at growth modification before
graduating from high school. She now presented with a Class II anterior open-bite dental protrusive malocclusion. She underwent a combined
orthodontic and surgical approach without extractions. The patient’s surgery included maxillary Le Fort I osteotomy in segments (vertical intrusion,
horizontal advancement, correction of the curve of Spee, and arch width expansion); sagittal split ramus osteotomies (advancement and counter­
clockwise rotation); and septoplasty and inferior turbinate reduction. A, Frontal views in repose before and after treatment. B, Frontal views with
smile before and after treatment.
Continued

926 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 24-8, cont’d

927
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
E
Prior to surgery
Prior to re-treatment
After surgery
E, Occlusal views before treatment, with orthodontics in progress, and after treatment.
• Figure 24-8, cont’d 
Continued

928 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
F
Mandibular counter-
clockwise rotation
Arch adjustment and correction of
Curve of Spee
G
Maxillomandibular advancement
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radio­
graphs before and after treatment.
• Figure 24-8, cont’d

929
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 24-9  A 17-year-old Caucasian boy was referred for the surgical evaluation of gummy smile, lip incompetence, and Class II anterior open-
bite protrusive malocclusion. He presented with orthodontics in progress. The patient’s surgery included maxillary Le Fort I osteotomy in segments
(horizontal advancement, vertical shortening, and arch expansion); sagittal split ramus osteotomies (horizontal advancement and counterclockwise
rotation); osseous genioplasty (vertical shortening and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recon­
touring. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.
Continued

930 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 24-9, cont’d

931
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
F
G
Maxillary vertical intrusion
Mandibular counter-
clockwise rotation
Arch expansion
E
Pre surgery
After treatment
E, Occlusal views before surgery and after treatment. F, Articulated dental casts that indicate analytic
model planning. G, Lateral cephalometric radiographs before and after treatment.
• Figure 24-9, cont’d

932 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 24-10  A 22-year-old Caucasian man was referred for the surgical evaluation of an anterior open-bite bimaxillary protrusive malocclusion.
He has lip incompetence with mentalis strain and limited horizontal jaw projection, and his nasal airway was open without obstruction. He agreed
to a combined orthodontic and surgical approach. The patient’s procedures included maxillary Le Fort I osteotomy in segments (horizontal advance­
ment, clockwise rotation, and arch form correction); sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); and
osseous genioplasty (horizontal advancement). A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment.

933
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 treatment. D, Profile views before and after treatment.
• Figure 24-10, cont’d 
Continued

934 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Pre surgery
Pre treatment
After treatment
E, Occlusal views before orthodontics, before surgery and after treatment.
• Figure 24-10, cont’d

935
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
F
G
Maxillary clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric
radiographs before and after treatment.
• Figure 24-10, cont’d

936 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 24-11  A 20-year-old Caucasian man was referred for the surgical evaluation of horizontal deficiency of both jaws and anterior open-bite
malocclusion. Orthodontics had previously been tried without success. The patient had a lifelong history of nasal obstruction. He agreed to a
combined orthodontic and surgical approach. The patient’s procedures included maxillary Le Fort I osteotomy in segments (horizontal advancement
and arch form correction); 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 treatment. B, Frontal views with smile before and after treatment.

937
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
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 treatment. D, Profile views before and after treatment.
• Figure 24-11, cont’d 
Continued

938 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
Pre surgery
Prior to retreatment
After treatment
E, Occlusal views before retreatment orthodontics, before surgery and after treatment.
• Figure 24-11, cont’d

939
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
segmental surgery or orthodontics only) will decrease an
elongated lower facial height or improve a retrusive pogo­
nion (i.e., neither approach will correct an associated jaw
disharmony); doing so would require an orthognathic
approach.
Iino and colleagues described a single case of bimaxil­
lary dental protrusion (not associated with jaw disharmony)
that was treated with corticotomy-facilitated orthodontics
and titanium mini-plate anchorage devices (TADs).54 The
authors performed orthodontic treatment after multiple
corticotomies and the placement of TADs for skeletal
anchorage in an adult patient who desired a shortened treat­
ment period. The patient had an Angle Class I molar occlu­
sion with flaring of the maxillary and mandible incisors.
Other findings included moderate dental crowding in both
arches and a limited overbite relationship (i.e., a 5.5-mm
For a subgroup of individuals with bimaxillary dental
protrusion, some clinicians find that there are advantages to
an alternative surgical approach, including intraoperative
first bicuspid extractions; the removal of associated alveolar
bone; and anterior maxillary and mandibular segmental
osteotomies with incisor uprightening and posterior repo­
sitioning. This approach should be compared with the
classic mechanics of orthodontic retraction of the anterior
teeth after extractions. Theoretic advantages of the anterior
segmental dentoalveolar surgical approach include the
ability to simultaneously reshape the pyriform rims and the
anterior nasal spine region; alter the labiomental fold; and
shorten the treatment time. Interestingly, in North America,
the anterior segmental approach for the correction of
bimaxillary dental protrusion has never gained traction.
Unfortunately, neither approach (i.e., dentoalveolar
F
G
Mandibular counter-
clockwise rotation
Arch expansion
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric
radiographs before and after treatment.
• Figure 24-11, cont’d