Orthognathic Surgery

941
CHAPTER 24  Bimaxillary Dental Protrusive Growth Patterns with Dentofacial Disharmony
of splint removal and replaces the maxillary sectional arch
wires with a rigid continuous one (i.e., ≈5 weeks after
surgery). The teeth are ligated together to maintain the arch
form. The use of a transpalatal wire or a palatal acrylic plate
may also be used to stabilize the arch form for several addi­
tional months if significant transverse expansion was carried
out. Close orthodontic monitoring for skeletal and dental
shifts and detailing during the first 6 months after surgery
is essential.
Complications, Informed Consent, and
Patient Education
The orthodontist and the surgeon are frequently asked to
evaluate jaw disharmonies and malpositioned teeth and
then to attempt to alter nature’s events. With an under­
standing of the natural progression of the uncorrected
bimaxillary dental protrusion associated with dentofacial
disharmony and knowledge of how specific interventions
will affect head and neck function and facial aesthetics,
predictable results are generally achieved. Complications
and patient dissatisfaction will always occur in a small
percentage of individuals. The clinician’s ability to com­
municate the potential risks, complications, alternative
approaches, and benefits of the recommended treatment
plan to the patient and the patient’s family is essential to
achieve a favorable result. When the patient, his or her
family, and all treating clinicians are fully informed, shared
responsibility for the treatment outcome is more likely (see
Chapter 16).
Malocclusion after Orthodontics and
Orthognathic Surgery
There are inherent biologic challenges to the orthodontic
movement of the teeth in the alveolar process and to the
surgical repositioning of the jaws or jaw segments in the
individual with bimaxillary dental protrusion and an asso­
ciated dentofacial disharmony.51,102,110,114,117 This includes
the technical aspects of the repositioning; the initial healing
requirements; and the difficulties associated with the long-
term maintenance of the mechanically relocated teeth,
jaws, and jaw segments. By following sound biomechanical
and facial aesthetic principles, clinicians are able to carry
out orthodontic treatment and surgical procedures and to
effectively maintain the results in most cases. Potential
intraoperative technical difficulties associated with sagittal
split ramus osteotomies of the mandible and maxillary Le
Fort I osteotomies can result in immediate (early) maloc­
clusion, but this is generally preventable (see Chapter 17).
Timing the surgery to limit ongoing mandibular growth
from occurring afterward is usually possible (see Chapter
17). Condylar resorption after orthognathic surgery is
rarely seen in the patient with bimaxillary dental protru­
sion (see Chapter 36). All of these factors must be taken
is undertaken to treat a significant associated dentofacial
disharmony or if dentoalveolar surgery (i.e., anterior
segmental osteotomies) is undertaken to manage bimaxil­
lary dentoalveolar protrusion with anterior open bite (i.e.,
occlusal disharmony), then the surgical option selected
should be in accordance with patient-specific facial character­
istics and dental findings.11-15,26,27,29,38,39,45,49,57,63,66,74,79,81,129
In this author’s opinion, the dentoalveolar surgical approach
has aesthetic advantages over the standard orthodontic
approach for only a very specific subgroup of patients. A
key point is that neither of these dentoalveolar approaches
(i.e., segmental osteotomies versus orthodontics only) will
reduce the anterior lower facial height; correct significant
horizontal discrepancies; or alter chin height or projection.
To accomplish these objectives, orthognathic surgery is
required. Details of the individual’s presenting dysmorphol­
ogy are important when choosing either of the limited
dentoalveolar forms of treatment (i.e., segmental osteoto­
mies versus orthodontics only) or when selecting an orthog­
nathic (jaw) approach.20,23,97,105,108,130
The orthognathic surgical correction of bimaxillary
dental protrusion in association with excess vertical height
and horizontal disproportion of the jaws should include
maxillary Le Fort I osteotomy (often with segmentation)
in combination with sagittal split ramus osteotomies of
the mandible (see Chapter 15). This approach provides
the flexibility needed to alter the maxilla and the man­
dible in all three dimensions (i.e., horizontal, vertical,
and transverse). The maxilla will generally require anterior
vertical shortening, transverse widening, correction of
the curve of Spee, minimal horizontal advancement,
and a degree of clockwise rotation. The mandible will
generally require horizontal advancement and counter­
clockwise rotation. An osteotomy of the chin with
minimal horizontal advancement is generally useful to
further improve profile aesthetics and ease of lip closure.
The simultaneous management of lifelong nasal obstruc­
tion may include septoplasty, inferior turbinate reduction,
and recontouring of the nasal floor. This orthognathic
and intranasal approach is carried out to achieve improved
head and neck function (i.e., breathing, swallowing,
chewing, speech, and lip competence) and to enhance
facial aesthetics.98,99
Postsurgical Orthodontic Maintenance
and Detailing
Managing the details of the in-hospital and at-home
convalescence during initial healing after orthognathic
surgery is essential for a successful outcome (see Chapter
11). Cephalometric and Panorex radiographs as well as
facial and occlusal photographs are obtained at standard
postoperative intervals to document healing. If segmental
maxillary osteotomies were carried out, a prefabricated
splint will have been secured to the occlusal surfaces during
surgery. The orthodontist sees the patient within 24 hours

942 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Conclusions
Bimaxillary dental protrusion is characterized by the procli­
nation of the anterior maxillary and mandibular dentition
with an open-bite malocclusion. The correction of the
dental disharmony in most individuals is carried out with
the extraction of four premolars and conventional ortho­
dontic incisor retraction and uprighting. An alternative
approach, which is preferred in only limited and specific
circumstances, involves the combination of four bicuspid
extractions and anterior maxillomandibular segmental oste­
otomies with set-back. This dentoalveolar surgical approach
may shorten the treatment time, but subtle differences in
the expected aesthetic results and the potential for compli­
cations must be considered.
In the patient with bimaxillary dental protrusion, facial
characteristics associated with significant skeletal dishar­
mony include the following: excessive separation of the lips
at rest and effort required to bring the lips into closure;
excessive incisor show when the upper lip is at rest and
gingiva show with smile; and significant vertical and hori­
zontal facial disproportion. If these skeletal findings are
present, then orthognathic surgery will be required to maxi­
mize head and neck function and to enhance facial
aesthetics.
into account to best achieve and then maintain the desired
result.
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 TMD, whereas an average
of 55% of the population demonstrates at least one clinical
sign of the condition. TMD includes various symptoms and
signs that involve the temporomandibular joint, the masti­
catory muscles, and the related structures. The symptoms
and signs may include a spectrum of referred head and neck
pain; joint noise (i.e., popping, clicking, or crepitus);
reduced or altered mandibular movements as a result of
muscle spasm or disc displacement with or without reduc­
tion; condylar head erosion; and pain during the direct
palpation of either of the temporomandibular joints or the
masticatory muscles. Occlusal factors (i.e., degrees of mal­
occlusion) are often claimed to be associated with TMD.
Interestingly, the correction of a skeletal anterior open bite
through orthodontics and orthognathic surgery is likely to
relieve symptoms and signs of TMD; however, this is not
predictable for each individual patient (see Chapter 9).1
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127. Wilcko WM, Wilcko MT, Bouquot JE,
Ferguson DJ: Rapid orthodontics with
alveolar reshaping: Two case reports of
decrowding. Int J Periodontics Restorative
Dent 21:9–19, 2001.
128. Worms FW, Meskin CH, Isaacson RJ: Open
bite. Am J Orthod Dentofacial Orthop
59:589, 1971.
129. Wunderer S: Die prognathieoperation mittels
frontal gestieltem maxillafragment. Oest Z
Stomat 59:98, 1962.
130. Yokoo S, Komori T, Watatani S, et al:
Indications and procedures for segmental
dentoalveolar osteotomy: A review of 13
patients. Int J Adult Orthodon Orthognath
Surg 17:254–263, 2002.

945

25
Dentofacial Disharmonies in Adults:
Reconstruction and Rejuvenation
JEFFREY C. POSNICK, DMD, MD
• Special Medical Considerations
• Functional Assessment of Head and
Neck Structures
• Temporomandibular Disorders: Effects of
Orthodontics and Orthognathic Surgery
• Special Wound Healing Risk Factors
• Comprehensive Dental Rehabilitation
• Unique Orthodontic Treatment
Considerations
• Previous Suboptimal Facial Surgery
• Facial Aging and Rejuvenation
• Recovery for the Adult after Orthognathic
Surgery
• Conclusions
and occult malignancy. As with teenagers and young adults,
taking a thorough history, performing a review of the
medical records, and completing a physical examination are
essential. To clarify areas of concern in these patients, there
should be emphasis placed on the need for a thorough clear­
ance examination by a primary care physician; evaluations
by other medical specialists; (e.g., cardiologist, pulmonolo­
gist); the completion of an electrocardiogram, chest radiog­
raphy, and laboratory tests (e.g., chemistries, hematology,
thyroid tests, coagulation tests); and other special studies
(e.g., stress test, echocardiogram, sleep study, pulmonary
function tests). Obtaining a hemoglobin A1C level and a
serum or urine cotinine level are useful checks to address
long-term diabetes effects and smoking compliance, respec­
tively. The adult with a dentofacial deformity and an ele­
vated body mass index is at risk for obstructive sleep apnea
(OSA) and therefore more vulnerable to intraoperative and
postoperative complications (see Chapter 26).
Functional Assessment of Head and
Neck Structures
The orthognathic surgeon should evaluate the baseline head
and neck functions of their patients, which include speech,
swallowing, chewing, breathing, hearing, vision, cognition,
and psychosocial competence (see Chapters 7 and 8). The
documentation of cervical spine and temporomandibular
joint (TMJ) baseline function and of any limitations in
neck or mandibular range of motion is also essential (see
Chapter 9). Each of these aspects may be negatively affected
by the presenting maxillofacial malformations and influ­
enced favorably or unfavorably by the treatment being con­
templated. Baseline chronic obstructive nasal breathing as
a result of septal deviation, enlarged inferior turbinates, or
a tight nasal aperture should not be ignored (see Chapter
10).103,104,106,107 In the adult, weight gain with adipose
hypertrophy within the upper airway in combination with
The techniques for the correction of a dentofacial deformity
are basically the same for the middle-aged adult as they are
for the teenager and the young adult. To achieve a favorable
result in the adult orthognathic patient, it is essential to
recognize age-related treatment pitfalls such as medical risk
factors; progressive upper airway dysfunction; dental reha­
bilitation needs, including periodontal and restorative
aspects; the effects of facial soft-tissue aging; and the often
prolonged physiologic and psychosocial responses to surgery
(Figs. 25-1 through 25-11).
Special Medical Considerations
For the adult who is more than 40 years old and who is
considering orthognathic surgery, additional medical risk
factors may include cardiovascular disease; the effects of
obesity; smoking history and pulmonary function; the
potential for deep vein thrombosis or pulmonary embolus;
the effects of bisphosphonate medication on wound healing;
Text continued on p. 981

946 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
C
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C.
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C.
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Or
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Orthththththththththththth
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Su
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Su
Su
Su
Su
Su
Su
Surg
r ery
ry
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C.
C.
C.
C.
C.
C Pos
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osnicicicicicicicicick
A
B
• Figure 25-1  A woman in her mid 50s was
referred by her general dentist to an orthodontist for
the management of a longstanding Class II excess
overjet malocclusion that had gradually resulted in
the deterioration of the posterior dentition. The
orthodontist recognized that the malocclusion
resulted from a retrusive mandible and a constricted
maxilla. With referral for surgical evaluation, a head
and neck examination was completed. In addition
to a developmental jaw deformity that involved
both the maxilla and mandible, chronic obstructive
nasal breathing and a sleep history consistent with
obstructive sleep apnea was clarified. Suboptimal
facial aging with a desire for an improved neck–chin
angle was also discussed. An attended polysomno­
gram confirmed moderate obstructive sleep apnea.
The patient agreed to proceed with orthodontics,
including lower first bicuspid extractions to relieve
dental compensation in combination with jaw and
intranasal surgery. The objectives were to improve
the airway, to enhance facial aesthetics, and to
achieve improved long-term dental health. The
patient’s surgical procedures included maxillary Le
Fort I osteotomy in segments (horizontal advance­
ment, counterclockwise rotation, arch expansion,
and the correction of the curve of Spee); bilateral
sagittal split ramus osteotomies (horizontal advance­
ment and counterclockwise rotation); osseous
genioplasty (horizontal advancement); an anterior
approach to the soft tissues of the neck (cervical flap
elevation, neck defatting, and vertical platysma
muscle plication); and septoplasty and inferior turbi­
nate reduction. A, Facial views before and after
reconstruction. B, Oblique facial views before and
after reconstruction. C, Profile views before and after
reconstruction. Note the improved A-point to
B-point relationship.

947
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Arch expansion
Mandibular counter
clockwise rotation
F
E
Pharyngeal
airway
expansion
Prior to surgery and after lower bicuspid extractions
After treatment
D
D, Occlusal views with orthodontics in progress (lower bicuspid extractions) and after treatment. E, Articulated
dental casts that indicate analytic model planning. F, Lateral cephalometric radiographs before and after surgery. Note the improved
posterior airway space documented.
• Figure 25-1, cont’d

948 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
C
©Elsevier Inc.
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Or
Or
Or
Or
Or
Or
Or
Orththththththththththththth
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gnatatatatatathicici Su
Su
S rg
r ery
ry
ry; J.C.
C.
C Pos
os
os
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©Elsevier Inc.
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O ththththththththththth
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Su
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S rg
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Surg
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Su
Su
Su
Su
Su
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Su
Su
Surg
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C.
C. Pos
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Su
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Su
Su
Su
Su
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Surg
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C.
C Pos
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©Elsevier Inc.
Or
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Orthththththththththth
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Su
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Su
Su
Su
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Su
Su
Surg
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ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
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ry; J.C.
C.
C.
C Pos
osnicicicicici k
A
B
• Figure 25-2  A woman in her early 50s was
referred by a prosthodontist for surgical evaluation.
There had been a gradual deterioration of her denti­
tion that was at least partially a result of the
longstanding Class II excess overjet deep-bite mal­
occlusion. The head and neck evaluation confirmed
a retrusive mandible, which also resulted in retro­
glossal airway obstruction. A desire for improved
profile aesthetics was also discussed. A compre­
hensive approach to dental rehabilitation, improve­
ment of the upper airway, and facial rejuvenation/
reconstruction was chosen. Coordinated endodon­
tic, orthodontic, periodontic, prosthodontic, and
surgical care was required. Periodontal treatment,
extractions, dental implant placement, restorative
temporization, and orthodontic alignment were
carried out. This was followed by surgery that
included bilateral sagittal split ramus osteotomies
(horizontal advancement and counterclockwise
rotation); osseous genioplasty (vertical lengthening)
with interpositional grafting; and an anterior
approach to the soft tissues of the neck (cervical flap
elevation, neck defatting, and vertical platysma
muscle plication). This was followed by crown
lengthening and then by the final dental restorations.
A, Frontal views before and after reconstruction/
dental rehabilitation. B, Facial oblique views
before and after reconstruction/dental rehabilitation.
C, Profile views before and after reconstruction/
dental rehabilitation.

949
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Prior to treatment
Pre surgery with dental implants in place
After surgery and dental rehabilitation
D
D, Occlusal views at presentation, before surgery, and after reconstruction/dental rehabilitation.
• Figure 25-2, cont’d 
Continued

950 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
12 mm advancement and
counter clockwise rotation
Fully temporized
prior to surgery
Hydroxyapatite interpositional
block graft to lengthen chin
F
E, Articulated dental casts that indicate analytic model planning. F, Profile view of the chin. The intraoperative view of the
chin osteotomy indicates vertical lengthening with hydroxyapatite interpositional bloc graft.
• Figure 25-2, cont’d

951
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
G
X X X
X
H
G, Panorex radiographs before and after lower jaw and chin surgery with the placement of dental implants. H, Lateral
cephalometric radiographs before and after reconstruction.
• Figure 25-2, 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 25-3  A woman in her late 40s with a long face growth pattern suffered deterioration of the dentition. Her periodontal risk factors included
inadequate attached gingiva; dental root crowding within limited alveolar bone support, nasal airway obstruction with forced mouth breathing, and
lip incompetence with drying of the exposed gingiva. An attended polysomnogram confirmed obstructive sleep apnea. Unfavorable soft-tissue
envelope distortions and premature facial aging were also present. She agreed to a comprehensive surgical and dental rehabilitative approach.
Periodontal treatment was followed by restorative temporization and orthodontic alignment, including four first bicuspid extractions. This was fol­
lowed by surgery that included maxillary Le Fort I osteotomy in segments (vertical shortening, horizontal advancement, transverse widening, and
limited clockwise rotation); bilateral sagittal split ramus osteotomies (horizontal advancement and limited counterclockwise rotation); osseous genio­
plasty (vertical shortening and horizontal advancement); an anterior approach to the soft tissues of the neck (cervical flap elevation, neck defatting,
and vertical platysma muscle plication); 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.

953
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
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. Note the pretreatment
tendency for the patient to hyperextend her neck to achieve an improved airway. After successful surgery and with improved daytime breathing,
her neck rests in a natural (neutral) position.
• Figure 25-3, cont’d 
Continued

954 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to treatment
After treatment with 4 bicuspid extractions, surgery and dental rehabilitation
E
Arch expansion
Mandibular counter
clockwise rotation
Pharyngeal
airway
expansion
After 4 bicuspid extractions
Maxillary clockwise
rotation
F
G
E, Occlusal views before treatment and after reconstruction/dental rehabilitation. F, Articulated dental casts
that indicate analytic model planning. G, Lateral cephalometric radiographs before and after treatment. Note the improved posterior
airway space.
• Figure 25-3, 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 25-4  A woman in her mid 50s was experiencing significant dental deterioration as a result of occlusal trauma. An orthodontic consulta­
tion followed by surgical evaluation was carried out. The longstanding developmental jaw deformity was characterized by a short face growth
pattern in combination with maxillary transverse constriction. There was a Class II deep-bite excess overjet malocclusion. The patient’s head and
neck evaluation confirmed a lifelong history of obstructed nasal breathing, restless sleeping at night, and a degree of daytime fatigue that was
consistent with obstructive sleep apnea. Unfavorable facial aging that is typical of maxillomandibular deficiency was recognized. A comprehensive
surgical and dental rehabilitative approach was selected. The objectives included dental rehabilitation, the enhancement of facial aesthetics, and
an improved airway. The patient’s procedures included maxillary Le Fort I osteotomy in segments (horizontal advancement, vertical lengthening,
and arch expansion); bilateral sagittal split ramus osteotomies (horizontal advancement); osseous genioplasty (vertical lengthening and horizontal
advancement); an anterior approach to the soft tissues of the neck (cervical flap elevation, neck defatting, and vertical platysma muscle plication);
and septoplasty and inferior turbinate reduction. A, Frontal views in repose before and after reconstruction/dental rehabilitation. B, Frontal views
with smile before and after reconstruction/dental rehabilitation.
Continued

956 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction/dental rehabilitation. D, Profile views before and after reconstruction/
dental rehabilitation.
• Figure 25-4, cont’d

957
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Prior to treatment
Pre surgery
After surgery and dental rehabilitation
E
E, Occlusal views before treatment, with orthodontics in progress, and after reconstruction/dental
rehabilitation.
• Figure 25-4, cont’d 
Continued

958 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Arch expansion
F
G
F, Articulated dental casts indicate analytic model planning. G, Lateral cephalometric radiographs before
and after reconstruction.
• Figure 25-4, 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 25-5  A woman in her early 40s wished to correct her malocclusion and improve her smile. She was referred to an orthodontist who then
requested surgical evaluation. She was found to have a long face growth pattern and a lifelong history of obstructed nasal breathing. There was
dental crowding in each arch, mild gingival recession associated with the posterior dentition, and a Class II anterior open-bite malocclusion. The
patient was aware of unfavorable facial aesthetics, which included a retrusive chin and an obtuse neck–chin angle. She agreed to a comprehensive
surgical and dental rehabilitative approach. She underwent extraction of four bicuspids, orthodontic alignment, and then surgery. The patient’s
procedures included Le Fort I osteotomy (vertical intrusion, horizontal advancement, and counterclockwise rotation); bilateral sagittal split ramus
osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); an
anterior approach to the neck (cervical flap elevation, neck defatting, and vertical platysma muscle plication); and septoplasty, inferior turbinate
reduction, and nasal floor recontouring. A, Frontal views in repose before and after reconstruction. B, Frontal views with smile before and after
reconstruction.
Continued

960 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
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 25-5, cont’d

961
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Prior to treatment
Pre surgery with 4 bicuspid extractions
After treatment
E
E, Occlusal views before treatment, with extractions and orthodontic decompensation complete, and after
treatment.
• Figure 25-5, cont’d 
Continued

962 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Mandibular counter
clockwise rotation
Maxillary clockwise
rotation
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after surgery.
• Figure 25-5, 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 25-6  A woman in her early 50s arrived for surgical evaluation and requested facial rejuvenation. Her head and neck examination confirmed
a lifelong history of obstructed nasal breathing and a long face growth pattern with gummy smile and lip incompetence. Unfavorable soft-tissue
envelope facial aging added to the original dentofacial deformity. Early during her life, posterior occlusal equilibration was carried out to close down
the anterior open bite; this resulted in dental deterioration that required crowns in the posterior dentition and the need for root canal therapy in
many of the teeth. At this time, the patient agreed to a combined surgical and dental rehabilitation approach. After orthodontic preparation, the
patient’s surgical procedures included maxillary Le Fort I osteotomy (vertical intrusion, horizontal advancement, and counterclockwise rotation);
bilateral sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical reduction and hori­
zontal advancement); and septoplasty, inferior turbinate reduction, and nasal recontouring. A, Frontal views in repose before and after treatment.
B, Frontal views with smile before and after treatment.
Continued

964 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
C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 25-6, cont’d

965
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
F
E
E, Occlusal views before and after treatment. F, Lateral cephalometric radiographs before and after
surgery.
• Figure 25-6, cont’d

Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Sur
u g
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 25-7  A woman in her mid 50s was seen by a prosthodontist for the management of a deteriorating posterior dentition. She was confirmed
to have secondary dental trauma as a result of a longstanding malocclusion. She was referred to an orthodontist and then for surgical assessment.
Her head and neck evaluation confirmed a short face growth pattern with a Class II excess overjet deep-bite constricted maxillary arch malocclu­
sion. There was a lifelong history of obstructed nasal breathing and the suggestion of obstructive sleep apnea, which was confirmed with an
attended polysomnogram. Facial aesthetic concerns included the downturned corners of the mouth, the deep perioral creases, the early jowl
formation, the weak profile, the obtuse neck–chin angle, and the loose skin of the neck. The patient agreed to a comprehensive surgical and dental
rehabilitative approach. Periodontal evaluation, initial restorations, and orthodontic decompensation preceded surgery. The patient’s surgical pro­
cedures included maxillary Le Fort I osteotomy (horizontal advancement, counterclockwise rotation, and vertical adjustment); bilateral sagittal split
osteotomies of the mandible (horizontal advancement and counterclockwise rotation); osseous genioplasty (horizontal advancement); an anterior
approach to the neck (cervical flap elevation, neck defatting, and vertical platysma muscle plication); and septoplasty, inferior turbinate reduction,
and nasal recontouring. A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after treatment.

967
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
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 25-7, cont’d 
Continued

968 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to treatment
Pre surgery
After treatment
E
E, Occlusal views before treatment, with orthodontics in progress, and after treatment.
• Figure 25-7, cont’d

969
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
12 mm advancement
counter clockwise
rotation
Nasopharyngeal
airway expansion
Maxillary counter
clockwise rotation
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after
treatment. Note the improved posterior airway space.
• Figure 25-7, 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 25-8  A woman in her mid 30s was referred by an orthodontist for surgical evaluation. She had a lifelong history of obstructed nasal
breathing and a long face growth pattern. Throughout her middle childhood and teenage years, she had undergone attempted growth modification
followed by orthodontic camouflage that included four bicuspid extractions in an effort to neutralize the occlusion. This resulted in periodontal
deterioration and dental relapse with residual malocclusion. She now agreed to a comprehensive surgical and dental rehabilitative approach. Peri­
odontal treatment was followed by orthodontic decompensation. The patient’s surgery included maxillary Le Fort I osteotomy in segments (horizontal
advancement, vertical shortening, counterclockwise rotation, arch expansion, and the correction of the curve of Spee); bilateral sagittal split ramus
osteotomies in segments (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical reduction and horizontal advance­
ment); and septoplasty, inferior turbinate reduction, and nasal recontouring. A, Frontal views in repose before and after reconstruction/dental
rehabilitation. B, Frontal views with smile before and after reconstruction/dental rehabilitation.

971
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C
D
C, Oblique facial views before and after reconstruction/dental rehabilitation. D, Profile views before and after reconstruction/
dental rehabilitation.
• Figure 25-8, cont’d 
Continued

972 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment with 4 bicuspid extractions as a teenager
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontics in progress, and after treatment.
• Figure 25-8, cont’d

973
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Arch expansion
Mandibular counter
clockwise rotation
Maxillary counter
clockwise rotation
F
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before
and after treatment.
• Figure 25-8, cont’d

974 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Or
Or
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatathicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicick
Or
Or
Orthththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatata hicicicicicicicicicicicicic Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicick
Or
Or
Orthththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatathicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicick
Or
Or
Orthth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicici k
A
B
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatathicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
osnicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicick
C
• Figure 25-9  A woman in her mid 40s
requested the correction of her malocclu­
sion and an improved smile. She was
referred by a restorative dentist to an
orthodontist and then for surgical evalua­
tion. The developmental jaw deformity
was characterized by mandibular defi­
ciency in combination with maxillary arch
width constriction. A lifelong history of
obstructed nasal breathing with a desire
for an improved airway was also con­
firmed. A combined orthodontic and
surgical approach was chosen. After
orthodontic decompensation, the patient’s
surgery included maxillary Le Fort I oste­
otomy in segments (transverse expan­
sion);
bilateral
sagittal
split
ramus
osteotomies (horizontal advancement and
counterclockwise rotation); osseous geni­
oplasty (horizontal advancement); and
septoplasty and inferior turbinate reduc­
tion. A, Frontal views in repose before
and after reconstruction. B, Facial views
with smile before and after reconstruction.
C, Oblique facial views before and after
reconstruction.

975
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Arch expansion
Mandibular counter
clockwise rotation
F
E
Prior to treatment
After treatment
D
D, Occlusal views before treatment and after reconstruction. E, Articulated dental casts that indicate analytic
model planning. F, Lateral cephalometric radiographs before and after reconstruction.
• Figure 25-9, cont’d

976 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
C
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatata hicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
r ; J.C.
C. Pos
os
os
os
os
os
os
os
o nicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gnatatatatatata hicicicicicicicicici Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatathicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
o nicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Orththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatathicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Surg
r e y
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
os
os
os
o nicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatathicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C. Pos
os
os
os
os
os
os
os
os
os
os
o nicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
o nicicicicicicicicicicick
A
B
• Figure 25-10  A 70-year-old woman arrived for
surgical evaluation. She desired a stronger chin, less
“loose” neck skin, and an improved smile. She ini­
tially requested a face lift and a chin implant. She
was found to have a retrusive mandible and dental
deterioration made worse by dental crowding and a
deep-bite negative overjet malocclusion. She under­
went orthodontics that included four bicuspid
extractions and then surgery that included sagittal
split ramus osteotomies (horizontal advancement)
and osseous genioplasty (horizontal advancement).
A, Frontal views with smile before and after treat­
ment. B, Oblique facial views before and after treat­
ment. C, Profile views before and after treatment.

977
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Prior to treatment
Pre surgery with 4 bicuspid extractions
After treatment
D
D, Occlusal views before treatment, with orthodontics in progress (including four bicuspid extractions), and
after treatment.
• Figure 25-10, cont’d 
Continued

978 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
E
F
E, Articulated dental casts that indicate analytic model planning. F, Lateral cephalometric radiographs before and after
surgery.
• Figure 25-10, cont’d

979
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
C
©Elsevier Inc.
Or
Or
Orthththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatathicicicic Su
S rg
r ery
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicick
©Elsevier Inc.
Or
O ththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatathicicicicicicici Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicici k
©Elsevier Inc.
Or
Or
Or
Or
Orththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatathicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry; J.C.
C.
C. Pos
os
os
os
osnicicicicicicicicicicicici k
©Elsevier Inc.
Or
Or
Orthththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatathicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
o nicicick
©Elsevier Inc.
Or
Or
Or
Orthththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatata hicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C Pos
os
os
os
os
os
os
os
os
o nicick
A
B
• Figure 25-11  An Asian woman in her mid 30s
had a developmental jaw deformity that was char­
acterized by maxillary deficiency and relative man­
dibular excess. In the childhood years, she had been
treated with growth modification followed by four
bicuspid extractions and orthodontic camouflage
mechanics. Periodontal deterioration resulted, and
malocclusion remained. She also had a lifelong
history of obstructed nasal breathing. She now
agreed to a comprehensive surgical and dental
rehabilitative approach. Periodontal treatment was
followed by orthodontic decompensation. The
patient’s surgery included maxillary Le Fort I oste­
otomy in segments (horizontal advancement, verti­
cal
intrusion,
counterclockwise
rotation
and
transverse widening); bilateral sagittal split ramus
osteotomies (horizontal advancement); osseous
genioplasty (vertical shortening and horizontal
advancement); and septoplasty, inferior turbinate
reduction, and nasal floor recontouring. A, Frontal
views with smile before and after treatment.
B, Oblique facial views before and after treatment.
C, Profile views before and after treatment.
Continued

980 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Prior to retreatment with 4 bicuspid extractions as a teenager
Pre surgery
After treatment
D
D, Occlusal views before retreatment, with orthodontics in progress, and after reconstruction/dental
rehabilitation.
• Figure 25-11, cont’d

981
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
discomforts; joint noise (e.g., popping, clicking, crepitus);
reduced or altered mandibular movements as a result of
muscle spasm or disc displacement with or without reduc­
tion; condylar head erosion; and pain on direct palpation
of either TMJ or of the masticatory muscles.
The effects of orthodontics and orthognathic surgery
on TMJ function for each specific adult patient cannot be
fully predicted. Many clinical studies report improvement
in TMJ symptoms and signs in a majority of individuals
after successful orthodontics and orthognathic surgery,
although some patients will deteriorate after the procedures.
The favorable TMJ effects of orthognathic surgery often
observed in patients with preoperative TMD may be the
result of the improved occlusion, the restoration of normal
facial height and jaw projection, or the reduced emotional
stress. Adults with longstanding TMD should be cautioned
that their pretreatment findings may not respond to occlusal
correction and jaw-straightening surgery. Baseline TMD
hypotonia of the pharyngeal muscles in the presence of an
uncorrected dentofacial deformity is likely to result in OSA.
A formal attended polysomnogram, a complete upper
airway evaluation, and a consultation with a sleep specialist
are frequently indicated (see Chapter 26).
Temporomandibular Disorders:
Effects of Orthodontics and
Orthognathic Surgery
It is estimated that an average of 32% of the population
report at least one symptom of temporomandibular disor­
der (TMD) and that an average of 55% demonstrate at least
one clinical sign of such a condition.117 TMDs include
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
Arch expansion
Mandibular
straightening
F
E
E, Articulated dental casts that indicate analytic model planning. F, Lateral cephalometric
radiographs before and after treatment.
• Figure 25-11, cont’d

982 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
closure. It is known that bisphosphonate treatment for
osteoporosis affects osteoclastic activity and may negatively
affect bone healing (see Chapter 16).
Comprehensive Dental Rehabilitation
Recognizing when a patient who is seeking orthognathic
surgery has additional dental needs beyond standard ortho­
dontics is essential to the achievement of a favorable
outcome (see Figs. 25-1 through 25-11). The need for peri­
odontal evaluation and treatment as well as the need for
complex dental restorative work should be considered for
every adult patient before the initiation of a coordinated
orthodontic and jaw surgical approach. This is especially
true for the adult who has suffered dental and periodontal
sequelae from a longstanding uncorrected dentofacial defor­
mity and who may have undergone camouflage treatment
in an attempt to neutralize the occlusion (e.g., orthodontics,
occlusal equilibration, restorative dentistry). The American
Board of Orthodontics now requires evidence of the pre­
treatment periodontal condition for all adult patients.49
Proceeding with surgical and orthodontic management in
an adult without considering a comprehensive dental reha­
bilitation plan is discouraged and only undertaken with full
disclosure to the patient and discussion among the treating
clinicians (see Chapters 6 and 16).
Unique Orthodontic Treatment
Considerations
There has been a continuous increase in the number of
adults seeking orthodontic treatment in North America as
well as throughout Europe, South America, and the Asian
countries. There is a worldwide increase in facial aesthetic
awareness and a desire to maintain the dentition throughout
life. The orthodontic movement of teeth in adults has
potential effects on the periodontium that depend on the
level of orthodontic force; the adequacy of alveolar bone
and mucogingival tissue; and the presence of active peri­
odontal disease (see Chapters 5 and 6). With aging, there
may be progressive change of the periodontium with an
increase in the crown-to-root ratio; a decrease in the resis­
tance to spontaneous tooth migration; and a change in the
center of resistance of periodontally affected teeth. The
initial response of the periodontal ligament and the alveolar
bone to orthodontic loading in the adult may be delayed;
however, after tooth displacement has started, it can be
carried out in the same way as it is for a teenager or a young
adult. Although there is no known age limit to the orth­
odontic movement of teeth, the periodontium should be
healthy when tooth movement is initiated.
As compared with a teenager, a middle-aged adult (i.e.,
someone >40 years old) with an uncorrected jaw deformity
often requests a timely solution to his or her jaw, dental,
and airway problems. Interestingly, the anticipation of an
extended orthodontic treatment timeframe may be this
problems in the patient with a dentofacial may primarily be
masticatory muscle disorders (i.e., myofascial conditions)
or, less commonly, the result of joint pathology (i.e., inter­
nal derangement). These two problems may coexist, and the
distinction in some individuals may be difficult. It is unlikely
that the correction of an existing dentofacial deformity will
correct either internal joint problems or other non-muscular
sources of pain. Myofascial pain develops when muscles are
fatigued, because they then tend to go into spasm. Myofas­
cial pain generally occurs after clenching or grinding the
teeth for many hours each day, presumably as a response to
stress. It is also true that some types of occlusal discrepancies
predispose the individual who clenches or grinds his or her
teeth to TMD. A compelling argument against malocclu­
sion as the primary cause of TMD is the observation that
TMD is not more prevalent among individuals with maloc­
clusion as compared with those with a more normal occlu­
sion. Interestingly, for those individuals with myofascial
pain, the orthodontic mechanics required as part of the
orthognathic correction are often helpful. This is because
orthodontic treatment makes the teeth sensitive, which
tends to limit grinding and clenching. Therefore, when the
parafunctional (i.e. clenching, grinding) activity stops, the
myofascial pain is often diminished. The changing occlusal
relationships during the orthodontic phase of treatment
may also contribute to a break in the cycle that contributed
to the initial muscle fatigue and pain. The cycle of clenching
and grinding is also broken during the healing phase that
takes place just after orthognathic surgery. Unfortunately, it
is also recognized that, at some point after successful ortho­
dontics and orthognathic surgery, the individual with a long
history of myofascial TMD symptoms may return to the
clenching and grinding parafunctional habits. The use of an
intra-occlusal splint in this situation will often be the best
way to break the cycle and keep symptoms at bay. For all
of these reasons, the individual’s rationale for the correction
of the jaw deformity and the associated malocclusion should
not be solely based on a desire for the permanent relief of
TMJ symptoms and signs (see Chapters 7 and 9).
Special Wound Healing Risk Factors
Special wound healing risk factors may include previous
radiation therapy, diabetes mellitus, smoking or other forms
of nicotine use, and past or current bisphosphonate treat­
ment for osteoporosis. Diabetes mellitus, high blood pres­
sure, hyperlipidemia, and OSA are frequent comorbidities
of obesity that may complicate wound healing. A significant
incidence of postoperative infections among diabetic
patients undergoing maxillary or mandibular osteotomies
has been reported, despite adequately controlled glucose
levels. The inhalation of nicotine via cigarette smoke affects
pulmonary function as well as tissue oxygenation and the
healing of the surgical wounds. Smoking (nicotine inges­
tion) has been shown to delay the chondrogenic phase of
bone (osteotomy) healing, thereby negatively affecting the
circulation of elevated flaps and their healing after wound

983
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
Facial Aging and Rejuvenation
Background
The visual appearance of facial aging may be affected by all
tissue layers and cell types, including the surface layer of the
skin; the subcutaneous tissue; the superficial and deep
mimetic muscles and the investing fascia (i.e., the submus­
cular aponeurotic system); the superficial and deep adipose
tissue; and the retaining ligaments that connect the soft
tissues to the skeleton and that separate them into compart­
ments.10,14,18,67,85,90,114 Although facial aging is visualized
through the soft-tissue envelope, it is profoundly affected
by the underlying maxillomandibular skeletal structures.
Soft-tissue facial rejuvenation procedures generally focus on
the following:
1. The elevation, redraping, and excision of the skin, the
subcutaneous tissue, and the submuscular aponeurotic
system and platysma layer. This is to correct gravita­
tional (descent) changes that have occurred over time.
2. The management of the volumetric changes of adipose
tissue that occur with age. This includes compartment-
specific depletion (deflation), hypertrophy (expan­
sion) of the fat cells, and stretching of the retaining
ligaments that then affect the facial contours and
curvatures.*
3. The management of the surface layer of the skin. This
layer is affected by both hereditary (genetic) and envi­
ronmental factors (e.g., chronic exposure to strong
ultraviolet light, nicotine/cigarette smoke, dehydra­
tion, nutritional deficiencies, temperature extremes,
traumatic influences).15,16,20,23,45,72,78,93,138
4. The consideration of expressive muscle alteration with
age (i.e., the “facial recurve” concept). Ligamental relax­
ation may be a prominent component of facial aging.
For example, it may be responsible for malar descent
in the midface. In the nasal region, “tip drooping”
may be caused by ligament loosening of the lower
lateral cartilage and clockwise rotation of the
columella.124
An important morphologic fact is that, in the presence
of a baseline uncorrected developmental dentofacial deformity,
the overlying soft-tissue envelope will be distorted and less
attractive (see Figs. 25-1 through 25-11).103,115,145 The long­
standing skeletal dysmorphology will likely be responsible
for a majority of the patient’s concerns about premature
and unfavorable facial aging. An example of this phenom­
enon is seen in patients with the short face growth pattern
(see Chapter 23). With age, the decreased lower anterior
facial height and the diminished horizontal projection asso­
ciated with this condition result in the premature loss of a
patient’s greatest personal deterrent to proceeding. The
adult is also more likely to present with advanced periodon­
tal disease; dental migration and defective areas; traumatic
occlusal problems; dental ankylosis; and the presence
of fixed dental elements (e.g., titanium implants). These
factors, by definition, will alter orthodontic mechanics.
Contemporary orthodontic now offers a spectrum of
options to improve the efficiency of treatment, including
the use of light continuous forces; computer-aided design
of orthodontic devices (e.g., Sure Smile, Insignia); and the
regional acceleratory phenomena as described by Wilko and
Wilko (see Chapter 5). These options must be viewed in
light of their potential risks, complications, and costs (see
Chapter 5).
Previous Suboptimal Facial Surgery
It is not uncommon to see an adult with an uncorrected
dentofacial deformity who has undergone facial cosmetic
procedures in an attempt to camouflage aesthetic con­
cerns.4,31,132-136 In the individual with an uncorrected jaw
deformity, the most commonly seen camouflage procedures
include reduction rhinoplasty; a chin implant; cheek
implants; and, to a lesser degree, angle of the mandible or
perinasal implants.13,27,34,46,59,79,87,88,110,111,129,137,139 Autoge­
nous and allogenic soft-tissue fillers and Botox injections
(e.g., to lower the upper lip and to decrease a gummy smile)
are also frequently tried.
A rhinoplasty carried out in the patient with an uncor­
rected jaw deformity patient is often over-reduced in an
attempt to “shrink” the nose. This is most frequently seen
in association with a horizontally retrusive lower face (e.g.,
short face growth pattern, long face growth pattern, isolated
mandibular deficiency; see Chapters 19, 21, and 23). There
may have been over-reduction of the nasal dorsum (i.e.,
bone and cartilage), over-resection of the lower lateral
cartilages, and excess narrowing of the nasal base (i.e., Weir
excisions; see Chapter 38). A reduction in nasal airflow
as a result of the collapse of the internal or external nasal
valves may have been an unanticipated side effect (see
Chapter 10).
A chin implant placed in the patient with a mandibular
deficiency often adds excess horizontal projection without
addressing the vertical deformity; this will result in a deep­
ened labiomental crease and an overly prominent pogonion
(see Chapter 37). In the individual with a long face Class
II open-bite growth pattern, the placement of a standard
chin implant (i.e., without shortening the vertical chin
height) further increases mentalis strain. Resorption of the
bone below the implant and excess stretching of the overly­
ing soft tissues with capsule formation may also occur. This
is more frequently seen with the use of non-porous implant
materials (e.g., Silastic) and when the implant is not secured
in a stable manner (e.g., screw fixation) to the underlying
bone (see Chapter 37). These failed camouflage surgical
procedures further complicate plans for an anatomic recon­
struction and effective facial rejuvenation.
*References 3, 21, 29, 30, 32, 50, 61, 64, 65, 73-77, 81, 82, 86, 122,
123, 131

984 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
and on the achievement of a more functional upper airway.
Adults with dentofacial deformities who undergo successful
orthognathic surgery will experience a quantum change:
they will look younger and better as compared with how
they looked earlier during their lives. A variety of reactions
from the patient’s social network are to be expected; these
will range from positive responses to surprise, bewilder­
ment, and even resentment. The individual’s response to
these initial reactions will depend on his or her personality
type, preoperative preparation, and inner ego stability (see
Chapter 7).
Periorbital and Midface Aging
Most cosmetic surgeons focus on the soft tissues when they
are considering options for the management of periorbital
and midface aging.1,2,9,19,24,26,33,39,42,51,54,55,119 The traditional
approach to aging in this region of the face focuses on the
management of the laxity of the soft-tissue envelope and
the reduction of protruding lower eyelid fat bags.40,47,80,116
The spectrum of current theories of periorbital and midface
aging as well as methods of management are varied and have
strong advocates, including the following.
1. Lambros has demonstrated through longitudinal
photographic imaging that descent probably does not
have as large a role in the aging process as previously
thought.66
2. Coleman believes that the role of fat atrophy with
volume loss and secondary sagging of the soft-tissue
envelope is critical.25
3. Gosain evaluated changes in the cheek fat pad
with aging through magnetic resonance imaging
and found a combination of hypertrophy and
ptosis (rather than atrophy) to be an important
factor.48,150-152
4. Le Louarn postulates that the facial mimetic muscles
are a predominant cause of the visual appearance of
aging in the midface. He believes that repeated
motion (i.e., contraction) of these muscles results in
the redistribution of the facial fat over time, which
eventually creates the aged face.69
5. Jelks has drawn attention to the importance of the
anatomic relationship between the ocular globe, the
periorbital soft tissues, and the underlying skeleton
with respect to midface aging.62,63 A positive relation­
ship (i.e., a positive vector) is said to exist when the
most anterior projection of the globe in profile lies
behind the lower eyelid margin.91 A negative relation­
ship (i.e., a negative vector) exists when the most
anterior projection the globe in profile lies anterior to
the lower lid. Individuals with a negative vector rela­
tionship are more likely to have scleral show, to
exhibit an apparent loss of cheek prominence, and
to have a deep nasojugal groove. They are also prone
to suboptimal results if traditional soft-tissue eyelid
rejuvenation procedures are carried out. To achieve
the most favorable result, the underlying skeletal defi­
youthful appearance (see Fig. 40-1). There will be accentu­
ated perioral creases (i.e., marionette lines), early and exces­
sive jowl formation, loose skin in the neck (i.e., a “turkey
gobble” appearance), and a further worsening of the already
deficient neck–jaw angle. Reconstruction of this pattern of
dentofacial deformity in the adult to reflect Euclidean pro­
portions is likely to have a profound rejuvenating effect (see
Chapter 23).
The usual modus operandi of the cosmetic surgeon
who has been asked to manage facial aging in the indi­
vidual with a baseline dentofacial deformity involves
neck and cheek soft-tissue flap undermining, redraping,
and then the excision of skin that is under tension in
the horizontal and vertical planes; this is also known as
a face lift.5,6,8,52,53,56,57,83,108,125,128,130 Augmentation implants
may be considered and occasionally placed (e.g., the
chin, the angle of the mandible, the cheek, the pyriform
rim) in an attempt to modify underlying skeletal deficien­
cies.13,27,34,46,59,60,79,87,88,137,139 In most cases, this approach
predictably makes the face look different but not youthful
or attractive. A natural-appearing rejuvenation in the adult
with a dentofacial deformity requires reconstructing the
normal curves and contours to the skeleton; these changes
will then be favorably reflected in the overlying soft-tissue
envelope. This is most naturally accomplished through
orthognathic procedures that restore Euclidian proportions
to the maxillomandibular complex.22,44,103,105,112,113,115,118
It is also true that facial aging—even in the presence
of a proportionate skeleton—tends to gradually result in a
transition from a heart-shaped face to a rectangular and
then a pear-shaped face as gravity-induced descent and
anterior drift of the soft-tissue envelope occur from the
malar region superiorly through the nasolabial fold and
from the submalar region to the jowls. At some point, as
the individual ages, ideal rejuvenation is likely to require
restoration of the lax and altered soft-tissue envelope,
possibly via a brow lift, an eye lift, and a face lift. Fat
volume redistribution frequently occurs with age (e.g.,
atrophy, hypertrophy) and may also benefit from rejuvena­
tion procedures.3,21,29,30,32,50,61,64,65,73,77,81,82,86 The surface
layer of the skin may have weathered with age and be
improved with quality skin care or resurfacing procedures
(e.g., chemical peels, laser treatments, dermabrasion; see
Chapter 40).15,16,20,23,45,72,78,93,138
The term reconstruct can be defined as “to bring to
normal.” The term rejuvenate means “to restore the look
of the individual at a younger age.” In the adult with a
baseline dentofacial deformity, the creation of normal facial
curvatures—first through skeletal reconstruction and then
via soft-tissue rejuvenation procedures—is required to fully
capture the appearance of health, vitality and beauty. If
successful, the enhancement of facial appearance will be
immediately obvious for all to see without the need for
quantitative analytic assessment. The maxillofacial surgeon
has a unique opportunity to reconstruct the skeletal struc­
tures and to rejuvenate the soft tissues of the adult with an
uncorrected dentofacial deformity. Attention is also focused
on the rehabilitation of the dentition and the periodontium

985
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
In the past, many cosmetic surgeons have not paid
enough attention to these deep-layer skeletal morphologic
facts. They tended to focus energy on the soft-tissue details
without giving enough thought to the effects of the underly­
ing skeletal framework for facial aging. Attempts to camou­
flage an underlying maxillary deficiency with techniques
such as excess fat grafting to fill the soft-tissue lower eyelid
envelope; the removal of excess skin to “smooth out” the
eyelids; excessive repositioning or tightening of the deep
soft-tissue layer (i.e., the submuscular aponeurotic system)
to manage descent; and excessive hard-tissue augmentation
of the zygomatic prominence and the infraorbital region are
all likely to result in a poorly contoured and unnatural
appearing midface and periorbital region. This camouflage
approach should be compared to the more favorable direct
management of the anterior maxilla and the perinasal
regions through orthognathic surgery.
Consideration of Craniofacial Morphologic
Change with Age: Does it Occur?
Although it has been much discussed, there is little
convincing evidence to suggest that the craniofacial
skeletal structures either significantly atrophy or hyper­
trophy with age after traditional growth maturity is
reached.11,12,17,28,35-38,43,68,84,89,92,109,120,126,127,153 This should not
be confused with the documented facial changes that do
occur in association with the loss of teeth; occlusal surface
erosion; the ongoing eruption of teeth; and disease of the
periodontium. With extensive dental loss, significant dete­
rioration of the horizontal projection, the vertical height,
and transverse width of the midface and the lower face will
unquestionably alter the soft-tissue drape and result in a
more aged look. After skeletal maturity is reached (i.e., 14
to 16 years of age in girls and 16 to 18 years of age in boy)
and in the absence of dental loss or significant deterioration,
neither notable atrophy nor hypertrophy of the craniofacial
prominences has been convincingly proven to occur. This
specifically includes the following structures:
• The supraorbital ridges
• The lateral orbital rims
• The infraorbital rims
• The zygomatic prominences
• The nasal height and the frontonasal angle
• The pyriform rims and the anterior nasal spine
• The gonial regions of the mandible
• The pogonion prominence
Midface Skeletal Change with Age: Does it Occur?
In 1927, Hellman proposed the theory that the facial
skeleton continues to grow throughout life58; he called
this process morphological differentiation. Pessa and col­
leagues proposed an algorithm of facial aging to support
Hellman’s theory on the basis of the review of a limited
number of radiographs that suggested to him that bony
changes of the midface (i.e., the zygoma and the infraorbital
rim) occurred with age.95 The data that were used to support
ciency and the lower lid laxity (i.e., lateral cantho­
pexy) should also be addressed.
6. Pessa and colleagues agree with Jelks that skeletal
deficiency is responsible for the negative vector rela­
tionship documented in adults with unattractive peri­
orbital and midface aging.95-101 These authors postulate
that, with age, the infraorbital rims partially resorb
and regress posterior relative to the cornea. They also
believe that, with age, the upper aspect of the anterior
maxilla is partially resorbed with progressive curve
distortion (i.e., concavity). They infer that, to achieve
the most favorable result, the underlying skeletal defi­
ciency must be addressed.
7. In his analysis of periorbital and midface aging,
Yaremchuk agrees with Jelks and Pessa that the nega­
tive affects of aging in the periorbital midface region
are greatly influenced by the underlying skeleton.140-149
He believes that a key element for attractive midface
rejuvenation is reconstructing the skeleton to achieve
convexity and a positive vector relationship. He
accomplishes this via augmentation of the zygoma,
the infraorbital rim, the anterior maxilla, and the base
of the nose, as indicated. He frequently combines
skeletal enhancement with lower lid and midface soft-
tissue suspension to create and restore youthful and
attractive periorbital aesthetics.
NOTE:  This author believes that horizontal (sagittal)
deficiency of the anterior maxilla—rather than a lack of
projection of the zygomatic complex or of the
infraorbital rims per se—is a frequent cause of the
observed negative-vector eyelid relationship originally
described by Jelks.
Maxillary horizontal (sagittal) deficiency that has been
present since the teenage years is a frequent cause of the
observed negative vector and results in an unattractive
midface and lower eyelid appearance that worsens with age.
Exceptions may include individuals of Asian decent with a
hereditary tendency for excess bizygomatic width and
limited zygomatic buttress projection. These individuals are
more likely to benefit from zygomatic buttress (sagittal)
augmentation to achieve aesthetic advantages.
A critical review of the literature provides little convinc­
ing evidence to support the theory put forth by Pessa and
colleagues regarding a progressive deterioration or resorp­
tion of the infraorbital rim, the zygoma, or the anterior
maxilla with advancing age in humans. The more logical
explanation for the observed negative vector in some indi­
viduals is the presence of a developmental skeletal deformity
that changes little after the teenage years (i.e., after skeletal
maturity is reached). The common developmental jaw
deformities with which maxillary horizontal (sagittal)
deficiency is seen include: the long face growth pattern;
maxillary deficiency with relative mandibular excess; maxil­
lomandibular deficiency (i.e., the short face growth pattern);
and cleft maxillary hypoplasia.

986 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
cephalograms taken during two different time frames. The
first group ranged in age from 5 to 17 years, and the
second group ranged in age from 46 to 60 years. Seven
difficult-to-reproduce data points were chosen along the
inferior border of the mandible on each radiograph;
an analysis was carried out with the use of these points.
From this data, the authors theorized that the “youthful
mandible had a greater degree or curvature whereas the
mature [middle-aged] mandible can be described as having
a less convex curvature” and that “the mandible increases
in size [length] with continued growth.” A critical review
of Pessa’s methods suggests that the posteroanterior cepha­
lometric radiographs of the young study subjects were
not standardized for head position (i.e., flexion and exten­
sion) as compared with the radiographs taken of the older
subjects. Therefore, the accuracy of the comparison mea­
surements taken along the inferior border of the mandible
on each of the non-longitudinal radiographs is question­
able. This inaccuracy is caused by inherent distortions
that result from differences of positioning of the subjects’
heads at the time that the two-dimensional radiographs
were taken.
Shaw and colleagues recently reviewed computed
tomography scans of dentate Caucasian subjects; they
included an equal number of women (n = 60) and men
(n = 60) in an attempt to identify changes in mandibular
morphology with age.121 The patient population was not
evaluated longitudinally, and it was not standardized. The
radiographs were taken from a hospital-based data pool
and not controlled to exclude those with jaw deformities,
significant malocclusions, congenital anomalies, or trauma.
The researchers further subdivided the radiographs into
three groups in accordance with the age brackets of the
patients (i.e., 20 to 40 years, 41 to 64 years, and >65
years). The authors took measurements from each scan
related to the width and length of the mandible and at the
gonial angles. Interestingly, the authors drew conclusions
from these data that are contradictory to those of pub­
lished studies carried out by other investigators with the
similar intention of clarifying the effects of age on man­
dibular morphology. For example, the study by Pecora
and colleagues suggests that the mandible continues to
grow in length in both men and women during aging.94
Pessa and colleagues also suggest that there is an increase
in mandibular width, height, and length with aging. The
analysis by Bartlett and colleagues of postmortem human
skull data suggest that there is an increase in the width—
but not the length—of the mandible with age.7
this theory were collected from computed tomography
scans performed on just 12 men: six with a mean age of
20 years and six with a mean age of 56 years. These scans
were not obtained for the same individuals over time,
and they were not selected in a controlled fashion. Pessa
made four difficult-to-reproduce angular measurements in
each midface region on each scan (i.e., the glabellar angle,
the orbital angle, the pyriform angle, and the angle of the
maxillary wall). He concluded from the limited data that
“the craniofacial skeleton continues to change with age
resulting in remodeling of the maxilla [clockwise rotation]
relative to the cranial base.”95 Despite Pessa’s theory, no
scientific data confirm significant changes in the midface
skeleton with age.
Levine and colleagues have also found fault with the
“skeletal-aged” theories of Pessa and colleagues.70,71 They
contend that Pessa’s theory of midface skeletal atrophy with
age is based on an unsound interpretation of data from a
limited number of non-longitudinal computed tomography
scans and that it is not consistent with clinical observations
or available research. Levine does believe that, in the pres­
ence of maxillary deficiency, soft-tissue descent and volume
loss with age lead to the frequently observed unattractive
changes seen in the midface periorbital region. He goes on
to state that the negative vector relationship of the ocular
globe and the lower eyelid in this subgroup of adults is more
likely the result of a longstanding horizontal (sagittal) max­
illary hypoplasia that has been present since the teenage
years. It is the longstanding developmental midface skeletal
deficiency that does not provide adequate support for the
overlying soft tissues.41 As a result, retaining ligaments even­
tually give way, the fat may then atrophy or protrude, and
the skin becomes lax.
Whether the negative vector eyelid aging characteristics
(i.e., rounding of the palpebral fissure, lengthening of
the lower lid, and loss of cheek prominence) results from
a developmental skeletal midface hypoplasia or from skel­
etal atrophy with continued aging, most informed clinicians
agree that the correction of the baseline bony deficiency
is a key aspect of a natural-appearing rejuvenation. Yarem­
chuk’s analysis and clinical results are convincing evi­
dence that the underlying skeleton is often where attention
should be directed if effective rejuvenation is desired.141-149
Free fat grafting, the injection of various fillers, and the
redistribution of the midface and lower lid soft tissues
have more limited roles in the presence of a deficient
skeletal framework. Too much attention given to the soft
tissues or to imprecise skeletal augmentation will predict­
ably result in an operated look that is visually obvious for
all to see.
Mandibular Skeletal Change with Age: Does it Occur?
Pessa and colleagues also hypothesized that the mandible
changes in shape during the aging process after normal
skeletal maturity.98 The authors tested this theory in just
16 subjects (eight male subjects and eight female subjects)
with the use of acetate tracings of frontal (posteroanterior)
NOTE:  Despite differing assertions and opinions
offered by a handful of authors, in the absence of the
loss of the teeth or the significant alteration of the
dentition, no reproducible convincing data confirms
significant changes in the shape of the mandible
with aging.

987
CHAPTER 25  Dentofacial Disharmonies in Adults: Reconstruction and Rejuvenation
at least satisfactory. Others will not accept a complication
even though the risks were explained in advance and all
reasonable precautions were taken. Experience has shown
that there are no shortcuts to thorough patient education;
comprehensive care must be provided every step of the way
(see Chapter 7).
Body Dysmorphic Disorder
To minimize patient disappointment after surgery, an infor­
mal (and, in some cases, a more rigorous) psychosocial
assessment is indicated. The clinician must keep in mind
that some individuals who are seeking treatment will have
a true psychiatric disorder. Body dysmorphic disorder is a
medical condition that can be difficult for a clinician to
recognize before surgery. If this condition is present, it will
be a predictable cause of unhappiness after surgery. It is
estimated that 7% to 15% of individuals who are pursuing
cosmetic surgery may have body dysmorphic disorder (see
Chapter 7).
Sensory Loss and Incidence of Dysesthesia
Inferior Alveolar and Mental Nerve Injury and Recovery
During sagittal split ramus osteotomies of the mandible,
the inferior alveolar nerve can be directly damaged by a burr
on a rotary drill, a blade on a reciprocating saw, or a chisel
used to complete the split. The nerve can also be compressed
during osteotomy stabilization (i.e., plate and screw fixa­
tion). Studies document that, with time, inferior alveolar
nerve sensory function is generally sufficient in most
patients, although complete recovery is uncommon. The
exact reasons why, over time, most patients experience only
a degree of simple loss of sensation in the distribution of
the inferior alveolar nerve, some continue to experience
active sensations that are not normally present but are of
little concern, and a small percentage have active sensations
that are subjectively uncomfortable or painful (i.e., dyses­
thesia) is not known. Zuniga and colleagues (see chapter
16) report a 5% incidence of dysesthesia of the inferior
alveolar nerve after sagittal split ramus osteotomy (see
Chapter 16 for a more complete review of the literature).
Infraorbital Nerve Injury and Recovery
A degree of injury to the infraorbital nerve at the time of
Le Fort I osteotomy that results in paresthesia is expected,
whereas long-term dysesthesia of the cheek skin, the upper
lip, the palatal mucosa, and the gingiva is less common.
Infraorbital nerve injury may result from compression,
stretching, or direct injury from saw blades, burs, or hand­
held instruments. A study by Thygesen and colleagues (see
Chapter 16) found continued changes (i.e., less than full
recovery had occurred) in somatosensory infraorbital nerve
function 12 months after Le Fort I osteotomy in 7% to
60% of patients. This included the regions of the cutaneous
skin, the lip, the gingiva, and the palatal mucosa. Fortu­
nately, the authors did not find instances of significant
Recovery in the Adult after
Orthognathic Surgery
Physiologic and Psychosocial Effects
Although the middle-aged adult’s basic maxillofacial skeletal
and soft-tissue healing capacity is in most cases similar to
that of a teenager or young adult, their return of energy
level, oromotor function, sensation (i.e., the infraorbital
nerve and the inferior alveolar nerve), and psychosocial
readiness to resume preoperative daily activities and work-
related matters may be more prolonged. For example, the
teenager will typically return to schoolwork, computer
work, reading, and desk-type activities by 2 weeks after his
or her procedures, even after complex jaw and intranasal
surgery. These patients may have concerns about the percep­
tions of their peers, but in general a rapid return to the
presurgery environment is expected. For the middle-
aged adult, returning to a competitive activity schedule at
work (e.g., business telephone conversations, conferences,
meeting new clients, engaging in sales-type activities)
and feeling comfortable around family and friends is gener­
ally more challenging and will require extra preparation,
planning, and discussion between the surgeon and the
patient. Aspects of greater concern for the middle-aged
adult as compared with the teenager include rehabilitation
requirements and personal adjustments to the following:
1) facial region sensory loss and recovery; 2) limitations of
mouth opening; 3) changes in occlusion; 4) changes in
speech articulation; 5) lingering general fatigue; 6) persis­
tent soft-tissue swelling and “tightness” during dynamic
expression; and 7) altered body image.
NOTE:  This author has found that an adult patient’s
recovery is best and his or her satisfaction is highest
when he or she has an upbeat and optimistic attitude;
when immediate family members and friends are
available and supportive; when there is a documented
need for and advantage to simultaneous improvements
in: the upper airway; the occlusion and dental health;
and when there are clearly defined tangible aesthetic
objectives.
Setting Clear Objectives with
Realistic Expectations
All parties involved should agree on the treatment objectives
and accept the risks and limitations of the planned surgical
procedures. Unfortunately, the patient’s preoperative psy­
chosocial assessment, the surgeon’s understanding of unique
wound healing requirements, and the uncertainties of
surgery are not completely predictable. Furthermore,
orthognathic surgery should not be carried out with a belief
that it will repair broken personal relationships, save jobs,
or overcome financial concerns. The reality is that a small
percentage of patients will perceive an unfavorable surgical
outcome even when the clinicians feel that the results are

988 SECTION 3  Classic Patterns and Presentations of Dentofacial Deformity
Interestingly, Pogrel and colleagues documented that, with
time, men tend to achieve a more tolerable decrease in these
uncomfortable sensory symptoms than women.102
Conclusions
The surgical techniques for the correction of a dentofacial
deformity are generally the same for the middle-aged adult
as for the teenager and the young adult. To achieve a favor­
able result in the adult orthognathic patient, it is essential
to recognize age-related treatment pitfalls such as medical
risk factors; progressive upper airway obstruction; dental
rehabilitation needs, including periodontal and restorative
aspects; effects of facial soft-tissue aging; and the often
prolonged physiologic and psychosocial response to surgery.
An important observation is that, in the presence of a base­
line jaw disharmony, the overlying soft-tissue envelope will
tend to show premature and unattractive aging. Adults who
undergo successful orthognathic surgery are likely to experi­
ence a quantum change when they look younger and more
attractive than they did earlier during their lives.
dysesthesia associated with the documented sensory loss in
any of the study patients (see Chapter 16 for a more com­
plete review of the literature).
Patient Age and Sensory Recovery
It is believed that older patients (i.e., >25 years old and
especially >40 years old) who sustain the same extent of
injury to either the infraorbital nerve or the inferior alveolar
nerve after maxillary or mandibular osteotomies, respec­
tively, will not experience the same degree of subjective
sensory recovery as younger individuals. It appears that the
time required for “acceptable” subjective recovery of facial
and oral sensation is longer and that the percentage of
middle-aged adults who have undergone these operations
and who interpret their lack of full sensory return as dyses­
thesia (i.e., uncomfortable sensory loss) is higher than that
observed among teenagers and young adults (see Chapter
16). Adults are more likely to complain about a lack of
sensory return to the mucosa of the palate and the gingiva.
They may be annoyed by the lack of proprioception when
flossing and when managing food on the roof of the mouth.
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