Orthognathic Surgery

1541
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
Prior to re-do orthodontics. She previously underwent maxillary bicuspid extractions
Re-do orthodontics in progress including mandibular bicuspid extractions
After treatment
E
E, Occlusal views before retreatment, before surgery but after mandibular bicuspid extractions, and after
surgery.
• Figure 36-2, cont’d 
Continued

1542 SECTION 6  Post-Traumatic Dentofacial Deformities
Mandibular counter-
clockwise rotation
Pharyngeal
airway
expansion
H
G
Roll Orientation Correction
F
Bilateral condylar head erosion
F, Panorex view before surgery. G, Articulated dental casts that indicate analytic model plan­
ning. H, Lateral cephalometric views before and after surgery. A, B, C, D, E (center row, bottom row), F, G, H, from
Posnick JC, Fantuzzo JJ: Idiopathic condylar resorption: current clinical perspectives, J Oral Maxillofac Surg 65:1617-
1623, 2007.
• Figure 36-2, cont’d

1543
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
CASE 36-3 
Idiopathic Condylar Resorption (Fig. 36-3)
History
A 12-year-old female underwent orthodontic treatment
when she was between the ages of 12 and 15 years; includ-
ing four bicuspid extractions. She was felt to have achieved
a satisfactory occlusion without the need for further care.
When she was 19 years old and away at college, she expe-
rienced an episode of temporomandibular disorder that
involved TMJ region and masticatory muscle discomfort
and that limited her mandibular range of motion and her
ability to chew. Over a 6-month period, the symptoms
subsided. During this time, a progressive anterior open-
bite and a retrusive mandibular profile occurred. For the
next two years (i.e., from the ages of 19.5 years to 21.5
years), she was followed by a restorative dentist and an
orthodontist; no clinical progression was found. There were
no further changes in her occlusion, but she did have inter-
mittent masticatory muscle discomfort that improved with
the use of an occlusion neutralization splint.
• Figure 36-3  Patient before and after treatment. A, Frontal views in repose before and after treat­
ment. B, Frontal views with smile before and after treatment.
Or
Or
Or
Or
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
gn
gn
gnatatatatathicic Su
Su
Surg
r ery
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
o nicicici k
Or
Or
Orthththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatata hicic Su
Surg
r ery; J.C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatathicicic Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatathicicic Su
S rg
r ery
ry
r ; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicicick
A
B
Continued

1544 SECTION 6  Post-Traumatic Dentofacial Deformities
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 views before and after treatment. D, Profile views before and after treatment.
• Figure 36-3, cont’d

1545
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
Prior to re-do orthodontics. Earlier treatment included four bicuspid extractions
Pre surgery
After treatment
E
E, Occlusal views before retreatment, before surgery, and after treatment.
• Figure 36-3, cont’d 
Continued

1546 SECTION 6  Post-Traumatic Dentofacial Deformities
G
H
Mandibular counter-
clockwise rotation
Pharyngeal
airway
expansion
F
Condylar head resorption
F, Panorex view before surgery. G, Articulated dental casts that indicate analytic model plan­
ning. H, Lateral cephalometric views before and after surgery.
• Figure 36-3, cont’d

1547
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
6 months prior to surgery
6 months after surgery
J
6 months prior to surgery
6 months after surgery
K
6 months prior to surgery
6 months after surgery
I
I, Coronal computed tomography views of the condyle 6 months before and 6
months after surgery. J, Axial computed tomography views of the condyle 6 months before and 6 months
after surgery. K, Sagittal computed tomography views of the condyle 6 months before and 6 months
after surgery.
• Figure 36-3, cont’d

1548 SECTION 6  Post-Traumatic Dentofacial Deformities
Evaluation
The patient arrived for surgical consultation when she was
21 years old having just graduated from college with the
hope of achieving improved function (i.e., mastication,
breathing, lip posture/closure, and speech articulation)
and enhanced facial aesthetics (i.e., an improved profile
and a less gummy smile). She underwent evaluations by
a speech pathologist, an otolaryngologist/head and neck
surgeon, an orthodontist, a restorative dentist, and a TMJ
specialist.
Treatment
With successful splint therapy for the relief of masticatory
muscle discomfort and a 2-year history of no progression
of condylar resorption (i.e., stable occlusion), orthodontic
dental decompensation was initiated. A computed tomog-
raphy scan of the TMJ was obtained before surgery. The
patient’s surgery included the following:
• Maxillary Le Fort I osteotomy
• Vertical intrusion at the incisors
• Horizontal advancement at the incisors
• Bilateral sagittal split ramus osteotomies
• Mandibular plane counterclockwise rotation
• Horizontal advancement
• Oblique osteotomy of the chin
• Horizontal advancement
• Vertical shortening
• Intranasal procedures
• Septoplasty
• Reduction of the inferior turbinates
• Recontouring of the nasal floor
• Removal of retained wisdom teeth
After initial surgical healing (5 weeks), finishing orthodon-
tics continued, with the removal of the appliances 6 months
postoperatively. The patient continued with preventative
splint therapy and orthodontic retention.
CASE 36-4 
Progressive Condylar Resorption/Idiopathic Condylar Resorption? (Fig. 36-4)
History
When she was 15 years old, the occlusion of this female
high school student was characterized as having a normal
overjet/overbite relationship, with mild anterior crowding.
When she was 16 years of age, she experienced an episode
of temporomandibular disorder that was characterized by
TMJ region and masticatory muscle discomfort. This was
accompanied by a painful and limited mandibular range of
motion and chewing difficulties. When she was 17 years old,
the TMD was successfully managed with the use of con­
servative measures (e.g., splint therapy, anti-inflammatory
agents, and diet modifications). Mouth opening was satis-
factory and without direct TMJ region pain but with an
anterior open-bite skeletal Class II malocclusion. As a result
of other signs and symptoms that were present, a diagnosis
of chronic fatigue syndrome and fibromyalgia was made.
Evaluation
The patient arrived for surgical consultation when she was
19 years old in the hopes of achieving improved function
(i.e., mastication, breathing, lip closure/posture, speech
articulation, and swallowing) and enhanced facial aesthetics
(i.e., smile and profile). She underwent evaluation by a
speech pathologist, an otolaryngologist/head and neck
surgeon, an orthodontist, a TMJ specialist, a restorative
dentist, and a general physician.
Treatment
With conservative measures used to control masticatory
muscle discomfort, satisfactory TMJ function, and no
clinical progression of condylar resorption after 2 years of
observation, orthodontic dental decompensation was initi-
ated. No extractions were required to relieve crowding. A
computed tomography scan of the TMJ was obtained 2
months before surgery. The patient’s surgery included the
following
• Maxillary Le Fort I osteotomy
• Vertical intrusion
• Horizontal advancement
• Segmentation for arch expansion and correction of
the curve of Spee
• Bilateral sagittal split ramus osteotomies
• Mandibular plane counterclockwise rotation
• Horizontal advancement
• Oblique osteotomy of the chin
• Horizontal advancement
• Vertical shortening
• Intranasal procedures
• Septoplasty
• Inferior turbinate reduction
• Nasal base recontouring
• Removal of Wisdom Teeth
After surgical healing (5 weeks), finishing orthodontics con-
tinued for 9 months. With the removal of the orthodontic
appliances, preventative splint therapy and orthodontic
retention continued.

1549
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
• Figure 36-4  Patient before and after treatment. A, Frontal views in repose before and after surgery. B, Frontal views with smile before and after
surgery.
A
B
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Continued

1550 SECTION 6  Post-Traumatic Dentofacial Deformities
C
D
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
Orth
r ognathic Surg
r ery; J.C. Posnick
C, Oblique views before and after surgery. D, Profile views before and after surgery.
• Figure 36-4, cont’d

1551
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
Prior to treatment
Pre surgery
5 weeks after surgery
After treatment
E
• Figure 36-4, cont’d  E, Occlusal views before treatment, before surgery, and at 5 weeks and after treatment.
Continued

1552 SECTION 6  Post-Traumatic Dentofacial Deformities
G
H
Mandibular counter-
clockwise rotation
Pharyngeal
airway
expansion
Arch expansion
Curve of Spee
F
Bilateral condylar head erosion
F, Panorex view before surgery. G, Articulated dental casts that indicate analytic model planning.
H, Lateral cephalometric views before and after surgery.
• Figure 36-4, cont’d

1553
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
I
J
Right side 2 months pre surgery
Right side 14 months after surgery
Left side 2 months pre surgery
Left side 14 months after surgery
Measurement 1
Length: 1.651 cm
Measurement 1
Length: 0.617 cm
Measurement 1
Length: 1.305 cm
Measurement 1
Length: 0.419 cm
Measurement 1
Length: 0.919 cm
Measurement 1
Length: 1.211 cm
Measurement 1
Length: 0.775 cm
Measurement 1
Length: 1.137 cm
Measurement 1
Length: 1.651 cm
Measurement 1
Length: 0.617 cm
Measurement 1
Length: 1.305 cm
Measurement 1
Length: 0.419 cm
Measurement 1
Length: 0.919 cm
Measurement 1
Length: 1.211 cm
Measurement 1
Length: 0.775 cm
Measurement 1
Length: 1.137 cm
I, Coronal computed tomography views of the condyle 2 months before and
14 months after surgery. J, Axial computed tomography views of the condyle 2 months before and 14 months
after surgery.
• Figure 36-4, cont’d

1554 SECTION 6  Post-Traumatic Dentofacial Deformities
CASE 36-5 
Idiopathic Condylar Resorption (Fig. 36-5)
History
When she was 12 years old, she was referred by a pediatric
dentist to an orthodontist for evaluation of her malocclu-
sion. She was felt to have dental crowding, and she under-
went standard orthodontic therapy (without extractions)
when she was between 12 and 14 years old, after which time
the appliances were removed. She was left with a mild
gummy smile, satisfactory lip competence, and a stable
Class I occlusion.
When she was approximately 22 years old, she experi-
enced an episode of bilateral TMJ and masticatory muscle
discomfort that affected her mandibular range of motion
and her chewing ability. An insidious anterior open-bite and
retrusive mandibular profile was recognized during the
ensuing 6 to 12 months. The symptoms subsided, and the
patient was left with a satisfactory mandibular range of
motion without TMJ region discomfort. She returned to
the treating orthodontist when she was 26 years old com-
plaining of difficulty with chewing as a result of malocclu-
sion and masticatory muscle discomfort. Radiographic
examination confirmed the partial resorption of the condy-
lar heads.
Evaluation
The patient initially arrived for surgical evaluation when she
was 26 years old and requested reconstruction. The history,
physical examination, and radiographic findings were con-
sistent with ICR. Conservative management of the mastica-
tory muscle discomfort and the confirmation of condylar
stability were recommended. The patient continued with
splint therapy. Over the next 12 months, a consistent occlu-
sion with good mandibular range of motion confirmed
condylar stability. As a result of her work and school
schedules, the patient elected to postpone reconstruction
until a future date.
She returned when she was 30 years old and again
requested reconstruction. Now, with documentation of at
least 5 years of no measurable progression of condylar
resorption and with a negative quantitative condylar
head bone scan, definitive therapy was offered. She under-
went current evaluations by a speech pathologist, an
otolaryngologist/head and neck surgeon, an orthodontist, a
restorative dentist, and a general physician.
Treatment
Orthodontic dental decompensation was carried out over
the course of 9 months. The patient’s surgery included the
following:
• Maxillary Le Fort I osteotomy
• Vertical intrusion at the incisors
• Horizontal advancement at the incisors
• Maxillary plane counterclockwise rotation
• Bilateral sagittal split ramus osteotomies
• Mandibular plane counterclockwise rotation
• Horizontal advancement
• Oblique osteotomy of the chin
• Horizontal advancement
• Vertical change
After initial surgical healing (5 weeks), finishing orthodon-
tics continued for approximately 6 months, and orthodon-
tic retention continued. With good relief of masticatory
muscle discomfort, the patient had a limited need for splint
therapy.

1555
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
• Figure 36-5  Patient before and after treatment. A, Frontal views at 14, 27, and 30 years of age. B, Profile views at 14, 27, and 30 years of age.
14 years of age
27 years of age
30 years of age
A
30 years of age
27 years of age
14 years of age
B
sevier Inc.
Or
Or
Or
Or
Orththththththtr ogn
gn
g atatatata hicicicici Su
Su
Surg
r ery
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C.
C.
C. Pos
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os
os
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©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Orththththththththth
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gn
gn
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Su
Surg
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ry
ry
ry; J.C.
C.
C.
C.
C Pos
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©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicic 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; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
o nicicicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thtr ogn
gn
gn
gn
gnatatatathicicicicicicicicicicicicicicic 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
r ; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
osnicicicicicici k
©Elsevier Inc.
Or
Or
Or
Or
O th
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatata hicicicicicicicicic 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; J.C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
o nicicicick
©Elsevier Inc.
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
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
o nicicicicicicicicick
Continued

1556 SECTION 6  Post-Traumatic Dentofacial Deformities
C
D
E
30 years of age
27 years of age
14 years of age
30 years of age
27 years of age
14 years of age
26 years of age
C, Left condyle Panorex views at 14, 27, and 30 years of age. D, Right condyle Panorex views at 14,
27, and 30 years of age. E, Coronal computed tomography view of the condyles at 26 years of age.
• Figure 36-5, cont’d

1557
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
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
F
G
F, Frontal views in repose before and after surgery. G, Frontal views with smile before and after surgery.
• Figure 36-5, cont’d 
Continued

1558 SECTION 6  Post-Traumatic Dentofacial Deformities
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
H
I
H, Oblique views before and after surgery. I, Profile views before and after surgery.
• Figure 36-5, cont’d

1559
CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
Prior to retreatment
Pre surgery
After treatment
J
J, Occlusal views before retreatment, before surgery, and after surgery.
• Figure 36-5, cont’d 
Continued

1560 SECTION 6  Post-Traumatic Dentofacial Deformities
K
L
Mandibular counter-
clockwise rotation
Maxillary counter-
clockwise rotation
K, Articulated dental casts that indicate analytic model planning. L, Lateral cephalometric
views before and after surgery.
• Figure 36-5, cont’d 
Conclusions
In patients with the condition of uncertain etiology known
as ICR and in those with a known association (PCR), the
condyles of the mandible partially resorb, thereby causing
a loss of condylar height and secondary alterations of the
maxillo-mandibular complex with effects on the occlusion,
the upper airway, and the facial aesthetics. Theories of the
condition’s etiology continue to evolve.
When the condylysis process is believed to be “burnt
out,” a comprehensive approach to resolve the secondary
deformities generally involves an orthodontist, an orthog­
nathic surgeon, a TMJ specialist, and appropriate imaging
studies to achieve optimal results. The keys to a favorable
result for the secondary maxillo-mandibular deformities are
as follows: to await the presumed remission of condylar
resorption; to define the func­tional deficits; and to then
successfully perform joint-preserving orthognathic and
intranasal procedures in conjunction with orthodontic
treatment as indicated. In the future, the use of disease-
modifying anti-rheumatic drugs may play a prominent role
in limiting condylar resorption in affected individuals.
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1561
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CHAPTER 36  Idiopathic Condylar Resorption: Evaluation and Treatment
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1564

SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
37
Aesthetic Alteration of the Chin:
Evaluation and Surgery
JEFFREY C. POSNICK, DMD, MD
• Anatomy of the Chin
• Aesthetics of the Chin
• Biologic Foundation of Osseous Genioplasty
• Frequent Patterns of Chin Deformities
• Osseous Genioplasty: Surgical Technique
• Achieving Favorable Chin Aesthetics
• Avoiding Pitfalls during Chin Surgery
• Complications and Unfavorable Results
• Alloplastic Chin Augmentation
• Conclusions
• Patient Education Materials
muscles are attached to the posterior portion of the inferior
border of the symphysis. The sensory innervation to the
cutaneous chin, the lower lip, and the inner vestibule is
derived from the mental nerve on each side. The motor
innervation to the muscles within the soft tissues of the chin
occurs through the marginal mandibular and cervical
branches of the facial nerve.
Aesthetics of the Chin
In Western society, a “weak” or deficient chin is associated
with timidity, indecision, femininity, a lack of athleticism,
and shy behavior. Conversely, a “strong” or forwardly pro­
jecting chin is associated with athleticism, aggressiveness,
decisiveness, and bold behavior. The fact that an average
adult from any number of ethnic backgrounds and nation­
alities from around the world will frequently characterize a
chin as either “weak” or “strong” demonstrates the sublimi­
nal messages communicated about the character of a person
as a result of the presenting chin morphology. When people
speak about chin contour, emphasis is generally placed on
the profile view (Fig. 37-1).2,13,90,91 Although it is true that
a retrusive pogonion is a frequently mentioned concern, the
chin may also be asymmetric or out of the normal range in
more than one dimension.
When it is taken with the patient in the natural head
position, with the lips relaxed (i.e., in repose) and with the
lower jaw at rest (i.e., the condyles seated in the fossa and
with a normal freeway space between the teeth), a lateral
cephalometric radiograph provides an accurate image of the
facial skeleton and the overlying soft tissues from which to
judge profile aesthetics.28,30,31,43,44,83,105,112 When viewing
either a full-face lateral photograph or a soft-tissue lateral
cephalometric radiograph taken in this way, a vertical line
(i.e., perpendicular to the floor with the patient in the
natural head position) can be drawn through the subnasal
region to assess the relative prominence of the nose, lips,
and chin.36 Ideally, the chin should lie on this line, with
the lips slightly anterior (Figs. 37-2 through 37-5).9 It is
also true that there are many complex interrelationships
Hugo Obwegeser introduced the intraoral approach to
completing an osseous genioplasty in 1957.74 More than
half a century later, this relatively simple technique still
remains underused when surgeons are asked to make cos­
metic changes to the chins of their patients.
Anatomy of the Chin
The word chin describes a region of the face that includes
both soft tissue and bone.79,125 The soft-tissue portion
encompasses the labial mental fold superiorly, the oral com­
missures laterally (just anterior to the jowls), and the
submental–cervical crease inferiorly. The bony portion of
the chin encompasses the mandibular symphyseal region. It
includes the region inferior to the root apices of the anterior
teeth and the area in front of and below the mental foramen
on each side. Within the soft tissues of the chin are found
a series of paired muscles that include the mentalis, the
quadratis labii inferioris, the triangularis, and the superior
portions of the platysma that extend over the symphysis
region.22 Attached to the genial tubercle of the chin poste­
riorly are the tendinous attachments of the geniohyoid and
genioglossus muscles.66 The anterior bellies of the digastric
Text continued on p. 1571

1565
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
• Figure 37-1  A 29-year-old woman arrived to discuss her chin aesthetics. During the mixed dentition, she was recognized as having mandibular
deficiency and a constricted maxillary arch width. At that time, she underwent growth-modification techniques, including the use of headgear.
She also underwent rapid palatal expansion followed by compensatory orthodontic mechanics to neutralize the occlusion, but this resulted in
proclination of the incisors. A retrusive profile and a dual bite remained. She recently underwent the placement of an extended silastic chin implant
but without fixation by another surgeon. Aesthetic modification of the anterior maxillary dentition was also completed by a restorative dentist.
She is displeased with the cosmetic facial results of a deepened labiomental fold, a mobile chin implant, and a “button” appearance during lip
closure. There is a dual bite with Class II malocclusion in centric relation. A, Oblique and frontal facial views after chin implant placement.
B, Profile facial view and lateral cephalometric radiograph 6 months after chin implant placement.
B
Chin implant
in place
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1566 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
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• Figure 37-2  A 17-year-old boy arrived
with his father for the evaluation of a “weak
chin” and requested chin augmentation. He
had undergone orthodontic treatment with
the establishment of a satisfactory occlusion
that required minimal dental compensation.
He agreed to undergo osseous genioplasty
(horizontal advancement) to resolve the chief
complaint. A, Profile views before and
after reconstruction. B, Oblique facial views
before and after reconstruction. C, Lateral
cephalometric radiographs before and after
reconstruction.

1567
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
• Figure 37-3  A 16-year-old girl arrived with her mother and requested a cosmetic rhinoplasty to reduce the dorsal hump and to improve the
drooped nasal tip seen in profile. She also had a lifelong history of nasal obstruction. Evaluation confirmed the aesthetic nasal needs as well as
sagittal deficiency of the chin. She agreed to undergo septorhinoplasty and osseous genioplasty. The rhinoplasty included nasal osteotomies
(in-fracture); dorsal reduction (bone and cartilage) and tip maneuvers (modification of lower lateral cartilages and septal cartilage caudal strut
grafting); septoplasty; and the reduction of the inferior turbinates. Osseous genioplasty included horizontal advancement. A, Profile facial views
before and after reconstruction. B, Oblique facial views before and after reconstruction.
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1568 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
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A
B
• Figure 37-4  A 17-year-old girl arrived with her mother and requested a cosmetic rhinoplasty to reduce the dorsal hump and to improve the
drooped nasal tip seen in profile. She also had a lifelong history of nasal obstruction. Evaluation confirmed the aesthetic nasal needs as well as
sagittal and vertical deficiency of the chin. She agreed to undergo septorhinoplasty and osseous genioplasty. The rhinoplasty include nasal oste­
otomies (in-fracture); dorsal reduction (bone and cartilage) and tip maneuvers (modification of lower lateral cartilages and septal cartilage caudal
strut grafting); septoplasty; and the reduction of the inferior turbinates. Osseous genioplasty included horizontal advancement and vertical length­
ening with interpositional grafting (bloc hydroxyapatite). A, Frontal views in repose before and after reconstruction. B, Oblique facial views before
and after reconstruction.

1569
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
D
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C
C, Profile facial views before and after reconstruction. D, Lateral cephalometric radiographs before and after surgery.
• Figure 37-4, cont’d

• Figure 37-5  An 18-year-old girl arrived with her parents and requested a cosmetic rhinoplasty and a chin implant. She hoped for a smaller nose,
a reduction of the dorsal hump, and a stronger profile. She also had a history of nasal obstruction after a sports injury earlier during her life. Exami­
nation confirmed mild sagittal deficiency of the mandible but with a functional occlusion and minimal dental compensation after earlier orthodontic
treatment. She agreed to undergo septorhinoplasty and osseous genioplasty. The patient’s nasal procedures included nasal osteotomies (in-fracture);
dorsal reduction (bone and cartilage); tip maneuvers (modification of lower lateral cartilages and septal cartilage caudal strut grafting); septoplasty;
the reduction of the inferior turbinates; and osseous genioplasty with horizontal advancement. A, Frontal views in repose before and 8 years after
reconstruction. B, Oblique facial views before and 8 years after reconstruction.
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1571
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
g atatatatatathicicicicicicic Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
osnick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththth
r ogn
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gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatathicicicicicicicicici Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C.
C Pos
osnicicick
C
D
C, Profile views before and 8 years after reconstruction. D, Lateral cephalo­
metric radiographs before and 8 years after reconstruction.
• Figure 37-5, cont’d 
among the facial structures that should be taken into
consideration.1-3,51,52,60,69,95,118 Critical decisions with regard
to where to position the chin through osseous genioplasty
are made when viewing the patient “face to face” from
varying perspectives in repose and during broad smile in the
clinic setting.4,16,124,126
Biologic Foundation of Osseous
Genioplasty
When carrying out an osseous genioplasty, a horizontal
osteotomy below the roots of the anterior teeth and the
mental foramen on either side is completed. After osteot­
omy, the distal segment of the chin remains attached to a
musculoperiosteal pedicle. Healing is optimal when the cir­
culation of blood to bone and its enveloping soft tissue is
continuously maintained. In 1988, Bell and colleagues
completed microangiographic and histologic studies in
adult rhesus monkeys that indicated that an intraoral ped­
icled flap that involved an osteotomy of the inferior man­
dibular border maintains circulation and osseous viability
after manipulation and repositioning of the chin segment.106
According to Bell’s experimental work, circulation to the
dental pulp should not be discernibly affected during the
process.
Frequent Patterns of Chin Deformities
Horizontal Chin Deficiency with or without
Vertical Discrepancy
Contemporary maxillofacial surgeons now recognize that
individuals who are seeking a “stronger chin” (i.e., horizontal

1572 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
projection) frequently also have disproportions in the verti­
cal dimension of their face.23,33,45,59,61,77,88,89,92,116,120,123,127,131
Studies suggest that approximately 40% of individuals with
horizontal (sagittal) chin deficiency have a decreased lower
anterior facial height (i.e., short face growth pattern) (Figs.
37-4, 37-6, and 37-7). It is also known that another 25%
of these will have the other extreme of an increased lower
anterior facial height (i.e., long face growth pattern) (Figs.
37-8 through 37-11). In either case, the bony chin dysmor­
phology will also result in soft-tissue abnormalities (distor­
tions) of the labiomental fold. This often includes a deep
labiomental angle in those with a short face growth pattern
and a flat labiomental fold in those with a long face growth
pattern. Fifty percent of individuals with a horizontally
deficient chin will have an Angle class II malocclusion,
which is indicative of mandibular retrusion. Forty percent
will have previously undergone orthodontic camouflage
treatment in an attempt to mask their micrognathia (see
Fig. 37-1). Incisor flaring will have resulted from the ortho­
dontic camouflage approach that attempted to neutralize a
Class II excess overjet malocclusion as an alternative to a
more biologic correction of the mandibular deficiency
through orthognathic surgery. Some of these individuals
will have also undergone chin implant augmentation, often
with a suboptimal result (see Fig. 37-1, 37-7, and 37-9).
A pleasing labiomental fold is an essential component
of optimal lower face aesthetics. A strong correlation exists
between the lower anterior facial height and the labiomental
fold morphology. Individuals with decreased lower anterior
facial height in combination with a retrusive-appearing chin
tend to have an exaggerated and excessively deep labiomen­
tal fold with acute angulation between the lower lip and the
soft-tissue chin pad (i.e. primary mandibular deficiency or
maxillomandibular deficiency; see Figs. 37-4, 37-6, and
37-7). Individuals with increased lower anterior facial height
in combination with a horizontally deficient chin are likely
to have a labiomental fold that is flattened and effaced, with
poor fold definition, excess mentalis strain, and difficult lip
closure (i.e., long face growth pattern). The long face growth
pattern classically consists of vertical excess of the maxillary
and mandibular alveolar regions. This is combined with
mandibular retrognathia and an anterior open-bite Class II
malocclusion (see Figs. 37-8 and 37-9).
Rosen and others have pointed out that many individuals
with mandibular deficiency and decreased lower anterior
facial height who have a functional occlusion are unwilling
to undergo an orthognathic correction and may opt for
a compromise approach to at least achieve some aesthetic
advantage (Figs. 37-12 through 37-17).88-93An osseous
genio­plasty to simultaneously vertically lengthen and hori­
zontally advance the chin will generally achieve a degree of
improved lower facial height and chin projection while
reducing the deep labiomental fold. When this compromise
is undertaken, no improvement in any baseline malocclu­
sion or any significant opening of the airway should be
expected. From an aesthetic perspective, it is essential to
prevent an operated look when choosing a chin-only
approach. This aesthetic error can be limited by avoiding
the temptation to fully correct a moderate to severe man­
dibular deficiency through an isolated chin procedure (see
Figs. 37-13 and 37-15).
In the individual with a functional occlusion, a retrusive
chin and an increased lower anterior facial height (i.e., long
face growth pattern), the surgical camouflage approach will
be different than what is used for the patient with a short
face growth pattern, as described previously. As an aesthetic
compromise, it will be an advantage to vertically shorten
and horizontally advance the chin (see Fig. 40-9). This will
at least marginally decrease the mentalis strain to improve
the ease of lip closure and also to enhance the appearance
of the lower face (see Fig. 37-11).
Text continued on p. 1595
To review, when evaluating a “weak” profile, it is impor­
tant to consider not only the horizontal (sagittal) position
of the chin but also the vertical dimension (excess or defi­
ciency). In addition, it is essential to analyze the maxillo-
mandibular proportions of the face (i.e., any existing jaw
deformity) and the alignment of the teeth in the alveolar
bone (e.g., dental compensation such as incisor flaring).
Only after all facial and dental aspects are evaluated will the
ideal treatment be understood and any reasonable compro­
mise options be rationally considered in the light of their
shortcomings.
Horizontal Chin Prominence and Associated
Vertical Discrepancy
Individuals who present with a prominent pogonion are
likely to have disproportions of the lower anterior facial
height (i.e., the vertical dimension), which in turn affect
labiomental fold morphology.6,64,99,135 When an individual
presents with a prominent pogonion and asks for a chin
reduction only, he or she will likely not be pleased with the
aesthetic result if this limited request is honored.
A commonly seen pattern of jaw deformity is maxillary
deficiency in combination with relative mandibular excess
(i.e., skeletal Class III growth pattern; see Chapter 20). This
often presents in association with a vertically long (i.e., as
measured in millimeters from the mandibular incisor edge
to the menton height) and protrusive (i.e. forwardly pro­
jected) chin (Fig. 37-18). These individuals generally benefit
from Le Fort I advancement with or without simultaneous
vertical lengthening and clockwise rotation. Mandibular
Note: There are some patients with the long face
growth pattern who do not have a long chin as part of
their dysmorphology. These individuals do not have a
flat labiomental fold, and they should not undergo a
camouflage chin-only procedure consisting of horizontal
advancement and vertical shortening as described
previously.

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B
A
• Figure 37-6  A 24-year-old woman arrived for evaluation. She had previously undergone four bicuspid extractions and orthodontics to neutralize
her occlusion during her high school years. Analysis confirmed a short face growth pattern that accounted for her apparent large nose, weak
profile, obtuse neck chin angle, and edentulous look. She agreed to a combined orthodontic and surgical approach. The patient’s surgery included
maxillary Le Fort I osteotomy (horizontal advancement, vertical lengthening, and clockwise rotation) with interpositional grafting; sagittal split ramus
osteotomies (horizontal advancement and clockwise rotation); and osseous genioplasty (vertical lengthening and minimal horizontal advancement)
with interpositional grafting. Minimal change in the occlusion was required (see Fig 23-3). A, Frontal views in repose before and after treatment.
B, Oblique facial views before and after treatment.
Continued

1574 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
C
Maxillary
clockwise
rotation
Mandibular
clockwise
rotation
C, Articulated dental casts that indicate analytic surgical planning. D, Lateral cephalometric radiographs before and after
treatment.
• Figure 37-6, cont’d

1575
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
• Figure 37-7  A 37-year-old man was referred with a request to have a chin implant removed because he was displeased with the aesthetic
results. When he was 20 years old, he underwent chin augmentation with a silicone implant in an attempt to camouflage his small lower jaw profile.
Ten years later, he underwent four bicuspid extractions and orthodontic alignment to improve his occlusion. He had also undergone a septorhino­
plasty procedure, but he was still experiencing continued difficulty breathing through the nose. During evaluation by this surgeon, he was recognized
as having a short face growth pattern with decreased lower anterior facial height and limited facial projection. There was an accentuated labiomental
lip curl and a “button” appearance to the chin. It became clear during a discussion that the patient suffered with snoring, restless sleeping, and
excessive daytime fatigue. An attended polysomnogram confirmed a respiratory disturbance index of 16 events/hr, with desaturations of up to
89%. A titration study confirmed the need for 12 cm of water pressure to reduce the respiratory disturbance index to 3 events/hr. The use of
continuous positive airway pressure was attempted but found to be uncomfortable and difficult for the patient to use. A, Frontal views with smile
before and after surgery. B, Profile views before and after surgery.
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A
B
Continued

1576 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
Silicone chin
implant to be
removed
C
9 mm
Consultations with a sleep specialist, an otolaryngologist, and an orthodontist confirmed the advantage of
an intranasal and orthognathic surgical approach. The patient agreed to perioperative orthodontics and surgery to improve the
airway and facial appearance. His procedures included maxillary Le Fort I osteotomy (horizontal advancement +9 mm, vertical
lengthening +5 mm), with interpositional grafting; bilateral sagittal split osteotomies of the mandible (horizontal advancement
+12 mm); removal of the chin implant; osseous genioplasty (horizontal advancement and vertical lengthening) with interpositional
grafting; reduction of the inferior turbinates; redo septoplasty; and an anterior approach to the neck (cervical flap elevation, defat­
ting, and vertical platysma muscle plication). As a result of the procedures, the patient experienced relief of his snoring, improved
quality of sleep, diminished daytime fatigue, and improved breathing during the day. Six months after surgery, he underwent an
attended polysomnogram that indicated a normal sleep study with no snoring or apnea events (see Fig. 26-10). C, Articulated
dental casts that indicate analytic surgical planning. D, Lateral cephalometric radiographs before and after surgery (note the pre­
operative chin implant).
• Figure 37-7, cont’d

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A
B
• Figure 37-8  A 21-year-old college graduate arrived for surgical evaluation. Her history and physical examination confirmed lifelong nasal obstruc­
tion, lip incompetence, difficulty chewing, and frequent speech articulation errors. Facial aesthetic concerns include a weak chin, a gummy smile,
lip strain, and the impression of having a “big nose.” The patient had been under an orthodontist’s care since the mixed dentition and through her
high school years. Growth modification attempts followed by rapid palatal expansion and full bracketing with four bicuspid extractions were unsuc­
cessful to close the anterior open bite. Early periodontal and dental deteriorization were evident. Further evaluations were carried out by a speech
pathologist, an otolaryngologist, and a periodontist; in addition, a fresh look was taken at this patient’s orthodontic needs. Orthodontic dental
decompensation in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures that were carried out included
Le Fort I osteotomy in segments (horizontal advancement, vertical shortening, counterclockwise rotation, arch expansion, and correction of the
curve of Spee); sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty (vertical shortening
and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring (see Fig. 21-5). A, Frontal views in repose
before and after reconstruction. B, Profile views before and after reconstruction.
Continued

1578 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
C
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
C, Articulated dental casts that indicate analytic model planning. D, Lateral cephalometric radiographs before and
after surgery.
• Figure 37-8, cont’d

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A
B
• Figure 37-9  A 21-year-old college graduate arrived for surgical evaluation. Her history and physical examination confirmed lifelong nasal obstruc­
tion, heavy snoring, lip incompetence, difficulty chewing, and frequent speech articulation errors. Facial aesthetic concerns included a weak chin,
a gummy smile, and the impression of having a “big nose.” She had been under an orthodontist’s care from the mixed dentition through her high
school years. Growth modification followed by rapid palatal expansion and full bracketing with attempted closure of the anterior open bite were
attempted, without success. She had undergone a chin implant in an attempt to improve the profile, but this was also suboptimal. Further evalu­
ations were carried out by a speech pathologist and an otolaryngologist, and a fresh look was taken at this patient’s occlusal/dental needs. Orth­
odontic decompensation in combination with orthognathic and intranasal surgery was chosen. The simultaneous procedures that were carried out
included Le Fort I osteotomy in segments (horizontal advancement, vertical shortening, counterclockwise rotation, arch expansion, and correction
of the curve of Spee); sagittal split ramus osteotomies (horizontal advancement and counterclockwise rotation); removal of the chin implant; osseous
genioplasty (vertical shortening and horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring. A, Frontal
views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.
Continued

1580 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
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C
D
C, Oblique facial views before and after reconstruction. D, Profile views before and after reconstruction.
• Figure 37-9, cont’d

1581
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
Prior to retreatment
Pre surgery
After treatment
E
E, Occlusal views before retreatment, with orthodontic decompensation in progress, and after the completion
of treatment.
• Figure 37-9, cont’d 
Continued

G
Chin implant
to be removed
F
Maxillary counter-
clockwise rotation
Mandibular counter-
clockwise rotation
Arch expansion
• Figure 37-10  Intraoperative views of four silicon/Silastic chin
implants removed from four separate patients who had suffered com­
plications and suboptimal results and who had requested chin implant
removal.
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs before and after surgery.
Note that the chin implant was inadequate to improve the profile. An osseous genioplasty in addition to an orthognathic correction achieved the chosen
objectives.
• Figure 37-9, cont’d

1583
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
• Figure 37-11  A woman in her early 50s with facial aging concerns. She had a mild long face growth pattern and a satisfactory occlusion. The
lower anterior facial height was increased, which resulted in mild lip incompetence and mentalis strain as well as deep perioral creases. She agreed
to blepharoplasty (elliptical excision of upper lid skin and redraping of lower lid tissue); osseous genioplasty (vertical reduction and horizontal
advancement); and a face lift (see Fig. 40-9). A, Frontal views before and after surgery. B, Profile views before and after surgery. Note the relief
of the perioral folds and mentalis strain as a result of vertical reduction and advancement genioplasty.
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A
B
A

1584 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
• Figure 37-12  A Caucasian man in his 30s arrived for the evaluation a “weak chin” and requested aesthetic improvement. Examination confirmed
a mild developmental mandibular deficiency (see Chapter 19). Successful orthodontics had been carried out during his teenage years, with only
mild flaring of the mandibular incisors. An osseous genioplasty was agreed to that included significant vertical lengthening and limited horizontal
advancement with interpositional bloc hydroxyapatite grafting. A, Profile views before and after reconstruction. B, Lateral cephalometric radio­
graphs before and after reconstruction.
B
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A

1585
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
• Figure 37-13  A 27-year-old Indian woman arrived and requested of a reduction rhinoplasty and a chin implant to treat her perceived “big
nose” and “small chin.” Analysis confirmed maxillomandibular sagittal deficiency that was treated during her teenage years with compensatory
orthodontics to neutralize the occlusion. There was marked procumbency of the maxillary and mandibular anterior dentition but with adequate
tooth and gingival show, without lip incompetence and with good to the periodontium. The nasal aesthetic unit had thick skin but satisfactory
proportions. The patient lacked lower anterior facial height and facial projection, especially at the pogonion. She was treated with an osseous
genioplasty (vertical lengthening and limited horizontal advancement) and interpositional bloc hydroxyapatite grafting. A, Frontal views before and
after reconstruction. B, Oblique facial views before and after reconstruction.
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A
B
Continued

1586 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
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C
C, Profile views before and after reconstruction. D, Lateral cephalometric radiographs before and after reconstruction.
• Figure 37-13, cont’d

• Figure 37-14  A woman in her early 20s arrived for the evaluation of her facial aesthetics. She had a developmental jaw deformity that was
characterized primarily by mandibular deficiency and a lifelong history of obstructed nasal breathing. During her teenage years, she underwent an
orthodontic camouflage approach that included maxillary bicuspid extractions with anterior dentition retraction to achieve an improved occlusion.
She perceived a “big nose” and a “small chin” and requested reduction rhinoplasty and a chin implant. She refused redo orthodontics and an
orthognathic correction (see Chapter 19). A compromise was agreed to that included open rhinoplasty and osseous genioplasty. The patient’s
rhinoplasty included nasal osteotomies (in-fracture and straightening); dorsal reduction (bone and cartilage); and tip maneuvers (modification of
lower lateral cartilages and septal cartilage caudal strut grafting). Osseous genioplasty included vertical lengthening with interpositional bloc hydroxy­
apatite grafting and minimal horizontal advancement. A, Frontal views with smile before and after reconstruction. B, Oblique facial views before
and after reconstruction.
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A
B
Continued

1588 SECTION 7  Frequent Aesthetic Considerations in the Dentofacial Deformity Patient
D
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C
C, Profile views before and after reconstruction. D, Lateral cephalometric radiographs before and after reconstruction.
• Figure 37-14, cont’d

1589
CHAPTER 37  Aesthetic Alteration of the Chin: Evaluation and Surgery
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A
B
• Figure 37-15  A woman in her mid 20s arrived for the evaluation of her facial aesthetics. She had a short face growth pattern (i.e.,
maxillomandibular deficiency) that was treated during her teenage years with compensatory orthodontic alignment only. An orthognathic
correction to improve her horizontal facial projection and to increase the lower anterior facial height was recommended (see Chapter 23).
She was unwilling to undergo further orthodontics and refused an orthognathic approach. A compromise was agreed to that included
open rhinoplasty and osseous genioplasty. The patient’s rhinoplasty included nasal osteotomies (in-fracture and straightening); dorsal
reduction (bone and cartilage); and tip maneuvers (modification of lower lateral cartilages and septal cartilage caudal strut grafting). Osseous
genioplasty included vertical lengthening and minimal horizontal advancement with interpositional bloc hydroxyapatite grafting. A, Frontal
views in repose before and after reconstruction. B, Frontal views with smile before and after reconstruction.
Continued