Orthognathic Surgery

191
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
Orth
r ognathic Surg
r ery; J.C. Posnick
A
B
• Figure 6-21  A 32-year-old man arrived for the evaluation of a longstanding jaw deformity with malocclusion, chronic obstructive nasal breathing,
and periodontal issues. Since his early childhood years, he was known to have a maxillary deficiency with a relative mandibular excess growth
pattern. The family elected a camouflage orthodontic approach in an attempt to neutralize the occlusion when the patient was 9 to 13 years old.
He is a forced mouth breather with increased nasal airway resistance as a result of septal deviation and turbinate hypertrophy. His general dentist
confirmed labial bone loss and gingival recession of the mandibular anterior and maxillary posterior dentition. He was referred to this surgeon, and
a comprehensive orthognathic and dental approach was approved. Consultation with a periodontist, an orthodontist, and an ear, nose, and throat
specialist was carried out. The patient was confirmed to have deviation of the septum and enlarged inferior turbinates. An attended polysomnogram
is pending. The need for gingival grafting to attain improved root coverage and to generate a wider band of attachment was recommended for
teeth nos. 3, 11, 14, 19, 20, 23 through 26, and 29 and 30. This will be followed by the orthodontic removal of dental compensation, including
the extraction of a mandibular incisor to address the severe bone loss and gingival recession. Orthognathic and intranasal procedures to improve
long-term dental health, to enhance facial aesthetics, and to open the upper airway will follow. A, Frontal facial and occlusal views before treatment.
B, Panorex radiograph with treatment in progress.

192
SECTION 1  Basic Principles and Concepts
Or
Or
Or
Or
Or
Orthththth
r ogn
gn
gn
gn
g atatathicicicicicic Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
o nicicicick
A
• Figure 6-22  A 30-year-old man arrived for the evaluation of a longstanding jaw deformity with malocclusion, chronic obstructive
nasal breathing, and awareness of periodontal issues. Since his early childhood years, he was known to have a jaw deformity with
malocclusion that included an anterior open bite. When he was between 8 and 12 years old, he underwent orthodontic camouflage
treatment in an attempt to close the open bite, including full bracketing and the use of heavy anterior elastics. By the time he gradu­
ated from high school, he was conscious of a significant recurrent anterior open bite with dental crowding. Through his college years,
he was aware of gingival recession on the labial aspect of many of the anterior teeth; this was apparent on the maxilla more so than
on the mandible. He was sent by his general dentist for an orthodontic evaluation and then to this surgeon for an opinion. He was
referred for periodontal evaluation to confirm significant labial bone loss of the anterior dentition (on the maxilla more than the man­
dible) with gingival recession. A comprehensive approach was recommended, including gingival grafting and four bicuspid extractions
with orthodontic retraction of the anterior dentition into solid alveolar bone. This would be followed by jaw reconstruction, finishing
orthodontics, and periodontal surveillance. A, Frontal facial and occlusal views before retreatment. B, Profile facial view and lateral
cephalometric radiograph before retreatment. C, Panorex radiograph before retreatment.
C
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatathicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C Pos
os
os
os
o nicicick
B

193
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
Or
Orthth
r ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatathicicicicicicicicicicicicicic 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
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
osnicick
A
Or
Or
Or
Or
Or
Or
Or
Orththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatata hicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C. Pos
os
os
osnicicick
B
• Figure 6-23  A 34-year-old man arrived for the evaluation of a longstanding jaw deformity with malocclusion, chronic obstructive nasal breathing,
and periodontal issues. Since his early childhood years, he was known to have a maxillary deficiency with relative mandibular excess growth pattern.
The family elected a camouflage orthodontic approach that included four bicuspid extractions and the introduction of dental compensation in an
attempt to neutralize the occlusion when the patient was 10 to 15 years old. He is a forced mouth breather as a result of the increased nasal
airway resistance. He underwent septoplasty when he was 20 years old, but this did not result in significant improvement. His general dentist
confirmed labial bone loss and gingival recession of the mandibular anterior and maxillary posterior dentition. He was referred to this surgeon, and
a comprehensive orthognathic and dental approach was recommended. Consultation with the periodontist, the orthodontist, and the ear, nose,
and throat specialist was carried out. The patient was confirmed to have residual deviation of the septum and enlarged inferior turbinates, which
explained the continued difficulty that he had breathing through his nose. A degree of root resorption of the anterior dentition was likely the result
of previous orthodontic mechanics. The need for gingival grafting to attain as much root coverage as possible and to generate a wider band of
attachment was recommended for teeth nos. 3, 11, 14, 19, 20, 23 through 26, and 29 and 30. This will be followed by the orthodontic removal
of dental compensation and then orthognathic and intranasal procedures to improve the patient’s long-term dental health, to enhance his facial
aesthetics, and to open his upper airway. A, Frontal facial and occlusal views before treatment. B, Profile facial view and lateral cephalometric
radiograph before treatment. C, Panorex radiograph with treatment in progress.
C
R
L

194
SECTION 1  Basic Principles and Concepts
• Figure 6-24  A 16-year-old girl with a primary mandibular deficiency growth pattern. She had undergone several
years of growth modification followed by orthodontic mechanics that included four bicuspid extractions in an attempt
to neutralize the occlusion. The patient was left with mandibular deficiency and malocclusion that included significant
overjet, anterior open bite, and proclination of the maxillary incisors. Labial bone loss with gingival recession that affected
the lower anterior dentition is evident. The patient was referred to this surgeon for a comprehensive orthodontic and
surgical approach (see Fig. 19-11). A, Frontal and occlusal views in repose at the time of referral. B, Profile and lateral
cephalometric radiograph views at the time of referral.
Or
Or
Or
Or
Orththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C. Pos
os
os
os
os
osnicicicicicicicicicicicicicicicicicick
A
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic 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; J.C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
o nicicick
B

195
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 6-25  A man in his early 20s with a primary mandibular deficiency growth pattern. He underwent many years of
growth modification followed by orthodontic camouflage maneuvers that included four bicuspid extractions in an attempt to
neutralize the occlusion. Deterioration of the periodontium with labial bone loss and gingival recession along the mandibular
anterior dentition are evident. A, Frontal facial and occlusal views before retreatment. B, Profile view and lateral cephalometric
radiograph before retreatment.
Or
Orthththththththththththth
r ogn
gn
g atathic Su
Su
Su
S rg
r ery
ry
ry; J.C.
C.
C.
C Pos
os
os
os
os
osnicicici k
A
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththththththththththththththththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicici 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
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
o nicicici k
B

196
SECTION 1  Basic Principles and Concepts
• Figure 6-26  A woman in her early 50s was referred by a prosthodontist for surgical evaluation. There had been a
gradual deterioration of the dentition, which was at least partially a result of the longstanding developmental Class II
excess overjet deep-bite skeletal pattern. A head and neck evaluation confirmed a retrusive mandible, which also resulted
in retroglossal airway obstruction. In addition, a desire for improved profile aesthetics was discussed. A comprehensive
approach to dental rehabilitation, improvement of the upper airway, and facial rejuvenation and reconstruction was recom­
mended. Coordinated endodontic, orthodontic, periodontic, prosthodontic, and surgical care was required. Periodontal
treatment, extractions, dental implant placement, restorative temporization, and orthodontic alignment were carried out.
These treatments were 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).
These procedure were followed by crown lengthening and then by final dental restorations (see Fig. 25-2). A, Frontal facial
and occlusal views before treatment. B, Profile facial view and lateral cephalometric radiograph during treatment.
C, Panorex radiograph before treatment.
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatathicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
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
os
o nicicicicicicicicicicicicicicicicicick
A
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatata hicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C. Pos
os
os
os
os
os
osnicicicici k
B
C
R
L

197
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 6-27  A 50-year-old woman was referred by her general dentist to an orthodontist and then for surgical evaluation. There
was a mandibular deficiency and a constricted upper jaw growth pattern. This resulted in a Class II deep-bite excess overjet maloc­
clusion. Over the years, there was destruction to the dentition and periodontal apparatus with generalized bone loss and gingival
recession. The patient was now under the care of a restorative dentist and a periodontist. To resolve the malocclusion, maxillary
expansion and mandibular advancement in combination with orthodontics were recommended. At referral to this surgeon, a history
documented heavy snoring, restless sleeping, and daytime somnolence. An attended polysomnogram confirmed a respiratory dis­
turbance index of 42.7 events per hour. There was intranasal obstruction caused by septal deviation and inferior turbinate enlarge­
ment, a retropositioned palate caused by maxillary retrusion, and a retropositioned tongue as a result of mandibular retrusion. The
soft palate and the tongue were of normal size and function. There were minimum tonsil and adenoid structures. Continuous positive
airway pressure was tried but not well tolerated. Surgery was agreed to in combination with orthodontics to improve the malocclusion
and to open the airway. The procedures carried out included a maxillary Le Fort I osteotomy (horizontal advancement, vertical length­
ening, and arch form correction); bilateral sagittal split osteotomies of the mandible (horizontal advancement); osseous genioplasty
(horizontal advancement); septoplasty and inferior turbinate reduction; and an anterior approach to the neck (cervical flap elevation,
neck defatting, and vertical platysma muscle plication). Subjectively, there was good relief of snoring and restless sleeping as well as
the resolution of daytime fatigue. Six months after surgery, an attended polysomnogram confirmed the resolution of the obstructive
sleep apnea with a respiratory disturbance index of 1.9 events per hour and minimum desaturation (see Fig. 26-8). A, Frontal facial
and occlusal views before treatment. B, Profile facial view and lateral cephalometric radiograph before treatment.
Or
Or
Or
Or
Or
Orthththththththththtr ogn
gn
gn
gn
gn tatatatatatatatatatathicicicicicicicicicicicicicicicic 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; J.C.
C.
C.
C Pos
os
os
os
o nicicicick
A
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatata hicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
r ; J.C.
C.
C.
C. Pos
os
osnicicick
B

198
SECTION 1  Basic Principles and Concepts
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatata hicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
g atatatatata hicicicicicic 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
osnicicicicicicicici k
Or
Or
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
g atatatatatatatatatata hicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
r ; J.C.
C.
C.
C.
C. Pos
os
os
os
os
os
os
os
o nicicicicicicicicicicicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g
tatatatatatatatatatatatatathicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
osnicicicicick
A
B
• Figure 6-28  A 70-year-old woman arrived for surgical evaluation. She desired a stronger profile,
less “loose” neck skin, and an improved smile. She initially requested a face lift and a chin implant.
She was found to have a retrusive mandible and dental deterioration that was made worse by dental
crowding and a deep-bite negative overjet malocclusion. She underwent orthodontics that included
four bicuspid extractions and then surgery that included sagittal split ramus osteotomies (horizontal
advancement) and osseous genioplasty (horizontal advancement) (see Fig. 25-10). A, Frontal views
with smile before and after treatment. B, Oblique facial views before and after treatment.

199
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
C
Prior to orthodontics
After treatment including four bicuspid extractions
After treatment
C, Occlusal views before treatment, with orthodontics in progress (including four bicuspid extractions), and
after treatment.
• Figure 6-28, cont’d

200
SECTION 1  Basic Principles and Concepts
Thin gingival tissue tends to be delicate and almost
translucent in appearance. The tissue is friable, with a
minimal zone of attachment; this is suggestive of minimal
bone over the labial roots of the teeth. The diametrically
opposite thin and thick gingival biotypes will respond dif­
ferently when subjected to inflammation, mechanical
trauma, orthodontic forces, or surgical insults. Results from
at least some clinical studies indicate that, as long as a tooth
is being orthodontically moved with light forces and within
or into (and not out of) the alveolar process, then the risk
of harmful side effects on the marginal (gingival) soft tissues
is minimal.212-215 In current clinical practice, pretreatment
gingival augmentation (i.e., free gingival grafts, lateral
pedicled flaps, and autogenous and allogenic connective
tissue grafts) to improve the presenting thin keratinized
gingiva—in combination with light orthodontic force—
generally achieves objectives and limits recession and alveo­
lar bone loss.
Effects of Inadequate Alveolar Bone
(Alveolar Bone/Dental Root Ratio)
There will be inherent biologic variations among individuals
with regard to the extent of alveolar housing as compared
with the cumulative dental root volume of the compliment
of teeth within each arch; this is known as the alveolar bone/
dental root ratio.184,199 When the roots are crowded into
Effects of Inadequate Attached Gingiva
There are significant intrinsic biologic variations between
humans with respect to the morphologic characteristics of
the gingiva; this is known as the gingival biotype.52,73,138 The
evaluation of the individual’s gingival biotype is important
to orthodontic treatment planning, because thick and thin
gingival biotypes are frequently associated with varied
osseous patterns. These two tissue types are likely to respond
very differently to similar orthodontic forces by demonstrat­
ing different patterns of osseous remodeling. With an
understanding of the nature of the individual’s biologic risk
factors (e.g., gingiva, alveolar bone, breathing pattern,
degree of malocclusion), appropriate periodontal, ortho­
dontic, and surgical preventative procedures and precau­
tionary measures may be instituted to provide a more
favorable tissue environment to minimize alveolar bone
loss and gingival recession. Historically, Ochsenbein and
Maynard discussed the importance of thick versus thin
gingiva with regard to restorative treatment planning.150 In
addition, in a group of patients reviewed by Olsson and
colleagues, a thick periodontal biotype (85% of population)
was found to be more prevalent than a thin periodontal
biotype (15% of population).152 Thick gingival tissue is
dense in appearance, with a fairly large zone (length) of
attachment. The gingival topography is relatively flat,
which is suggestive of a full underlying bony architecture.
• Figure 6-29  Frontal facial and occlusal views of a 16-year-old boy who had sustained a fracture of the
right condyle of the mandible early during his childhood and who presented with the resulting facial asym­
metry. He previously underwent several years of orthodontics to neutralize the occlusion. There was loss
of labial bone along the anterior mandibular teeth. After surgical evaluation, the patient agreed to a com­
prehensive orthodontic and orthognathic approach. The procedures included a Le Fort I osteotomy, a left
sagittal split ramus osteotomy, the reconstruction of the right condyle with a costochondral graft, and an
osseous genioplasty (see Fig. 35-8). Note the recession along the labial aspects of the mandibular incisors
before surgery. Gingival grafting is indicated. From Posnick JC: Management of facial fractures in children
and adolescents. Ann Plast Surg 33:453, 1994.
Or
Or
Or
Or
Or
Orththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatathicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
osnicicicicicicicicicicicicicici k

201
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
mouth breathers. The exact mechanism of these effects is
not entirely known, but it is thought that the gingiva of the
anterior teeth in particular is prone to drying out as a result
of a lack of saliva. This scenario will also lead to an absence
of the natural protective action of the saliva and the lips.
Gulati and colleagues undertook a study to assess the
effects of mouth breathing, lip seal, and upper lip coverage
on the gingival health of children.98 School-aged children
between the ages of 10 and 14 years (n = 240) were selected
for the study. After clinical examination, they were divided
into two major groups: mouth breathers and normal breath­
ers. These two groups were further subdivided into six sub­
groups on the basis of lip-seal ability and upper incisor lip
coverage. The results of the study indicate a gingival index
that is higher in mouth breathers with lip incompetence
than in normal breathers. Increased lip separation and
decreased upper lip coverage (i.e., excess exposure of the
maxillary incisors) were also associated with higher plaque
and gingival indices.
Alexander completed clinical research with the intent of
understanding habitual mouth breathing and its effect on
gingival health.7-9 The study included 200 patients with a
mean age of 30 years who were attending a clinic for routine
dental treatment. Each of the subjects underwent systematic
examinations to evaluate the presence of gingival inflamma­
tion, supragingival and subgingival calculus, and bacterial
plaque. Each detailed examination was carried out under
standardized conditions. Individuals were questioned care­
fully regarding the manner in which they usually breathe
(i.e., mouth breathing versus nasal breathing). Mean gingi­
val inflammation scores, calculus surface indices, and bacte­
rial indices (with erythrosine disclosing solution) were
calculated for each of their individual teeth. The study
results confirm that habitual mouth breathing is highly
associated with an increase in gingival inflammation and the
prevalence of supragingival and subgingival calculus (see
Figs. 6-15 through 6-22).
Fukuda and colleagues completed a study to evaluate
the influence of mouth breathing on the periodontal
tissues.76 Ten patients with chronic marginal periodontitis
who were found to be habitual mouth breathers were
included in the study, and they were evaluated for 30 days.
During the experimental time frame, the study patients
underwent taping of the lips to accomplish lip seal and to
limit the mouth breathing option while sleeping. Oral
examinations were completed and biopsy specimens of the
gingiva were taken before and after nighttime lip tapings.
The study indicates that, with satisfactory lip seal (i.e., lip
taping), forced primary nasal breathing was achieved in
these individuals while they were sleeping. This resulted in
the following:
1. Halitosis and the uncomfortable feeling in the mouth
upon awakening were decreased significantly.
2. The depth of the periodontal pockets and the labiolin­
gual width of the gingiva were both decreased. The
improvement was primarily seen on the labial side of the
maxillary dentition.
limited available alveolar housing, the periodontal tissues
are less able to withstand the routine inflammatory pro­
cesses and the mechanical demands that they experience. In
turn, the periodontium may recede (i.e., experience bone
loss and gingival recession). To prevent this, either the space
within the arch must be increased (e.g., rapid palatal expan­
sion, surgically assisted rapid palatal expansion, segmental
osteotomies) or extractions must be carried out as part
of orthodontic treatment to limit the risk of periodontal
deterioration.50,58,101,103,114,119,147,168,217 Orthodontic relief of
dental crowding in the upper jaw by simply expanding the
crown arch form in the presence of an inadequate alveolar
arch form may align the dental crowns, but it will predict­
ably result in cortical plate thinning, with the potential for
dehiscence, fenestrations, loss of alveolar ridge height, and
gingival recession (Fig. 6-8). Under these circumstances,
successful dental uncrowding without extractions requires
the initial expansion of the maxillary (skeletal) arch (e.g.,
rapid palatal expansion, surgically assisted rapid palatal
expansion, segmental osteotomy).108 By following these
principles, the achievement of improved arch form with the
preservation of periodontal health should be possible.147
Effects of Nasal Obstruction and Mouth
Breathing With Resulting Vertical Maxillary
Excess, Lip Incompetence, and Inadequate
Incisor/Gingiva Coverage
There is considerable variation among humans with respect
to biologic respiratory patterns (i.e., mouth breathing versus
nasal breathing). In the presence of significant nasal obstruc­
tion, a forced mouth-breathing pattern will occur and have
the potential to cause detrimental effects on the periodon­
tium.7,102,113,206 The existence of these two very different
airway biotypes (i.e., nasal breathing and mouth breathing)
and the secondary effects that may result should be recog­
nized. Mouth breathing is an important etiologic factor for
chronic gingivitis and chronic marginal periodontitis as well
as for the formation of dental plaque and calculus. The
presence of marginal gingivitis in individuals with mouth
breathing was described in the literature by Coleyer in
1920. Warwick and Hastings (1933) also claimed that the
surfaces of teeth and gingiva that were constantly exposed
to air (i.e., in individuals who breathe habitually through
the mouth) did not have the benefit of normal irrigation
with saliva; these surfaces also did not benefit from the
normal friction effects that result from the vestibular mucosa
moving against the teeth and gingiva that would normally
occur during lip closure.
In a normal human physiologic state, nasal breathing is
a primary source of air intake; it is essential for the supply
of properly cleansed, moist, warm air to the lungs. The
mouth is considered the secondary emergency source of air
for breathing. Individuals who primarily breathe through
the mouth also tend to have an excessively open lip posture
(i.e., >4 mm), and they often have reduced lip coverage of
the incisors and the gingiva. Epidemiologic studies suggest
an increased susceptibility to gingival inflammation among

202
SECTION 1  Basic Principles and Concepts
3. The vacuolar degeneration of the epithelial cells was
decreased as confirmed by histopathologic examination.
However, inflammation of the connective tissue did not
show improvement during the 30-day treatment time.
Effects of Malocclusion on Periodontal Health
Bollen completed a systematic review of the literature
to answer the question, “Does a malocclusion affect peri­
odontal health?”35 An electronic search included all publi­
cations from 1960 through 2006. A total of 25 studies that
evaluated the association between a malocclusion and peri­
odontal health were of sufficient quality for inclusion in
the review.* Only 5 of these 25 studies adjusted for factors
such as age, socioeconomic status, and oral hygiene. The
total number of subjects included in the 25 studies was
35,300, and they had a mean age of 22 years (range, 3 to
60 years). Pertinent results of the review included the
following:
1. Nineteen of the 25 studies found greater periodontal
disease among subjects with greater malocclusion.
2. Six studies considered the interaction between malocclu­
sion and “periodontopathies.” These studies found sig­
nificantly greater periodontal problems among subjects
with malocclusions as compared with subjects without
malocclusions (P < .0001).
3. Two studies looked at the interaction between maloc­
clusion and gingivitis. These studies found greater
levels of gingivitis among subjects with malocclusions
as compared with subjects without malocclusions
(P < .0001).
The conclusions drawn by Bollen suggest that there is
often a correlation between the presence of malocclusion
and periodontal disease. However, the extent of this correla­
tion, which is found in large population studies, should not
be interpreted as demonstrating a clear cause and effect for
any given individual.4,5
Potential Detrimental Effects of
Orthodontic “Camouflage”
Maneuvers on the Periodontium
Orthodontic camouflage maneuvers and dental restorative
procedures carried out in an attempt to neutralize the
malocclusion may be additive to the individual’s biologic
risk factors with regard to his or her potential for pro­
gressive deterioration of the periodontium (see Figs. 6-16
through 6-25).
Long Face Growth Pattern
In the individual with a long face growth pattern, orth­
odontic camouflage maneuvers may attempt to correct
maxillary arch–width deficiency via the buccal tipping of
the posterior teeth (see Figs. 6-15 through Fig 6-19). If
more than a few millimeters are required, this may result in
the remodeling of the alveolar process with dehiscence and
fenestration of the buccal cortex, followed by gingival
recession.27,205,207,209
Orthodontic mechanics that are carried out in an
attempt to manage the skeletal component of an anterior
open bite often “extrude” the incisors. A biologic conse­
quence may be the remodeling of the alveolar process with
dehiscence and fenestration of the mandibular labial cortex,
followed by gingival recession. Maxillary incisor root resorp­
tion may also occur.
Maxillary Deficiency With Relative Mandibular
Excess Growth Pattern
With a maxillary deficient and relative mandibular excess
growth pattern, orthodontic camouflage maneuvers often
attempt to correct upper arch–width deficiency via the
buccal tipping of the posterior teeth (see Figs. 6-14 and
6-20 through 6-23). If more than a few millimeters are
required, this may result in the remodeling of the alveolar
process with dehiscence and fenestration of the buccal
cortex, followed by gingival recession.27,205,207,209
Orthodontic mechanics that are carried out to manage
the skeletal component of the negative overjet often result
in the proclination of the maxillary incisors and retroclined
mandibular anterior teeth. This approach may result in the
remodeling of the alveolar process with dehiscence and
fenestration of the mandibular labial cortex, followed by
gingival recession. The remodeling of the alveolar process
with a loss of maxillary labial cortex may also be seen.185,194,210
Primary Mandibular Deficiency
Growth Pattern
In the individual who presents with a primary man­
dibular
deficiency growth pattern, orthodontic cam­
ouflage
maneuvers often attempt to uncrowd the
mandibular arch by “flaring” the anterior dentition and to
then decrease the overjet by proclining the incisors even
further (see Figs. 6-24 through Fig. 6-28). This may result
in the remodeling of the alveolar process with dehiscence
and fenestrations of the labial cortex, followed by gingival
recession.10-15,18,26,64,65,72,178,195,211
Another common error occurs when mandibular
advancement surgery is planned to correct the excess overjet.
Often an inter–arch-width discrepancy will be unmasked
(i.e., in approximately 30% of cases). It is not uncommon
for clinicians to then avoid maxillary surgery through the
process of orthodontic buccal tipping the maxillary poste­
rior teeth to relieve the crossbites. If more than a few
*References 23, 28, 32, 33, 44-46, 53, 55, 64, 65, 72, 77, 79-86, 95, 96,
105, 109, 110, 112, 118, 120, 123, 137, 143, 145, 149, 163, 187, 188-
190, 196, 201, 208

203
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
and an awareness of the importance of a comprehensive
dental rehabilitative approach to do so. The orthodontic
movement of teeth and the level of orthodontic force
applied have potential effects on the surrounding alveolar
bone, the PDLs, and the gingival attachments.
With aging, there tends to be progressive reduction of
the periodontium, an increase in the root–tooth ratio, and
a decrease in the resistance to spontaneous tooth migration.
For these reasons, a reduced baseline periodontium may be
millimeters are required, this may result in remodeling of
the alveolar process with dehiscence and fenestration of the
buccal cortex followed by gingival recession180 (see Figs.
6-24 through 6-28).
Establishing a Healthy Periodontium
and Periodontal Therapeutics
Before the initiation of orthodontic treatment, the clinician
should assess for adequate attached gingiva (i.e., the need
for grafting); adequate alveolar bone (i.e., the need for
extractions or alveolar expansion); caries and plaque control
(i.e., the need for hygiene instruction, deep scaling, and root
planing); the adequacy of dental restorations (i.e., the need
for restorative dentistry); the adequacy of nasal breathing
(i.e., the need to open the airway through intranasal
surgery); and the adequacy of lip closure (i.e., the need for
jaw surgery).16,17 When a jaw discrepancy is present (with
or without combined nasal obstruction and lip incompe­
tence), the orthodontic objectives should be modified to
include the coordination of surgical treatment to achieve
the desired end results.
A primary focus of periodontal therapeutics is to reduce
inflammation by creating an environment that can be main­
tained as free of plaque as possible.2,3,22,87,136,159,164,166 After
this is accomplished, the individual can be trained
to perform the task of deplaquing the dentition and
developing an effective habit of doing so at least once
every 24 hours.179,186 Plaque-retaining traps will limit the
individual’s ability to effectively deplaque the dentition.91
These traps include calculus, crowded teeth, malaligned
teeth, restorative overhangs, overcontoured teeth, root
anomalies, subgingival caries, and pocketing.97 Consulta­
tion with a periodontist is useful, because his or her
skills include the ability to diagnose and remove plaque
traps and also to effectively educate the affected individual
with regard to how best to maintain clean teeth.130 Limiting
plaque traps may also require orthodontic procedures to
reposition dental crowns into more healthy relationships
and to place roots more fully within the alveolar bone. This
may be combined with procedures to surgically align
the jaws (e.g., orthognathic correction) and to open the
nasal airway (e.g., septoplasty, inferior turbinate reduc­
tion).48,51,71,74,75,78,88,90,94,140,158,162,167,168 Misguided orthodon­
tic tooth movement carried out in isolation or in combination
with surgery can result in injuries that includes the loss of
alveolar crestal height, the dehiscence of or fenestrations
through the labial and lingual plates, gingival recession, root
resorption, tooth mobility, and inadequate occlusion (see
Figs. 6-29 and 6-30).42,60,61,127,128,146,148,153
Adult Orthodontic Treatment
Throughout the more advanced countries in the world,
there has been a continuous increase in the number of
adults who are seeking orthodontic treatment. There is a
growing desire to maintain the dentition throughout life
• Figure 6-30  A 17-year-old high school student was referred by his
orthodontist for surgical evaluation. The Class III negative overjet ante­
rior open-bite malocclusion required retreatment with orthodontics,
including maxillary bicuspid extractions and jaw surgery. With a lifelong
history of nasal obstruction and consistent physical findings, intranasal
procedures were also required. With orthodontic (dental) decompen­
sation complete, the patient’s surgery included a maxillary Le Fort I
osteotomy in segments (arch expansion, horizontal advancement, and
vertical lengthening); sagittal split ramus osteotomies (limited correc­
tions); osseous genioplasty (vertical reduction and minimal horizontal
advancement); and septoplasty and inferior turbinate reduction. Occlu­
sal views A, before retreatment, B, with orthodontics in progress, and
C, after the completion of treatment. The patient required and under­
went gingival grafting on the labial aspect of the right maxillary canine
after the removal of the orthodontic appliances.
A
B
C

204
SECTION 1  Basic Principles and Concepts
apparatus and the dentogingival unit. The degeneration of
the periodontium is likely to accelerate in the presence of
specific intrinsic biologic factors (i.e., the individual’s
biotype), which may include a baseline jaw discrepancy
with malocclusion; the crowding of the dental roots within
limited alveolar bone; a forced mouth-breathing pattern;
and an inadequate amount of attached gingiva at the
clinical crown interface of the teeth. Active infection or
inflammation of the periodontium, non-biologic restora­
tions at the dental–gingival interface, para-occlusal habits,
local toxins, and poor oral hygiene also negatively affect the
periodontium.
Before the initiation of orthodontic treatment, the clini­
cian should assess for the patient’s specific risk factors for
periodontal disease and address them. When a jaw discrep­
ancy is present, the orthodontic objectives should be modi­
fied to include the coordination of surgical treatment to best
preserve the periodontium and to achieve the desired end
result.
present more frequently in adults than in adolescents. These
periodontal findings must be taken into consideration
before the initiation of an orthodontic program. With age,
there may also be an increase in bone porosity (i.e., decreased
density). The initial reaction of the PDL and the alveolar
bone to orthodontic loading in the adult may be delayed.
However, after tooth displacement gets under way, treat­
ment can be carried out in the same way in the adult as it
is in a teenager or a young adult. There is no known age
limit to the orthodontic movement of teeth (see Fig. 6-28).
By contrast, it is known that the precondition of the peri­
odontium should be one of health and anatomic adequacy
to mitigate the risks to the periodontium during orthodon­
tic therapy. The presenting periodontium—whether normal
or diminished—should be healthy when tooth movement
is initiated.
Conclusions
The periodontium includes the investing and supporting
tissues of the teeth, and it consists of the attachment
References
1. Addy M, Dummer PMH, Griffiths G, et al:
Prevalence of plaque gingivitis and caries in
11-12-year-old children in South Wales.
Community Dent Oral Epidemiol 14:115–
118, 1986.
2. Addy M: Plaque control as a scientific basis
for the prevention of caries. J R Soc Med
79(Suppl):6–9, 1986.
3. Addy M, Griffiths G, Dummer PMH, et al:
The distribution of plaque and gingivitis and
the influence of toothbrushing hand in a
group of 11-12-year-old school children.
J Clin Periodontol 14:564–572, 1987.
4. Addy M, Griffiths GS, Duramer PMH, et al:
The association between tooth irregularity
and plaque accumulation, gingivitis, and
caries in 11-12-year-old children. Eur J
Orthod 10:76–83, 1988.
5. Ainamo J: Relationship between
malalignment of the teeth and periodontal
disease. Scand J Dent Res 80:104–110,
1972.
6. Albander JM: A 6-year study on the pattern
of periodontal disease progression. J Clin
Periodontol 17:467–471, 1990.
7. Alexander AG: Habitual mouth breathing
and its effect on gingival health.
Paradontologie 24:49–55, 1970.
8. Alexander AG, Tipnis AK: The effect of
irregularity of the teeth and the degree of
overbite and overjet on gingival health. Br
Dent J 128:539–544, 1970.
9. Alexander AG: The effect of lack of function
of teeth on gingival health, plaque and
calculus accumulation. J Periodontol 41:438,
1970.
10. Allais D, Melsen B: Does labial movement
of lower incisors influence the level of the
gingival margin? A case-control study of
adult orthodontic patients. Eur J Orthod
25(4):343–352, 2003.
11. Alstad S, Zachrisson BU: Longitudinal study
of periodontal condition associated with
orthodontic treatment in adolescents. Am J
Orthod 76:277–286, 1979.
12. Andlin-Sobocki A, Bodin L: Dimensional
alterations of the gingiva related to changes
of facial/lingual tooth position in permanent
anterior teeth of children: a 2-year
longitudinal study. J Clin Periodontol
20:219–224, 1993.
13. Andlin-Sobocki A, Persson M: The
association between spontaneous reversal of
gingival recession in mandibular incisors and
dentofacial changes in children: a 3-year
longitudinal study. Eur J Orthod 16:229–
239, 1994.
14. Årtun J, Osterberg SK, Kokich VG:
Long-term effect of thin interdental alveolar
bone on periodontal health after orthodontic
treatment. J Periodontol 57:341–346, 1986.
15. Årtun J, Krogstad O: Periodontal status of
mandibular incisors following excessive
proclination. A study in adults with
surgically treated mandibular prognathism.
Am J Orthod Dentofacial Orthop 91:225–
232, 1987.
16. Årtun J, Osterberg SK: Periodontal status of
teeth facing extraction sites long-term after
orthodontic treatment. J Periodontol
58(1):24–29, 1987.
17. Årtun J, Urbye KS: The effect of orthodontic
treatment on periodontal bone support in
patients with advanced loss of marginal
periodontium. Am J Orthod Dentofacial
Orthop 93(2):143–148, 1988.
18. Årtun J, Grobety D: Periodontal status of
mandibular incisors after pronounced
orthodontic advancement during
adolescence: a follow-up evaluation. Am J
Orthod Dentofacial Orthop 119:2–10,
2001.
19. Asikainen S, Jousimies-Somer H, Kanervo A,
Summanen P: Certain bacterial species and
morphotypes in localized juvenile
periodontitis and in matched controls.
J Periodontol 58:224–230, 1987.
20. Atherton JD, Kerr NW: Effect of
orthodontic tooth movement upon the
gingiva. Br Dent J 124:555–560, 1968.
21. Atherton JD: Gingival response to
orthodontic tooth movement. Am J Orthod
58:179–186, 1970.
22. Axelsson P, Lindhe J, Nystrom B: On the
prevention of caries and periodontal disease:
results of a 15-year longitudinal study in
adults. J Clin Periodontol 18(3):182–189,
1991.
23. Badzian-Kobos K, Stepien-Szczepanska J,
Strzelecka E: Oral hygiene, condition of
periodontium, and malocclusion in children
aged 7-15 years from a region of mining and
power production. Czas Stomatol 40:309–
315, 1987.
24. Baer PN, Cocarro PJ: Gingival enlargement
coincident with orthodontic therapy.
J Periodontol 34:436–439, 1964.
25. Baker DL, Seymour GJ: The possible
pathogenesis of gingival recession: a
histological study of induced recession in the
rat. J Clin Periodontol 3:208–219, 1976.
26. Beagrie CS, Thompson, GW, Basu MK:
Tooth position and anterior bone loss in
skulls. Br Dent J 129:471–474, 1970.
27. Beagrie GS, James GA: The association of
posterior tooth irregularity and periodontal
disease. Br Dent J 113:239–243, 1962.

205
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
28. Behlfelt K, Ericsson L, Jacobson L,
Linder-Aronson S: The occurrence of plaque
and gingivitis and its relationship to tooth
alignment within the dental arches. J Clin
Periodontol 8:329–337, 1981.
29. Bergström J, Eliasson S, Preber H: Cigarette
smoking and periodontal bone loss.
J Periodontol 62:242–246, 1991.
30. Bergström J, Preber H: Tobacco use as a risk
factor. J Periodontol 65:545–550, 1994.
31. Bernimoulin JP, Curiloviec Z: Gingival
recession and tooth mobility. J Clin
Periodontol 4(2):107–114, 1977.
32. Bibb CA: Occlusal evaluation and therapy in
the management of periodontal disease. In
Newman MG, Takei HH, Carranza FA,
editors: Carranza’s clinical periodontology, ed
9, Philadelphia, 2002, W.B. Saunders
Company, pp 698–701.
33. Bilimoria KF: Malocclusion: its role in the
causation of periodontal disease. J All India
Dent Assoc 35:293–300, 1963.
34. Bolin A, Eklund G, Frithiof L, Lavstedt S:
The effect of changed smoking habits on
marginal alveolar bone loss: a longitudinal
study. Swed Dent J 17(5):211–216, 1993.
35. Bollen AM, Cunha-Cruz J, Bakko DW, et al:
The effects of orthodontic therapy on
periodontal health: a systematic review of
controlled evidence. J Am Dent Assoc
139(4):413–422, 2008.
36. Bondemark L: Interdental bone changes after
orthodontic treatment: a 5-year longitudinal
study. Am J Orthod Dentofacial Orthop
114(1):25–31, 1998.
37. Boyd RL: Are your patients healthier
periodontically because of orthodontic
treatment? Bull Pac Coast Soc Orthod
56:54–57, 1984.
38. Boyd RL, Leggott PJ, Quinn RS, et al:
Periodontal implications of orthodontic
treatment in adults with reduced or normal
periodontal tissues versus those of
adolescents. Am J Orthod Dentofacial Orthop
96(3):191–198, 1989.
39. Boyd RL: Periodontal screening examination
guide. In American Association of
Orthodontists risk management program, St.
Louis, 1992, American Association of
Orthodontists, p 13.
40. Bragd L, Dahlen G, Wikstrom M, Slots J:
The capability of Actinobacillus
actinomycetemcomitans, Bacteroides gingivalis
and Bacteroides intermedius to indicate
progressive periodontitis; a retrospective
study. J Clin Periodontol 14(2):95–99,
1987.
41. Brägger U, Lang NP: Significance of bone in
periodontal disease. Semin Orthod 2(1):32–
38, 1996.
42. Brezniak N, Wasserstein A: Root resorption
after orthodontic treatment: Part 2.
Literature review. Am J Orthod Dentofac
Orthop 103:138–146, 1993.
43. Brown IS: The effect of orthodontic therapy
on certain types of periodontal defects: I.
Clinical findings. J Periodontol 44:742–756,
1973.
44. Buckley LA: The relationship between
malocclusion and periodontal disease.
J Periodontol 43:415–417, 1972.
45. Buckley LA: The relationship between
irregular teeth, plaque, calculus and gingival
disease. Br Dent J 148:67–69, 1980.
46. Buckley LA: The relationship between
malocclusion, gingival inflammation, plaque
and calculus. J Periodontol 52:35–40, 1981.
47. Burch JG, Bagci B, Sabulski D, Landrum C:
Periodontal changes in furcations resulting
from orthodontic uprighting of mandibular
molars. Quintessence Int 23:509–513, 1992.
48. Burke JL, Provencher RF, McKean TW:
Small segmental and unitooth ostectomies to
correct dentoalveolar deformities. J Oral Surg
35:453, 1977.
49. Burkett LW: Effects of orthodontic treatment
on the soft periodontal tissues. Am J Orthod
49:671, 1963.
50. Carroll WJ, Haug RH, Bissada NF, et al:
The effects of the Le Fort I osteotomy on the
periodontium. J Oral Maxillofac Surg
50:128–132, 1992.
51. Clarke NG, Hirsch RS: Personal risk factors
for generalized periodontitis. J Clin
Periodontol 22(2):136–145, 1995.
52. Coatoam GW, Behrents RG, Bissada NF:
The width of keratinized gingiva during
orthodontic treatment: its significance and
impact on periodontal status. J Periodontol
52:307–313, 1981.
53. Cohen W: A study of occlusal interferences
in orthodontically treated occlusions and
untreated normal occlusions. Am J Orthod
51:647–689, 1965.
54. Cooper MB, Landay MA, Seltzer S: The
effect of excessive occlusal forces on the pulp.
II. Heavier and longer term forces.
J Periodontol 42:353–359, 1971.
55. Davies TM, Shaw WC, Addy M, Dummer
PH: The relationship of anterior overjet to
plaque and gingivitis in children. Am J
Orthod Dentofacial Orthop 93:303–309,
1988.
56. Davies TM, Shaw WC, Worthington HV, et
al: The effect of orthodontic treatment on
plaque and gingivitis. Am J Orthod
Dentofacial Orthop 99(2):155–161, 1991.
57. Diamanti-Kipioti A, Gusberti FA, Lang NP:
Clinical and microbiological effects of fixed
orthodontic appliances. J Clin Periodontol
14:326–333, 1987.
58. Diedrich PR: Guided tissue regeneration
associated with orthodontic therapy. Semin
Orthod 2(1):39–45, 1996.
59. Dominiak M, Kalecinska E, Krzyszton E,
et al: Correlation between
temporomandibular dysfunction,
disturbances of occlusion, and gingival
recession in a group of youth students. Bull
Group Int Rech Sci Stomatol Odontol
47:40–46, 2006.
60. Dorfman HS: Mucogingival changes
resulting from mandibular incisor tooth
movement. Am J Orthod 74:286–297, 1978.
61. Dorfman HS, Turvey TA: Alterations in
osseous crestal height following interdental
osteotomies. Oral Surg Oral Med Oral Pathol
48:120–125, 1979.
62. Driel WD, Leeuwen EJ, Hoff JW, et al:
Time-dependent mechanical behavior of the
periodontal ligament. Proc Inst Mech Eng H
214:497–504, 2000.
63. Eliasson LA, Hugoson A, Kurol J, Siwe H:
The effects of orthodontic treatment on
periodontal tissues in patients with reduced
periodontal support. Eur J Orthod 4(1):1–9,
1982.
64. Emslie RD: The incisal relationship and
periodontal disease. Paradontologie 12:15,
1958.
65. Engelking G, Zachrisson BU: Effects of
incisor repositioning on monkey
periodontium after expansion through the
cortical plate. Am J Orthod 82:23–32,
1982.
66. Engström C, Granström G, Thilander B:
Effect of orthodontic force on periodontal
tissue metabolism. A histologic and
biochemical study in normal and
hypocalcemic young rats. Am J Orthod
Dentofacial Orthop 93:486–495, 1988.
67. Ericsson I, Thilander B, Lindhe J, Okamoto
H: The effect of orthodontic tilting
movements on the periodontal tissues of
infected and non-infected dentitions in dogs.
J Clin Periodontol 4:278–293, 1977.
68. Ericsson I, Thilander B, Lindhe J:
Periodontal condition after orthodontic
tooth movements in the dog. Angle Orthod
48:210–218, 1978.
69. Ericsson I, Thilander B: Orthodontic forces
and recurrence of periodontal disease. Am J
Orthodont 74:41, 1978.
70. Ericsson I, Lindhe J: Recession in sites with
inadequate width of the keratinized gingiva:
an experimental study in the dog. J Clin
Periodontol 11(2):95–103, 1984.
71. Feliu JL: Long-term benefits of orthodontic
treatment on oral hygiene. Am J Orthod
82(6):473–477, 1982.
72. Ferro A, Aronna P: Isolated gingival
recession “without cause” localized to the
lower incisors in Class II, 1 dental
malocclusion: further studies. Arch Stomatol
(Napoli) 29:1049–1062, 1988.
73. Forsberg A: A clinical study of the
periodontal tissues of the upper incisors in
two age groups. Acta Odontologjca Scand
Suppl 9(8):1–105, 1951.
74. Foushee DG, Moriarty JD, Simpson DM:
Effects of mandibular orthognathic treatment
on mucogingival tissue. J Periodontol
56:727–733, 1985.
75. Fox ME, Stephens WF, Wolford LM, Deeb
ME: Effects of interdental osteotomies on
the periodontal and osseous supporting
tissues. Int J Adult Orthodon Orthognath Surg
6:39–46, 1991.
76. Fukuda T, Yokomichi K, Kato H, Ishikawa J:
Studies on the influence of mouth breathing
to the periodontal tissue. The effect of oral
screen and lip-seal tape on the gingiva in
mouth breathers. Nihon Shishubyo Gakkai
Kaishi 2:280, 1975.

206
SECTION 1  Basic Principles and Concepts
77. Gardner JH: A survey of malocclusions and
some aetiological factors on 1,000 Sheffield
school children. Dent Practit 6:187–201,
1956.
78. Garib DG, Henriques JFC, Janson G, et al:
Rapid maxillary expansion—tooth-tissue-
borne vs tooth-borne expanders: a CT
evaluation of dentoskeletal effects. Angle
Orthod 75:548–557, 2005.
79. Geiger AM: Occlusal studies in 188
consecutively treated cases of periodontal
disease. Am J Orthod 48:330–360,
1962.
80. Geiger AM: Occlusion in periodontal
disease. J Periodontol 36:387–392, 1965.
81. Geiger AM, Wasserman BH, Thompson RH,
et al: Relationship of occlusion and
periodontal disease: Part I. A system for
evaluating periodontal status. J Periodontol
42:371–378, 1971.
82. Geiger AM, Wasserman BH, Thompson RH,
Turgeon LR: Relationship of occlusion and
periodontal disease: Part V. Relation of
classification of occlusion to periodontal
status and gingival inflammation.
J Periodontol 43:554–560, 1972.
83. Geiger AM, Wasserman BH, Turgeon LR:
Relationship of occlusion and periodontal
disease: Part VI. Relation of anterior overjet
and overbite to periodontal destruction and
gingival inflammation. J Periodontol
44:150–157, 1973.
84. Geiger AM, Wasserman BH, Turgeon LR:
Relationship of occlusion and periodontal
disease: Part VIII. Relationship of crowding
and spacing to periodontal destruction and
gingival inflammation. J Periodontol
45:43–49, 1974.
85. Geiger AM, Wasserman BH: Relationship of
occlusion and periodontal disease: Part IX.
Incisor inclination and periodontal status.
Angle Orthod 46:99–110, 1976.
86. Geiger AM, Wasserman BH: Relationship of
occlusion and periodontal disease: Part X.
Relation of cross-bite to periodontal status.
J Periodontol 47:785–789, 1977.
87. Genco RJ: Current view of risk factors for
periodontal diseases. J Periodontol 67(Suppl
10):1041–1049, 1996.
88. Goldberg D, Turley P: Orthodontic space
closure of edentulous maxillary first molar
area in adults. Int J Adult Orthodon
Orthognath Surg 4:255–266, 1989.
89. Goldie RS, King GJ: Root resorption and
tooth movement in orthodontically treated,
calcium-deficient, and lactating rats. Am J
Orthod 85:424–430, 1984.
90. Goldman HM: The development of
physiologic gingival contours by
gingivoplasty. Oral Surg Oral Med Oral
Pathol 3:879–888, 1950.
91. Goldman HM, Cohen DW: Periodontal
therapy, ed 4, St. Louis, 1968, The C.V.
Mosby Company.
92. Gould MSE, Picton DC: The relationship
between irregularities of the teeth and
periodontal disease: a pilot study. Br Dent J
121:20, 1966.
93. Graves DT, Fine D, Teng YT, et al: The use
of rodent models to investigate host-bacteria
interactions related to periodontal diseases.
J Clin Periodontol 35:89–105, 2008.
94. Greenbaum KR, Zachrisson BU: The effect
of palatal expansion therapy on the
periodontal supporting tissues. Am J Orthod
81:12–21, 1982.
95. Grewe JM, Chadha JM, Hagan D, Zermeno
JA: Oral hygiene and occlusal disharmony in
Mexican-American children. J Periodontal Res
4:189–192, 1969.
96. Griffiths GS, Addy M: Effects of
malalignment of teeth in the anterior
segments on plaque accumulation. J Clin
Periodontol 8:481–490, 1981.
97. Grossi SG, Genco RJ, Machtei EE, et al:
Assessment of risk for periodontal disease:
risk indicators for alveolar bone loss.
J Periodontol 66(1):23–29, 1995.
98. Gulati MS, Grewal N, Kaur A: A
comparative study of effects of mouth
breathing and normal breathing on gingival
health in children. J Indian Soc Pedod Prev
Dent 16(3):72–83, 1998.
99. Haber J: Cigarette smoking: a major risk
factor for periodontitis. Compendium
15(8):1004–1008, 1994.
100. Hamp SE, Lundstrijm F, Nyman S:
Periodontal conditions in adolescents
subjected to multiband orthodontic
treatment with controlled oral hygiene. Eur J
Orthod 4:77, 1982.
101. Handelman CS: Nonsurgical rapid maxillary
alveolar expansion in adults: a clinical
evaluation. Angle Orthod 67:291–305, 1997.
102. Hanson ML, Andrianopoulos MV: Tongue
thrust, occlusion, and dental health in
middle-aged subjects: a pilot study. Int J
Orofacial Myology 13:3–9, 1987.
103. Harry MR, Sims MR: Root resorption in
bicuspid intrusion: a scanning electron
microscope study. Angle Orthod 52:235,
1982.
104. Heimlich AC: Selective grinding as an aid to
orthodontic therapy. Angle Orthod 21:76–88,
1951.
105. Helm S, Petersen PE: Causal relation
between malocclusion and periodontal
health. Acta Odontol Scand 47:223–228,
1989.
106. Henrikson PA: Periodontal disease and
calcium deficiency: an experimental study in
the dog. Acta Odontol Scand 26(Suppl
50):1–132, 1968.
107. Hollender L, Rönnerman A, Thilander B:
Root resorption, marginal bone support and
clinical crown length in orthodontically
treated patients. Eur J Orthod 2:197–205,
1980.
108. Hom BM, Turley PK: The effects of space
closure of the mandibular first molar area in
adults. Am J Orthod Dentofacial Orthop
85:457–469, 1984.
109. Horup N, Melsen B, Terp S: Relationship
between malocclusion and maintenance of
teeth. Community Dent Oral Epidemiol
15:74–78, 1987.
110. Ingervall B, Jacobsson U, Nyman S: A
clinical study of the relationship between
crowding of teeth, plaque and gingival
condition. J Clin Periodontol 4:214–222,
1977.
111. Iyer VS: Reaction of gingiva to orthodontic
force: a clinical study. J Periodontol
33:26–28, 1962.
112. Jacobson L, Linder-Aronson S: Crowding
and gingivitis: a comparison between
mouthbreathers and nosebreathers. Scand J
Dent Res 80:500–504, 1972.
113. Jacobson L: Mouth breathing and gingivitis
I. Gingival condition in children with
epipharyngeal adenoids. J Periodontal Res
3:269–277, 1973.
114. Jager A, Polley J, Mausberg R: Effects of
orthodontic expansion of the mandibular
arch on the periodontal condition of the
posterior teeth. Dtsch Zahnarztl Z
45(2):113–115, 1990.
115. Janson G, Bombonatti R, Brandao AG, et al:
Comparative radiographic evaluation of the
alveolar bone crest after orthodontic
treatment. Am J Orthod Dentofacial Orthop
124(2):157–164, 2003.
116. Janson M: Gingival and periodontal
relationships after orthodontic therapy: a
study of class-II patients. Dtsch Zahnarztl Z
39(3):254–256, 1984.
117. Jenkins SM, Dummer PM, Addy M:
Radiographic evaluation of early periodontal
bone loss in adolescents: an overview. J Clin
Periodontol 19(6):363–366, 1992.
118. Kalamparov K, Gantsev GA, Ershov VN:
Relationship between dentomaxillary
deformities and periodontal diseases in
children. Stomatologiia (Mosk) 51:47–50,
1972.
119. Karring T, Numan S, Thilander B,
Magnusson I: Bone regeneration in
orthodontically produced alveolar bone
dehiscences. J Periodont Res 17:309–315,
1982.
120. Katz RV: An epidemiologic study of the
relationship between various states of
occlusion and the pathological conditions of
dental caries and periodontal disease. J Dent
Res 57:433–439, 1978.
121. Kessler M: Interrelationships between
orthodontic and periodontics. Am J Orthod
70:154–177, 1976.
122. KIoehn JS, Pfeiffer JS: The effect of
orthodontic treatment on the periodontium.
Angle Orthodont 44:127, 1974.
123. Klassman B, Zacher HW: Treatment of a
periodontal defect resulting from improper
tooth alignment and local factors.
J Periodontol 40:401, 1969.
124. Kois JC: The restorative-periodontal
interface: biological parameters. Periodontol
2000 11:29–38, 1996.
125. Kokich VG: Esthetics: the orthodontic-
periodontic restorative connection. Semin
Orthod 2(1):21–30, 1996.
126. Kraus BS, Jordan RE, Abrams L: Dental
anatomy and occlusion, Baltimore, 1969,
Williams & Wilkins Company.

207
CHAPTER 6  Periodontal Considerations in the Evaluation and Treatment of Dentofacial Deformities
127. Kwon H-J, Pihlstrom B, Waite DE: Effects
on the periodontium of vertical bone cutting
for segmental osteotomy. J Oral Maxillofac
Surg 43:952–955, 1985.
128. Langford SR, Sims MR: Root surface
resorption, repair, and periodontal
attachment following rapid maxillary
expansion in man. Am J Orthod 81:108–115,
1982.
129. Lau D, Grimths GS, Shaw WC:
Reproducibility of an index for recording the
alignment of individual teeth. Br J Orthod
11:80–84, 1984.
130. Lee H, Silness J: Periodontal disease in
pregnancy: I. Prevalence and severity. Acta
Odontol Stand 21:533–551, 1963.
131. Listgarten MA, Hellden K: Relative
distribution of bacteria at clinically health
and periodontally diseased sites in humans.
J Clin Periodontol 5:115–132, 1978.
132. Loe H, Theilade D, Jensen SB: Experimental
gingivitis in man. J Periodontol 36:177–187,
1965.
133. Loesche WJ: The role of spirochetes in
periodontal disease. Adv Dent Res 2:275–
283, 1988.
134. Lundeen HC, Gibbs CH: The function of
teeth, Gainesville, Fla, 2005, L and G
Publishers.
135. Magnusson I, Marks RG, Clark WB, et al:
Clinical, microbiological and immunological
characteristics of subjects with “refractory”
periodontal disease. J Clin Periodontol
18:291–299, 1991.
136. Marshall-Day CD: The epidemiology of
periodontal disease. J Periodontol 22:13,
1951.
137. Massler M, Sen Savara BS: Relation of
gingivitis to dental caries and malocclusion
in children 14-17 years of age. J Periodontol
22:87–96, 1951.
138. Maynard JG, Ochsenbein LD: Mucogingival
problems, prevalence and therapy in
children. J Periodontol 46:543–552, 1975.
139. McCombie F, Stothard D: Relationships
between gingivitis and other dental
conditions. J Can Dent Assoc 30:506–513,
1964.
140. Melsen B, Agerbaek N, Eriksen J, Terps S:
New attachment through periodontal
treatment and orthodontic intrusion. Am J
Orthod Dentofacial Orthop 94(2):104–116,
1988.
141. Melsen B, Agerbaek N, Makenstam G:
Intrusion of incisors in adult patients with
marginal bone loss. Am J Orthod Dentofacial
Orthop 96:232–241, 1989.
142. Melsen B: Biological reaction of alveolar
bone to orthodontic tooth movement. Angle
Orthod 69:151–158, 1999.
143. Miller J, Hobson P: The relationship
between malocclusion, oral cleanliness,
gingival conditions and dental caries in
school children. Br Dent J 111:43–52, 1961.
144. Motegi E, Nomura M, Miyazaki H, et al:
Gingival recession in long-term post-
orthodontic patients. J Dent Res 81:A372,
2002.
145. Musialowicz KJ: Relation between
malocclusion and periodontal diseases in
school children from urban and rural areas
covered and not covered by planned
stomatological care. Ann Acad Med Stetin
29:371–385, 1983.
146. Newman WG: Possible etiologic factors in
external root resorption. Am J Orthod
67:522, 1975.
147. Northway WM, Meade JB, Jr: Surgically
assisted rapid maxillary expansion: a
comparison of technique, response, and
stability. Angle Orthod 67:309–320, 1997.
148. Nyman S, Karring T, Bergenholtz G: Bone
regeneration in alveolar bone dehiscences
produced by jiggling forces. J Periodontal Res
17:316–322, 1982.
149. O’Leary TJ, Badell MC, Bloomer RS:
Occlusal characteristics and tooth mobility
in periodontally healthy young males
classified orthodontically. J Periodontol
46:553–558, 1975.
150. Ochsenbein C, Maynard JG: The problem of
attached gingiva in children. ASDC J Dent
Child 41:263–272, 1974.
151. Ogaard B: Marginal bone support and tooth
lengths in 19-year-olds following orthodontic
treatment. Eur J Orthod 10(3):180–186,
1988.
152. Olsson M, Lindhe J: Periodontal
characteristics in individuals with varying
forms of the upper central incisors. J Clin
Periodontol 118:78–82, 1991.
153. Omnell ML, Tong DC, Thomas T:
Periodontal complications following
orthognathic surgery and genioplasty in
19-year-old: a case report. Int J Adult
Orthodon Orthognath Surg 9:133, 1994.
154. Paolantonio M, Festa F, di Placido G, et al:
Site-specific subgingival colonization by
Actinobacillus actinomycetemcomitans in
orthodontic patients. Am J Orthod
Dentofacial Orthop 115(4):423–428, 1999.
155. Papapanou PN, Wennström JL, Gröndahl K:
Periodontal status in relation to age and
tooth type: a cross-sectional radiographic
study. J Clin Periodontol 15:463–478, 1988.
156. Parker GR: Transseptal fibers and relapse
following bodily retraction of teeth: a
histologic study. Am J Orthod 61:331–334,
1972.
157. Pearson LE: Gingival heights of lower central
incisors orthodontically treated and
untreated. Angle Orthod 38:337–339, 1968.
158. Pedrazzoli V, Kilian M, Karring T, et al:
Effect of surgical and nonsurgical periodontal
treatment on periodontal status and
subgingival microbiota. J Clin Periodontol
18:598–604, 1991.
159. Pfeifer JS: The reaction of alveolar bone to
flap procedures in man. Periodontics
3:135–140, 1965.
160. Pihlstrom BL, Ramfjord SP: Periodontal
effect of nonfunction in monkeys.
J Periodontol 42:748, 1971.
161. Polson AM: Long-term effect of orthodontic
treatment on the periodontium. In
McNamara JA, Ribbens KA, editors:
Orthodontic treatment and the periodontium.
Monograph 15, Craniofacial Growth Series,
Ann Arbor, Mich, 1984, Center for Human
Growth and Development, The University of
Michigan, pp 89–100.
162. Pontoriero R, Celenza F, Ricci G, Carvenale
G: Rapid extrusion with fiber resection: a
combined orthodontic-periodontic treatment
modality. Int J Periodontics Restorative Dent
7:31–43, 1987.
163. Poulton DR, Aaronson SA: The relationship
between occlusion and periodontal status.
Am J Orthod 47:690–699, 1961.
164. Preber H, Bergström J: The effect of
non-surgical treatment on periodontal
pockets in smokers and non-smokers. J Clin
Periodontol 13:319–323, 1985.
165. Preber H, Bergström J: The effect of cigarette
smoking on periodontal healing following
surgical therapy. J Clin Periodontol
17:324–328, 1990.
166. Pritchard JF: Gingivectomy, gingivoplasty,
and osseous surgery. J Periodontol 32:257–
262, 1961.
167. Pritchard JF: The effect of bicuspid
extraction orthodontics on the
periodontium. Findings in 100 consecutive
cases. J Periodontol 44:534–542, 1975.
168. Proffit WR, Phillips C, Fields HW, Turvey
TA: The effect of orthognathic surgery on
occlusal force. J Oral Maxillofac Surg
47:457–463, 1989.
169. Reitan K: Continuous bodily tooth
movement and its histological significance.
Acta Odontol Stand 6:115, 1947.
170. Reitan K: Tissue rearrangement during
retention of orthodontically rotated teeth.
Angle Orthod 29:105–113, 1959.
171. Ren Y, Maltha JC, Von den Hoff JW,
Kuijpers-Jagtman AM: Age effect on
orthodontic tooth movement in rats. J Dent
Res 82:38–42, 2003.
172. Ren Y, Maltha JC, Kuijpers-Jagtman AM:
The rat as a model for orthodontic tooth
movement: A critical review and a proposed
solution. Eur J Orthod 26:483–490, 2004.
173. Ribeiral MBC, Bolognese AM, Feres EJ:
Periodontal evaluation after orthodontic
treatment. J Dent Res 78(5):979, 1999.
174. Roberts WE, Goodwin WC, Jr, Heiner SR:
Cellular response to orthodontic force. Dent
Clin North Am 25:3–17, 1981.
175. Robertson PB, Schultz LD, Levy BM:
Occurrence and distribution of interdental
gingival clefts following orthodontic
movement into bicuspid extraction sites.
J Periodontol 48:232–235, 1977.
176. Roth RH: Five-year clinical evaluation of the
Andrews straight wire appliance. J Clin
Orthod 10:836–850, 1976.
177. Ruben RP, Frankl SN, Wallace S: The
histopathology of periodontal disease in
children. J Periodontol 42:473, 1971.
178. Ruf S, Hansen K, Pancherz H: Does
orthodontic proclination of lower incisors in
children and adolescents cause gingival
recession? Am J Orthod Dentofacial Orthop
114:100–106, 1998.

208
SECTION 1  Basic Principles and Concepts
179. Rugg-Gunn AJ, MacGregor IDM, Edgar
WM, Ferguson MW: Toothbrushing
behaviour in relation to plaque and gingivitis
in adolescent school children. J Periodontal
Res 14:231–238, 1979.
180. Ryon K: Effects of force, magnitude and
direction of tooth movement on different
alveolar bone types. Angle Orthod 34:244,
1964.
181. Sadowsky C, BeGole EA: Long-term status
of temporomandibular joint function and
functional occlusion after orthodontic
treatment. Am J Orthod 78:201–212,
1980.
182. Sadowsky C, BeGole EA: Long-term effects
of orthodontic treatment on periodontal
health. Am J Orthod 80(2):156–172, 1981.
183. Safkan-Seppala B, Ainamo J: Periodontal
conditions in insulin-dependent diabetes
mellitus. J Clin Periodontol 19(1):24–29,
1992.
184. Salonen LW, Frithiof L, Wouters FR,
Hellden LB: Marginal alveolar bone height
in an adult Swedish population: a
radiographic cross-sectional epidemiologic
study. J Clin Periodontol 18(4):223–232,
1991.
185. Sarikaya S, Haydar B, Ciger S, Ariyurek M:
Changes in alveolar bone thickness due to
retraction of anterior teeth. Am J Orthod
Dentofacial Orthop 122:15–26, 2002.
186. Schneider HG, Brendel AK: Oral hygiene
study of children under orthodontic
treatment. Stomatol DDR 31:258–264,
1981.
187. Schneider HG, Mauersberger I, Bruchmann
M: Relation between periodontal diseases
and malocclusions. Stomatol DDR
31:494–500, 1981.
188. Sergl HG, Krause H: Studies on the effects
of malocclusions on the periodontium. Dtsch
Zahnarztl Z 28:149–154, 1973.
189. Shaw WC, Addy M, Ray C: Dental and
social effects of malocclusion and
effectiveness of orthodontic treatment: a
review. Community Dent Oral Epidemiol
8:36–45, 1980.
190. Shefter GJ, McFall WT, Jr: Occlusal
relationships and periodontal status in
human adults. J Periodontol 55:368–374,
1984.
191. Shinberg OE, Saakian S, Zapashnik EK: The
functional periodontal overload in bite
anomalies in adults. Stomatologiia (Mosk)
Nov-Dec:42–44, 1991.
192. Sjolien T, Zachrisson BW: Periodontal bone
support and tooth length in orthodontically
treated persons. Am J Orthod 64:28–37,
1973.
193. Slots J: Microflora in the healthy gingival
sulcus in man. Scand J Dent Res 85:247–254,
1977.
194. Sperry TP, Spiedel TM, Isaacson RJ, Worms
FW: The role of dental compensations in the
orthodontic treatment of mandibular
prognathism. Angle Orthod 47:293–299,
1977.
195. Steiner GG, Pearson JK, Ainamo J: Changes
of the marginal periodontium as a result of
labial tooth movement in monkeys.
J Periodontol 52:314–320, 1981.
196. Sten IB: Tooth malpositions and periodontal
pathosis: an evaluation of etiology and
considerations in treatment. J Peridontol
29:253, 1958.
197. Stuteville OH: Injuries caused by
orthodontic appliances and methods of
preventing these injuries. J Am Dent Assoc
24:1494–1507, 1937.
198. Tad S, Zachrisson BU: Longitudinal study of
periodontal condition associated with
orthodontic treatment in adolescents. Am J
Orthod 76:277–286, 1979.
199. Thilander B, Nyman S, Karring T,
Magnusson I: Bone regeneration in alveolar
bone dehiscences related to orthodontic
tooth movements. Eur J Orthod 5:105–114,
1983.
200. Thilander B: Infrabony pockets and reduced
alveolar bone height in relation to
orthodontic therapy. Semin Orthod
2(1):55–61, 1996.
201. Thompson RH, Geiger AM, Turgeon LR:
Relationship of occlusion and periodontal
disease. Part III. Relation of periodontal
status to general background characteristics.
J Periodontol 43:540–546, 1972.
202. Tirk TM, Guzman CA, Nalchajian R:
Periodontal tissue response to orthodontic
treatment studied by panoramix. Angle
Orthod 37:94–103, 1967.
203. Trossello VK, Gianelly AA: Orthodontic
treatment and periodontal status.
J Periodontol 50:665–671, 1979.
204. Vanarsdall RL, Corn H: Soft-tissue
management of labially positioned
unerupted teeth. Am J Orthod 72(1):53–64,
1977.
205. Vanarsdall RL, Jr: Periodontal/orthodontic
interrelationships. In Graber TM, Vanarsdall
RL, editors: Orthodontics: current principle
and techniques, ed 2, St. Louis, 1994, Mosby,
pp 712–749.
206. Wagaiyu EG, Ashley FP: Mouth breathing,
lip seal and upper lip coverage and their
relationship with gingival inflammation in
11-14 year-old schoolchildren. J Clin
Periodontol 18:698–702, 1991.
207. Wainwright WM: Faciolingual tooth
movement: influence on the root and
cortical plate. Am J Orthod 65:278, 1973.
208. Wasserman BH, Geiger AM, Turgeon LR:
Relationship of occlusion and periodontal
disease: Part VII. Mobility. J Periodontol
44:572–578, 1973.
209. Watson WG: Expansion and fenestration or
dehiscence. Am J Orthod 77:330–332, 1980.
210. Wehrbein H, Fuhrmann RA, Diedrich PR:
Periodontal conditions after facial root
tipping and palatal root torque of incisors.
Am J Orthod Dentofacial Orthop 106:455–
462, 1994.
211. Wehrbein H, Fuhrmann RA, Diedrich PR:
Human histologic tissue response after
long-term orthodontic tooth movement. Am
J Orthod Dentofacial Orthop 107(4):360–
371, 1995.
212. Wennstrom JL, Lindhe J, Sinclair F,
Thilander B: Some periodontal tissue
reactions to orthodontic tooth movement in
monkeys. J Clin Periodontol 14(3):121–129,
1987.
213. Wennström JL: The significance of the width
and thickness of the gingiva in orthodontic
treatment. Dtsch Zahnarztl Z 45:136–141,
1990.
214. Wennström JL, Lindskog-Stokand B, Nyman
S, et al: Periodontal tissue response to
orthodontic movement of teeth with
infrabony pockets. Am J Orthod Dentofacial
Orthop 103:313–319, 1993.
215. Wennström JL: Mucogingival considerations
in orthodontic treatment. Semin Orthod
2(1):46–54, 1996.
216. World Health Organization: Epidemiology,
etiology and prevention of periodontal disease,
Geneva, 1978, Report of WHO Scientific
Group, Technical Report Series, p 621.
217. Yurkstas A, Curby W: Force analysis of
prosthetic appliance during function.
J Prosthet Dent 3:82–87, 1953.
218. Zachrisson BW, Alnaes L: Periodontal
condition in orthodontically treated and
untreated children: 1. Loss of attachment,
gingival pocket depth and clinical crown
heights. Angle Orthod 43:402–411, 1973.
219. Zachrisson BW, Alnaes L: Periodontal
condition in orthodontically treated and
untreated individuals. Angle Orthod
44:48–55, 1974.
220. Zachrisson S, Zachrisson B: Gingival
condition associated with orthodontic
treatment. Angle Orthod 42:26–34, 1972.
221. Zambon JJ, Grossi SG, Machtei EE, et al:
Cigarette smoking increases the risk for
subgingival infection. J Periodontol 67(Suppl
10):1050–1054, 1996.

209

7
Psychosocial Considerations
• Psychosocial Aspects to Consider Before
Surgery
• Body Dysmorphic Disorder
• Psychological Functioning in the Individual
With a Facial Deformity
• Patient and Family Decision for or Against
the Correction of a Dentofacial Deformity
• Patient and Family Education Regarding
Convalescence After Orthognathic Surgery
• Patient-Centered Assessment of Surgical and
Orthodontic Outcomes
• Controversies Surrounding “Successful”
Orthognathic Outcomes
• Conclusions
defect, or after tumor resection.9,10,37,68,71,80,81,101,103 Although
they have typically been aware of the malocclusion and the
associated facial characteristics for at least several years, the
patient and his or her family generally assume that ortho­
dontics alone or some other minimally invasive approach is
all that will be required for treatment.87 The orthodontist
may have already exhausted the patient and his or her fam­
ily’s energy and resources with several years of treatment to
“avoid surgery” before finally “giving up.” The family may
have inaccurate preconceived ideas about the surgery and
the patient’s expected convalescence. The decision-making
role of the parents and the compliance (i.e., the attitude) of
the adolescent patient will also be important. Any dysfunc­
tional family interactions involving the mother, the father,
the patient, or the patient’s siblings, stepparents, or grand­
parents at this moment of stress (i.e., when a decision is
needed) may also come into play. From the adolescent’s
point of view, social interactions with his or her peers and
concerns about the interpretation (by others) of any change
in his or her appearance—as well as his or her evolving
self-image and identity—will also have an impact on the
situation in ways that are ongoing and somewhat
unpredictable.
Frequently, the treating clinicians (i.e., the surgeon, the
orthodontist, the restorative dentist, and the general physi­
cian) judge success or failure according to specific anatomic
or numeric benchmarks, such as achieving a Class I occlu­
sion, normative cephalometric radiographic measurements,
and successful wound healing. Although patients and their
families do consider stable occlusion and a lack of wound
healing complications to be important aspects of success,
there are likely to be other motives and objectives that
cannot be overlooked if patient satisfaction is to be achieved.
It is not uncommon for an orthognathic surgical result to
be labeled as suboptimal by the surgeon, the orthodontist,
or the restorative dentist as a result of an imperfect occlu­
sion, whereas the patient’s satisfaction rating will be more
Individuals who present with dentofacial deformities do not
comprise a monolithic group. They may arrive for evalua­
tion during childhood, adolescence, early adulthood, or it
may be later in life. The etiology of the jaw deformity may
be congenital, developmental, or posttraumatic, or it may
have occurred after tumor resection that required radiation
therapy. A combination of orthodontic treatment and
orthognathic surgery—often in conjunction with addi­
tional dental rehabilitation—may be required to correct the
skeletal deformities, to improve head and neck function
(i.e., chewing, breathing, speech, swallowing, lip control),
to enhance facial aesthetics, and to restore the dentition.
The initial discussion regarding the need for orthogna­
thic surgery may come as a surprise to the patient and his
or her family. This is especially true for the individual whose
jaw dysmorphology occurred gradually during facial devel­
opment, without special attention being drawn to it all of
a sudden as would occur from a traumatic event, a birth
in the Evaluation and Treatment
of Dentofacial Deformities
JEFFREY C. POSNICK, DMD, MD

210
SECTION 1  Basic Principles and Concepts
favorable. It is just as likely that the treating clinicians may
feel that a successful outcome has been achieved (i.e., satis­
factory occlusion and uncomplicated wound healing),
whereas the patient may feel that the aesthetic objectives
have not been fully met.
Research confirms a correlation between an adolescent’s
self-reporting of improved appearance ratings and a decrease
in social, physical, and psychological problems after success­
ful reconstruction.58,67,73,78 Patel and Kapp-Simon prospec­
tively studied 70 teenagers who were slated to undergo
orthognathic surgery.69 Before surgery, 78% stated that a
functional reason was their primary motivation for under­
going orthognathic surgery. Not surprisingly, before surgery,
the adolescents rated their appearance significantly less
favorable than their parents did. Two years after surgery, the
adolescents reported significantly increased self-confidence,
and a majority (58%) felt that they had achieved improve­
ments in their facial appearance as a result of surgery. They
stated that improvements in their facial appearance would
be a motivating factor for them to undergo similar surgery
again. It would appear that, when all is said and done,
adolescents—like adults—rate the enhancement of their
facial appearance as a high priority when measuring the
success or failure of their orthognathic procedures. Experi­
ence confirms it is better to openly discuss facial aesthetic
aspects before surgery. This encourages the clinician to set
realistic objectives, and it forces the patient and the family
to confront their outcome expectations in advance.
Both adolescents and adults undergoing orthognathic
surgery should be screened to assess emotional baseline
functioning as well as psychological readiness for surgery.
The pre-surgical mental health screening should clarify any
past or current symptoms of depression, anxiety disorders,
panic attacks, aggression, drug/alcohol use, eating disorders,
school-related problems, family or social (peer) dysfunc­
tional relationships.4
Psychosocial Aspects to Consider
Before Surgery
Personal Motivation
The individual’s personal motivation to seek the correction
of a dentofacial deformity is an important factor for clini­
cians to consider (Figs. 7-1 through 7-5).* In 2000, Rivera
and colleagues surveyed 142 patients regarding their reasons
for choosing to undergo orthognathic surgery.86 Seventy-
one percent indicated facial aesthetic concerns, 47% stated
functional issues, and 28% confirmed temporomandibular
disorders as their reasons for seeking treatment. In 2007,
Narayanan and colleagues surveyed 50 patients who sought
orthognathic surgery and found that, for the majority, facial
aesthetics rather than the correction of their occlusions was
the primary motivating factor.59 In 2007, Stirling and
colleagues conducted a questionnaire and interview survey
of individuals who had undergone orthognathic surgery.
The 46 interviewed patients stated that their primary moti­
vations generally included both “improvement of the occlu­
sion and to gain a more normal facial appearance.”97 More
recently, Proothi, Drew, and Sachs completed a retrospec­
tive survey of 501 individuals who underwent orthognathic
surgery to determine why they sought the procedures.83 The
survey group was 43% male and 57% female, and the
individuals ranged in age from 12 to 45 years. Seventy-six
percent stated that facial appearance was negatively affected
by their pretreatment jaw condition, but only 15% claimed
that their appearance was their primary motivation for
undergoing surgical evaluation. Thirty-six percent stated
that their occlusion was the primary motivating force. Inter­
estingly, 33% admitted to having significant speech difficul­
ties, and 15% complained of swallowing problems that
resulted from their presenting jaw deformity.
All adolescents more or less struggle with issues related
to self-identity, social acceptance, and physical appearance.
The added factor of a dentofacial deformity with impaired
head and neck function and negative effects on physical
appearance—coupled with the need to make a decision for
or against surgical correction—may compound these psy­
chological issues. If the individual already has baseline
depression, anxiety, poor self-confidence, or other social
issues, the presence of a dentofacial deformity with the need
for surgical correction is likely to exacerbate these symp­
toms. The extent to which an exacerbation of baseline
symptoms occurs may depend on how much the lack of
self-confidence and social problems relate to the dentofacial
deformity.
A typical sequence of events is a pre-adolescent indi­
vidual being referred by his or her general dentist to an
orthodontist for the correction of a malocclusion. The
orthodontist may have then attempted growth-modification
techniques followed by a camouflage approach to “improve”
the occlusion for a period of time that ranges from 2 to 8
years before finally “giving up” and suggesting a surgical
referral. The adolescent and his or her family may also have
pushed for a surgical referral in response to concerns about
facial aesthetics and a lack of progress with regard to the full
correction of the malocclusion by the orthodontist who
initially felt that he or she could solve the problem with
orthodontics alone. With today’s evidence-based thinking,
knowledgeable clinicians should recognize the need for a
surgical approach from the outset.
The adolescent and his or her parents’ motivation for
correction may be clearly stated to the surgeon at the initial
introduction, or it may be only indirectly discussed. The
patients’ and their families’ perceptions of the surgical out­
comes will be important to achieving a smooth recovery and
a favorable outcome. The results—both functional and
aesthetic—should be clearly and realistically articulated by
the surgeon, openly discussed, and agreed to by all parties
before proceeding.
*References 2, 3, 6, 12, 25, 26, 34, 42, 46, 61, 63, 64, 75, 76, 83, 86,
97, 102, 104, 105
Text continued on p. 218

211
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 7-1  A 17-year-old boy who was born with a nonprogressive congenital myopathy was referred
by an orthodontist for surgical evaluation. The lack of masticatory muscle strength resulted in a constant
open mouth posture. The long face growth pattern is characterized by vertical maxillary excess; a
clockwise-rotated retrusive mandible; a vertically long and retrusive chin; and an Angle Class II anterior
open-bite malocclusion. The patient underwent a combined orthodontic and surgical approach. Four
bicuspid extractions relieved dental crowding. This was followed by surgery that included a maxillary
Le Fort I osteotomy (vertical intrusion and horizontal advancement); bilateral sagittal split osteotomies
of the mandible (horizontal advancement and counterclockwise rotation); and osseous genioplasty
(vertical reduction and horizontal advancement). A, Profile views before and after reconstruction.
B, Frontal views with smile before and after reconstruction.
Or
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B

212
SECTION 1  Basic Principles and Concepts
• Figure 7-2  A 15-year-old girl was referred by her orthodontist for surgical evaluation. She had a
long face growth pattern and a Class II anterior open-bite malocclusion. She had been treated for
several years with orthodontics alone, and this included four bicuspid extractions. The anterior open
bite was essentially closed, with only minor degrees of malocclusion. The history and physical exami­
nation confirmed lifelong nasal obstruction, heavy snoring, and the suggestion of sleep apnea. Facial
aesthetic concerns of the patient and her family included an awareness of a gummy smile, severe lip
strain, a weak profile, and an irregular shape and position of the lips. The family agreed to an orthog­
nathic approach. The procedures performed included a maxillary Le Fort I osteotomy (vertical shorten­
ing and horizontal advancement with counterclockwise rotation); bilateral sagittal split osteotomies
(horizontal advancement and counterclockwise rotation); osseous genioplasty (horizontal advancement
and vertical shortening); and septoplasty, inferior turbinate reduction, and nasal floor recontouring.
A, Oblique facial views before and after reconstruction. B, Frontal views with smile before and
after reconstruction.
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Orthththththththththththththththththththth
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C.
C Pos
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A
B
NOTE:  Improved sleep at night resulted in less daytime fatigue and better
concentration at school. Positive psychosocial effects were appreciated and easily
adjusted to by the patient.

213
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 7-3  A 16-year-old girl was referred by her orthodontist for surgical evaluation. She had a
long face growth pattern in combination with asymmetrical mandibular deficiency. This resulted in
difficulty with speech articulation, swallowing, chewing, and lip closure/posture. Facial aesthetic
awareness of a gummy smile, lip incompetence, a weak profile, and lip irregularities was discussed.
With orthodontic decompensation complete, orthognathic surgery was carried out. The procedures
performed included a maxillary Le Fort I osteotomy in three segments, with first bicuspid extractions
(vertical retrusion, arch form correction, and counterclockwise rotation); bilateral sagittal split ramus
osteotomies (horizontal advancement, counterclockwise rotation, and asymmetry correction); and
septoplasty, inferior turbinate reduction, and nasal floor contouring. A, Profile views before and after
treatment. B, Frontal views with smile before and after treatment.
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A
B
NOTE:  Improvements in function (chewing, speech, swallowing, and lip
closure) were immediately appreciated and accepted by the patient. The patient’s
psychosocial adjustment to the consistent positive comments from her peers
required some accommodation. This included adjusting to not being visually
recognizing as the same person by many past acquaintances.

214
SECTION 1  Basic Principles and Concepts
• Figure 7-4  A 14-year-old girl was referred by her orthodontist for surgical evaluation of a den­
tofacial deformity. She had a long face growth pattern that presented with excessive vertical height
and significant horizontal projection and narrowness of the maxilla and the midface. She had limited
airflow to the nose, severe lip incompetence, and the impression of a weak chin. Several years of
orthodontics have already been carried out, and she agreed to surgical reconstruction. The pro­
cedures performed included a maxillary Le Fort I osteotomy in three segments with first bicuspid
extractions (vertical intrusion, horizontal setback, and arch correction) as well as septoplasty, inferior
turbinate reduction, and nasal recontouring. A, Profile views before and after reconstruction.
B, Frontal views with smile before and after reconstruction.
©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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©Elsevier Inc.
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A
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NOTE:  Improvements in speech articulation, swallowing, chewing, and lip
closure were easily adapted to by the patient. After some time, her self-esteem
improved, and she became less shy and withdrawn as compared with her
behavior before surgery.

215
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
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A
B
• Figure 7-5  A 16-year-old congenitally blind girl presented with maxillary and mandibular protrusion
and anterior open-bite malocclusion. Although she was unable to visualize the deformity, she felt self-
conscious after years of teasing as a result of her facial appearance and her difficulties with chewing,
swallowing, and speech articulation. The patient underwent a combined orthodontic and surgical
approach. The procedures performed included a maxillary Le Fort I osteotomy (vertical intrusion and
horizontal setback) and bilateral sagittal split osteotomies of the mandible (horizontal setback). A, Frontal
views before and after reconstruction. B, Oblique facial views before and after reconstruction.
Continued

216
SECTION 1  Basic Principles and Concepts
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Orthththththththththththththththth
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ry
ry; J.C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicicicicicick
C
D
Pre treatment
After treatment
C, Profile views before and after reconstruction. D, Occlusal views before and after
reconstruction.
•  Figure 7-5, cont’d

217
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
E
F
G
E and F, Articulated dental casts that indicate analytic model planning.
G, Lateral cephalometric radiographs before and after treatment.
•  Figure 7-5, cont’d

218
SECTION 1  Basic Principles and Concepts
accomplishments. Patients with eating disorders often
exhibit rigid cognitive patterns that are characterized by an
all-or-nothing way of thinking.
Orthognathic procedures will significantly alter the diet
(i.e., liquids only) and appetite level, with an expected
change in nutritional intake for at least 5 weeks. Significant
weight loss during the initial 2 weeks of recovery is to be
expected, even among healthy individuals. The question is
raised as to whether or not these dietary and postsurgical
metabolic changes will tend to exacerbate a baseline
eating disorder. Maine and Goldberg completed a study
to determine if an elective dental manipulation—which,
by necessity, results in eating discomfort and dietary
restrictions—would likely influence the recovery of or
result in a relapse for an individual with a baseline eating
disorder.54 Three questions concerning dental and maxillo­
facial procedures were added to a standard questionnaire
assessment of a consecutive series of 97 individuals who
were entering an eating disorder therapy program. The addi­
tional questions were designed to determine the influence
of dental and maxillofacial interventions on individuals
with baseline eating disorders. All 97 study subjects com­
plied with the questionnaire; 75 of the study patients were
25 years old or younger, and 53 were diagnosed with
anorexia nervosa.
Interestingly, 9.3% of the study patients who had under­
gone either significant orthodontic therapy or the removal
of the wisdom teeth in the past indicated that the dental
procedure—which, by necessity, caused eating discomfort
and diet alterations—had either exacerbated or resulted in
a relapse of their baseline eating disorders. This study con­
firms that a history of an eating disorder should alert the
orthodontist and the orthognathic surgeon to potential
postoperative difficulties. With an awareness of the indi­
vidual’s baseline conditions, the orthodontist, the surgeon,
the primary care physician, and members of the psychoso­
cial team may establish guidelines for postoperative behav­
ioral and nutritional objectives to closely monitor to ensure
a smooth recovery.
Social Interaction Issues
Ongoing family or social peer conflicts or greater-than-
average worries expressed by the individual or his or her
family regarding the surgery, the preparation for the surgery,
or the anticipated recovery period are red flags.1,29,33,41 When
considering the timing of surgery for the adolescent or
young adult, the family should take into account the antici­
pated impact on the patient’s everyday school and social
activities, including examination schedules, college applica­
tions and interviews, and participation in sports activities.
The surgeon’s ability to provide a clear picture of the
expected recovery time and the patient’s ability to return to
partial and regular activities is important and will vary
according to the patient’s age and stage in life (e.g., adoles­
cent, college or graduate student, middle-aged adult with
family and work commitments). Clarifying anticipated
Baseline Mental Health
Individuals who do not have sufficient preoperative psycho­
logical or emotional stability are more likely to experience
depression, anxiety, or panic attacks and to demonstrate
difficulty complying with treatment demands during the
early postoperative phase.16,17,21,27 They will also have greater
difficulty with an outcome that does not meet their precon­
ceived and often incompletely articulated expectations. If
so, after surgery, they may become easily frustrated and then
angry, and this may involve a loss of confidence in the
surgeon. They may break off communication and seek addi­
tional opinions to justify their concerns. Some may even
resort to litigation should a perceived complication or sub­
optimal outcome occur. Recognizing and addressing these
patient-specific tendencies before surgery is the best way to
limit or mitigate problems after surgery.
After an initial screening examination, a more in-depth
psychological evaluation may be beneficial.8,18,24,96 The
patient and his or her family’s motivation and the patient’s
readiness for surgery should also be assessed. Unless a suf­
ficient support system is in place, the stress of the necessary
convalescence is likely to worsen any premorbid conditions
in the patient. An initial screening that results in red flags
for potential emotional problems is best followed up with
a more focused psychological evaluation. The patient’s ther­
apist should give clearance that the individual is considered
emotionally stable enough to undergo the proposed treat­
ment. When the treating clinicians (i.e., the surgeon, the
orthodontist, and the general physician) have knowledge of
the patient’s premorbid tendencies, coping strategies can be
instituted proactively to minimize postoperative stress. The
treating mental health professional should be available to
the patient, the family, and the surgical team during hospi­
talization, after discharge, and throughout the patient’s
convalescence.
High-Risk Social Behaviors
High-risk social behaviors that would be expected to affect
a successful outcome should be identified before surgery.
Examples include prior dependence on alcohol or on pre­
scription or non-prescription illegal drugs. The prevalence
of these past and current behavior patterns in the general
population is significant and cannot be ignored.
Baseline Eating Disorders
Clinical studies indicate that between 0.5% and 1.0% of
late adolescent and young adult women meet the criteria
for anorexia nervosa, and between 1% and 3% meet the
criteria for bulimia nervosa.92 Eating disorders are multi-
determined problems, and they are most commonly recog­
nized among female adolescents. Risk factors may include
a perfectionist personality type, a family history of an
eating disorder, a history of trauma, a tendency toward feel­
ings of inadequacy, and low self-esteem despite external

219
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
dysfunctions: 11% had anxiety; 6% had depression; 10%
had externalized problems; and 25% had a tendency to
internalize problems.100 The authors clarified that either an
actual or a perceived facial deformity can be a significant
stressor in life to which the affected individual must
adapt.13,55,72,84,89,93 The study also looked at differences
between congenital and acquired facial deformities. Many
of the study patients that acquired their facial deformities
later in life (i.e., those that were related to trauma or tumors)
had a more difficult time, which implied that a significant
percentage of those with congenital conditions had eventu­
ally adapted to their physical problems. The authors sur­
mised that, because the congenital patients had no knowledge
of how life would have been without facial disfigurement,
their adaptation was different and often more complete.
An individual’s fear of a negative facial appearance evalu­
ation by others during their everyday life is considered a
good predictor of psychological functioning. Therefore, psy­
chological support for the individual with either an obvious
facial deformity that cannot be further improved or a per­
ceived facial disfigurement should focus on educating the
individual to rely less on the opinions of others. From
another perspective, surgery carried out for the purpose of
enhancing facial appearance must reach or at least approxi­
mate the individual’s self-perceived expectations. This is the
reason why surgery to improve facial aesthetics in the indi­
vidual with BDD will not result in patient satisfaction; the
unrealistic expectations of these patients can never be fully
reached.
Patient and Family Decision for
or Against the Correction of
a Dentofacial Deformity
The patient and the family members or significant others
that comprise his or her immediate social network need a
clear and consistent explanation of the following:
• The surgical objectives, anticipated treatment outcomes,
and limitations with regard to predicting exact results
• How the surgery will fit in with the overall treatment
plan (e.g., orthodontics, dental rehabilitation, speech
therapy, airway management)
• The potential risks, complications, and limitations of
each planned procedure
• What to expect during hospitalization (e.g., discomfort,
swelling, hygiene needs, limitations in activity and diet,
limitations in mouth opening and lip seal control, dif­
ficulties with speech and communication)
• What to expect after discharge from the hospital (i.e.,
ongoing convalescence needs)
• What the patient and the family must do to maximize a
favorable outcome
• When the patient can expect to resume a more normal
routine
• The expected time required for full healing
postoperative limitations in physical, cognitive, and emo­
tional activities is important to setting the stage for a suc­
cessful outcome.
Body Dysmorphic Disorder
It is estimated that more than 5% of individuals who are
seeking cosmetic surgery consults have body dysmorphic
disorder (BDD).14,19,65,91 BDD is a somatoform disorder
that involves a preoccupation with a slight or imagined
defect in some aspect of the individual’s physical appearance
that leads to a significant disruption of daily functions. It
is important to distinguish an individual with a legitimate
cosmetic or functional concern from one who is hypercon­
cerned about minor imperfections of some aspect of his or
her face.
Cunningham and colleagues documented that a percent­
age of individuals who request orthognathic surgery will
have underlying BDD.19 A surgical procedure to improve
facial aesthetics typically does not change or fully satisfy the
appearance concerns of these individuals. Orthognathic
procedures may even exacerbate these symptoms, despite
the clinician’s accurate assessment of the presenting defor­
mity and the likelihood of the achievement of a favorable
morphologic and functional result. No matter how skilled
the surgeon and how perfect the end result, dissatisfaction
should be expected when treating a patient with BDD;
therefore, surgery should be avoided unless extensive coun­
seling is performed before the proposed procedure. The
development of an effective psychosocial screening inter­
view method or the use of a self-reporting assessment survey
to help identify individuals with BDD is needed in clinical
practice.
Psychological Functioning in the
Individual With a Facial Deformity
A spectrum of studies report that individuals with facial
deformities have a higher prevalence of psychological prob­
lems that may interfere with the ability of these individuals
to function socially. The psychological problems described
include (1) a reduced quality of life; (2) a tendency to
internalize behavior; (3) low self-esteem; (4) an increased
tendency toward depression; and (5) anxiety.13,100 Interest­
ingly, studies confirm that it is the patient’s satisfaction with
his or her own appearance rather than an objective standard
of the severity of the deformity that influences these psy­
chological problems. The individual’s personal dissatisfac­
tion with his or her facial appearance seems to be a better
predictor of higher rates of anxiety and depression and
lower rates of favorable quality of life and self-esteem as
compared with the clinician’s impression of how the indi­
vidual looks.
Versnel and colleagues conducted research that involved
adults with facial disfigurement and confirmed that a
subset of these individuals demonstrated psychological

220
SECTION 1  Basic Principles and Concepts
achievement of strict numerical parameters. The potential
for orthognathic procedures to have profound effects on the
individual’s psychosocial health—whether positive or
negative—should not be underestimated (see Figs. 7-1
through 7-5). During convalescence and after the return to
school or work, the clinician should ask the patient about
his or her interactions with others regarding the recent
surgery to determine if a more in-depth discussion is
required.
Patient-Centered Assessment of
Surgical and Orthodontic Outcomes
Many public health experts believe that the ultimate deter­
mination of a treatment’s quality and success is its effective­
ness for producing not just physical health as judged by
clinicians but also for resulting in the individual’s personal
satisfaction.5,22,23,38,44,45,51,56,57,59,82,94,95,98 Traditional surgical
outcome measurements such as mortality and improvement
in physiologic parameters (e.g., blood pressure) find limited
application in the treatment of dentofacial deformities. At
the same time, traditional orthodontic parameters of accom­
plishing specific change in millimeter distances or degrees
of angulation at standard anatomic sites do not necessarily
correlate with patient satisfaction. Despite the importance
of satisfaction as a proxy for quality, the concept of patient-
perceived well-being can be difficult to define. When devel­
oping a patient questionnaire for use as a self-administered
survey after orthognathic surgery, consideration should be
given to the features of care that influence the patient’s
satisfaction. These features may be categorized into one of
the following domains: (1) aesthetic outcomes; (2) func­
tional outcomes; or (3) psychological outcomes. A review
of the literature concerning patient-centered outcome
assessments after orthognathic surgery sheds light on the
issue of how to achieve patient-based satisfaction after
treatment.
Orthognathic Surgery and Health-Related
Quality of Life: Review of Study
Posnick and colleagues reported on data from a health-
related quality-of-life survey that was completed postopera­
tively by a consecutive series of patients who had undergone
bimaxillary orthognathic surgery in combination with
intranasal and other adjunctive procedures. The survey was
filled out by each study patient only after recovery from
surgery and after all orthodontic therapy and dental reha­
bilitation was complete (i.e., a minimum of 6 months after
surgery).82
A postsurgical patient satisfaction questionnaire was
designed by the authors to assess each patient’s overall sat­
isfaction with the procedures that he or she underwent,
patient-perceived functional improvements, and patient-
perceived negative effects. The self-assessment survey was
mailed to a consecutive series of 42 individuals who
Information should be provided in a number of different
ways, which may include (1) verbal discussion; (2) a dem­
onstration of surgical technique on a model skull; (3)
showing similar patients’ before and after photographs to
demonstrate the potential range of results; (4) reviewing
and discussing the patient’s own photographs, dental
models, and radiographs; and (5) providing reinforcement
with detailed and readable written material.32,66 The option
of discussing details with another patient of the same
approximate age and sex who has undergone similar surgery
may also be helpful.
Patient and Family Education
Regarding Convalescence After
Orthognathic Surgery
Early after surgery, while in hospital, the individual who (1)
appears to be more irritable and non-communicative; (2)
complains of greater-than-expected levels of pain with
demands for continued narcotics; and (3) is having more-
than-average difficulty complying with personal care needs
(i.e., achieving hydration and caloric requirements, oral and
body hygiene requirements, and adequate ambulation) may
be a candidate for a demanding convalescence.77,79 The ado­
lescent may comply just enough (e.g., ambulation, fluid
intake) to get out of the hospital. After he or she gets home,
unless the parents are able to remain firm concerning patient
care needs, the adolescent’s feeling of self-consciousness or
uncertainty about temporary levels of facial swelling, drool­
ing, loss of appetite, and difficulty with breathing and
speech can lead to further social withdrawal and non-
compliance. This may also lead to overreliance on narcotic
medication with the assumption that pain is the problem.
Unless this type of patient is closely monitored, dehydra­
tion, hypoglycemia, and depression will set in. Even if this
phase of convalescence is managed, some adolescents express
unwillingness to return to school within the expected time
frame as a result of concern about the reactions of their
peers. Many will lose this reluctance when a friend is invited
to their home to break the ice. As the recovering patient
perceives positive affirmation from their family and friends
regarding the changes brought about by surgery, their social
hesitation generally subsides.
The clinicians (i.e., the surgeon, the orthodontist,
and the treating dentist) often judge success on the
basis of measurable standards of (1) an “improved”
profile; (2) achieving normative cephalometric radiograph
measurements; (3) a corrected occlusion; and (4) achieving
specific wound-healing parameters. Discussions with the
patient and family should not overlook psychosocial aspects.
Individuals with baseline evidence of mental health issues
are likely to have a greater-than-average need for positive
reinforcement, and they may also require more formal psy­
chological support throughout the perioperative process.
The success of treatment should not be thought of solely in
terms of improving head and neck function or the

221
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
(i.e., an acceptable occlusion, an improved upper airway,
and enhanced facial aesthetics). The second dissatisfied
patient developed idiopathic condylar resorption approxi­
mately 3 months after surgery, with a resulting residual
malocclusion.
The Pearson correlation coefficient highlights several
points related to this study group. The global satisfaction
questions within the survey (question nos. 1, 2, and 3) all
correlate highly with each other. Of the three global satisfac­
tion questions asked, question no. 3 correlates closest with
the specific head and neck function questions (question nos.
4 through 9). Of the specific function questions that were
asked (question nos. 4 through 9), the perceived residual lip
and chin region numbness (question no. 9) had the weakest
correlation with overall patient satisfaction. In other words,
most individuals were overall satisfied with the results of
their orthodontics and orthognathic procedures, despite the
fact that they would have preferred a greater return of lip
and chin region sensation.
The following question was also asked: “Overall, how
satisfied are you with your current bite?” At the completion
of treatment, 5 out of 42 patients (12%) were not entirely
satisfied with their occlusion, whereas 2% (1 out of 42
patients) gave a neutral response to this question. The
majority of patients (36 out of 42 [86%]) expressed satisfac­
tion with their occlusal result after the completion of
treatment.
Speech articulation issues are not generally considered a
major factor in a patient’s decision to undergo jaw surgery.
The following question about this issue was asked: “Overall,
how satisfied are you with your current speech articulation?”
The data suggests that 34 out of 42 patients (80%) were
satisfied with their postoperative speech articulation. Nine
percent (4 out of 42 patients) had no strong feelings,
whereas 4 out of 42 patients (9%) were not completely
satisfied with their speech at the completion of treatment.
Patients in this study group were also asked the follow­
ing: “Overall, how satisfied are you with your current lip
posture and lip closure?” Eighty-six percent (36 out of 42)
of the patients were satisfied with static lip posture and their
ability to actively close their lips. Twelve percent (5 out of
42 patients) were not entirely satisfied; they apparently felt
that their ability to control their lips was not completely
normal.
The patients were then asked this question: “Overall,
how satisfied are you with your current breathing?” Eighty-
one percent (38 out of 42 patients) were overall satisfied
with their breathing after treatment. Five percent (2 out of
42) were neutral with regard to their assessment of their
own breathing, whereas 2 out of 42 patients (5%) remained
dissatisfied with at least some aspects of their breathing.
Each patient was asked the following question: “Overall,
how accepting are you with your current level of TMJ
[temporomandibular joint] function/facial pain?” Eighty-
eight percent (37 out of 42 patients) were accepting of their
current TMJ function and of any degree of facial pain that
they may have. Five percent (2 out of 42 patients) were
underwent bimaxillary orthognathic surgery (i.e., Le Fort I
osteotomy and sagittal split ramus osteotomies of the man­
dible) in combination with intranasal (i.e., septoplasty and
inferior turbinate reduction) and other patient-specific pro­
cedures by a single surgeon (Posnick) at one institution
during a 12-month time frame. Patients who underwent
orthognathic surgery for the correction of a syndrome, a
cleft, or a posttraumatic deformity during the same time
frame were excluded from the study. The study group
included 15 males and 27 females. The mean age was 25
years, and patient ages ranged from 15 to 55 years. Seven
of the 42 patients were less than 18 years old: four were 15
years old, 1 was 16 years old, and two were 17 years old.
The most frequent pattern of jaw deformity that was identi­
fied in the study group was a long face growth pattern (17
out of 42 patients [40%]), which was characterized as verti­
cal maxillary excess combined with mandibular deficiency.
This was followed by primary mandibular deficiency (9 out
of 42 patients [21%]). Simultaneous maxillofacial proce­
dures that were completed in addition to those listed previ­
ously varied in accordance with patient-specific needs.
Thirty-eight percent of the patients (16 out of 42) under­
went the simultaneous removal of wisdom teeth. Seventeen
percent of the patients (7 out of 42) also underwent suction-
assisted lipectomy of the neck. Eighty-six percent of the
patients (36 out of 42) underwent osseous genioplasty. The
postsurgical patient satisfaction questionnaire made use of
a 7-point Likert scale for the respondents to rate their levels
of satisfaction or acceptance for each of nine questions that
were asked.
To assess overall patient satisfaction three questions were
asked. The first question was phrased as follows: “If you had
to make the decision again, how likely would you be to
undergo this same surgery?” Eighty-three percent (35 out
of 42 patients) responded positively to this question; 12%
(5 out of 42 patients) were neutral, and 5% (2 out of 42
patients) reported that they would not have undergone
orthognathic surgery if they had to do it all over again. The
second question was written as follows: “How likely would
you be to recommend the same surgery to others?” Two
individuals (5%) stated that they would not recommend the
same surgery to others. One of the 42 patients (2%) was
neutral, whereas 93% of the patients (39 out of 42) stated
that they would recommend the same surgery to others. The
patients were then asked the following question: “Consider­
ing everything, how satisfied are you now with the results
of surgery?” Eighty-eight percent (37 out of 42 patients)
were satisfied; 1 patient (2%) was neutral, and 4 patients
(10%) had at least some degree of uncertainty. These results
showed that more than 70% of subjects gave a positive
response to all three global satisfaction questions. According
to the survey, only 2 out of the 42 consecutive patients (5%)
who were treated were dissatisfied (i.e., they answered nega­
tively to all three global satisfaction questions). Interest­
ingly, one of the two dissatisfied patients was judged by the
three treating clinicians (i.e., the surgeon, the orthodontist,
and the restorative dentist) to have a satisfactory result

222
SECTION 1  Basic Principles and Concepts
occlusion would be expected to influence that individual’s
level of satisfaction.
Kiyak and colleagues completed a study that evaluated
the psychological changes in patients who were undergoing
orthognathic surgery.46-51 They used a standardized ques­
tionnaire before and at intervals that extended for 2 years
after surgery. The data for all six measurement periods (2
weeks preoperatively, in the hospital, and 2 weeks, 4 months,
8 months, and 2 years postoperatively) were available for
46 patients. Several important findings from this research
included the following:
1. Complaints of functional head and neck problems
decreased significantly from before surgery to 24 months
after surgery.
2. A significant percentage of patients (49%) continued to
report lip paresthesia 2 years after surgery.
3. The incidence of early postsurgical problems or com­
plaints (i.e., at 2 weeks) had no consistent effect on the
satisfaction expressed with longer-term surgical out­
comes (i.e., at 2 years).
4. The satisfaction expressed by patients with surgical out­
comes at 4 months remained high throughout the post­
operative course (i.e., at 2 years).
5. Self-esteem appeared to rise in anticipation of surgery
(i.e., at 2 weeks preoperatively) but to decline at 8
months after surgery. The patients’ self-esteem then rose
again as documented at 24 months after surgery. Inter­
estingly, on average, self-esteem never reached the high
expectations of the surgical outcome that the patients
had expressed at 2 weeks before surgery.
6. Body image showed a decline at 9 months after surgery
as compared with its highest point. Fortunately, the
overall body image at 2 years after surgery was signifi­
cantly more positive than it was at 2 weeks before
surgery.
On the basis of this data, Kiyak’s group suggests that, if
feasible, clinicians should maintain periodic contact with
their orthognathic surgery patients for at least 2 years after
surgery.46-51 Although clinician interactions with the patient
immediately after surgery generally fall to the surgeon (i.e.,
at 0 to 5 weeks), during the intermediate stage after surgery
(i.e., 1 to 12 months), clinician feedback primarily falls to
the orthodontist and the general dentist. According to the
study, at 6 to 12 months after surgery, psychological uneven­
ness for the patient is not uncommon. The patient and the
orthodontist may experience conflict regarding the impor­
tance of “finishing the bite” and the timing of the comple­
tion of treatment. The patient may become adamant that
the braces be removed for a specific social event (e.g., gradu­
ation, yearbook photographs), whereas the orthodontist
may wish to continue detailing the bite. The orthodontist
may focus on dental aspects that are considered to be of less
immediate importance from the patient’s perspective. At the
same time, the patient may have concern about persistent
paresthesia (i.e., of the inferior alveolar and infraorbital
neutral about this issue, whereas 3 out of 42 patients (7%)
were not completely accepting of their level of TMJ dys­
function or facial pain after treatment.
Patients were asked to respond to the following question:
“Overall, how accepting are you with your current level of
lower lip/chin sensation?” This question registered the
highest level of patient dissatisfaction. Twenty-one percent
of patients (9 out of 42) wished that their postsurgical
sensory loss was not as much. Twenty-four percent of
patients (10 out of 42) were neutral on this issue, whereas
23 out of 42 (55%) were accepting of their level of lower
lip and chin region sensory return after treatment.
Controversies Surrounding “Successful”
Orthognathic Outcomes
Interestingly, although 5 out of 42 (12%) of the patients
studied by Posnick and colleagues were not completely satis­
fied with their occlusions, only 2 out of 42 (5%) of the
patients were dissatisfied with the overall experience of
having undergone the orthognathic procedures and the
orthodontic treatment. Therefore, it is apparent that the
occlusion achieved is not the only and not even the most
important factor when a patient is judging surgical success
or failure. Posnick’s study group data also showed that,
despite the fact that 21% (9 out of 42) of the patients were
not entirely comfortable with the degree of sensory return
to the lower lip and chin region, only 5% (2 out of 42) were
dissatisfied with the postoperative surgical results overall.
Not surprisingly, orthognathic surgery patients’ self-
verification needs (i.e., the need to feel accepted) are gener­
ally an important factor in their judgment of successful
treatment. This need cannot be over­looked if a favor­
able result is to be achieved.* For example, patients who
undergo orthognathic procedures may expect to draw atten­
tion to their new appearance. If orthodontic treatment and
orthognathic surgery result in positive and praising feed­
back from those in their social circles, self-verification is
fulfilled, and they are likely to be satisfied. Some orthogna­
thic patients may have realistic expectations but do not have
a supportive social network of family and friends to fulfill
their self-verification needs. Negative appearance–related
commentary (e.g., teasing by peers at school, or more
subtle forms of negative feedback by adults) has been shown
to significantly affect body image and psychosocial func­
tioning after surgery. If the comments of others are not
positive or do not meet personal expectations (which can
be unrealistically high), self-verification needs are not ful­
filled, and the patient is likely to be dissatisfied. One con­
crete self-verification need after orthognathic surgery is a
“normal” occlusion. The feedback that an individual receives
from his or her treating clinicians (i.e., the orthodontist, the
restorative dentist, and the surgeon) about his or her
*References 7, 11, 15, 20, 28, 30, 31, 35, 36, 39, 40, 43, 47-50, 52, 60,
62, 70, 74, 85, 88, 90, 99

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CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
authors concluded that significant positive changes in
quality of life occurred after orthognathic surgery in the
majority of patients when their healing was complete. There
was a marked but transient deterioration in many aspects
related to physical and emotional well-being during the
early postoperative period (i.e., the first 6 weeks after
surgery). This was followed by significant improvements
that were documented by 6 months after surgery.
In a discussion of their results, Lee and colleagues stated
that patients who report unexpected negative effects after
surgery are more likely to be dissatisfied with their overall
treatment. Soon after surgery, Lee’s group documented dif­
ficulties with the orthognathic patient’s ability to carry out
daily physical activities, work performance, and social
activities with friends and family. Patients experienced
moderate degrees of pain, tiredness or lack of energy, and
emotional impairment during the early recovery period.
All of these changes are predictable and temporary, and
they should be explained to the patient and the patient’s
family before surgery and then reinforced during the post­
operative visits. It was found that, even during the early
recovery period (i.e., the initial 6 weeks), as long as reason­
able preoperative education was provided, there is generally
improvement in the patient’s psychological status. The
authors believe that this is a reflection of the patient’s per­
ceived improvements in both occlusion and facial appear­
ance meeting his or her personal expectations despite
difficulties experienced as part of the normal healing
process. By 6 months after orthognathic surgery, there was
a trend toward further improvements in emotional well-
being. By then, the overall study group consciously experi­
enced marked improvements in facial aesthetics, oral and
jaw function, and social abilities.
Conclusions
A review of the literature regarding patient satisfaction after
orthognathic surgery confirms the need for the following:
(1) careful preoperative patient selection; (2) clear commu­
nication of realistic and agreed-upon objectives; and (3)
including the family or the immediate social network and
all collaborating clinicians in the process. Although the
majority of patients and their families will be pleased with
the results that are achieved, a small percentage will be dis­
satisfied, despite the clinician’s perception that the results
achieved were at least an improvement and even when no
specific complications occurred. In addition, as with any
form of treatment or surgery, complications may occur
despite the best of care. Until the science of patient selection
parallels clinical realities, anticipating a small percentage of
dissatisfied patients and families remains the norm. The
meticulous documentation of the interactions between the
patient and the doctor as well as the maintenance of open
lines of communication between the patient and all treating
clinicians beyond the initial healing period remain essential
components of patient management when performing
orthognathic procedures.
nerves) and whether this is a complication or an expected
consequence of the jaw surgery. If accurate information was
given before surgery and if the lines of communication
remain open between the patient and the surgeon, a favor­
able resolution of this issue is likely. The orthodontist should
be aware of the expected progression of sensory recovery
and suggest a return visit to the surgeon if he or she per­
ceives a potential conflict. If instead the orthodontist, the
restorative dentist, or the office personnel (e.g., the hygien­
ist, the dental assistant) make off-the-cuff disparaging
remarks about the patient’s facial aesthetics, occlusion, or
incomplete facial sensory return, then the patient may
assume the worst.
At the conclusion of their study (i.e., 24 months after
surgery), Kiyak and colleagues found that a majority of
patients had achieved their personal dental (occlusal) or jaw
function objectives.46-51 Nevertheless, a minority of the sub­
jects continued to have lingering concerns. If the patient
perceived that the facial aesthetic improvements did meet
his or her personal expectations, then overall satisfaction
was high, regardless of any residual functional complaints
(e.g., paresthesia, dysesthesia, temporomandibular disorder,
occlusal imperfection). The majority of the orthognathic
patients in the study by Kiyak and colleagues did in fact
perceive facial aesthetic improvements and were therefore
pleased.
The authors made several suggestions. First, it is helpful
to prepare patients thoroughly before surgery and to explain
not just the temporary functional impairment that they will
experience soon after surgery but also the psychological
changes toward themselves and toward others that are to be
expected throughout recovery. Second, it is important to
emphasize that these changes will likely continue to evolve
for as long as 2 years after surgery. Third, if the patient is
unprepared for the anticipated facial aesthetic changes, then
dissatisfaction is also more likely. For these reasons, both
the surgeon and the orthodontist should maintain open
lines of communication with the patient and each other
long after primary skeletal healing has occurred. Anticipat­
ing the persistence of lower lip and chin paresthesia as a
consequence of the mandibular osteotomies should be com­
municated clearly during the preoperative discussion and
then reinforced at several postoperative intervals.
Lee and colleagues completed a study to evaluate the
patient-centered assessment of health at 6 weeks and then
6 months after orthognathic surgery.53 Their 36 study
patients were evaluated at intervals that included baseline/
presurgery; 6 weeks postoperatively; and 6 months postop­
eratively. A standardized health-related survey was given at
each time interval. The results of this study demonstrated a
significant deterioration in both the physical and mental
health of the patients soon after surgery (at 6 weeks) as
compared with baseline. This matches the expected signs
and symptoms that are typically observed soon after surgery.
At 6 months after surgery, there was a statistical return to
baseline levels in combination with significant improve­
ments in several of the parameters that were measured. The

224
SECTION 1  Basic Principles and Concepts
References
1. Adams GR: The effects of physical
attractiveness on the socialization process. In
Lucker GW, Ribbens KA, McNamara JA,
editors: Psychological aspects of facial form.
Craniofacial Growth Series Monograph No. 11,
Ann Arbor, Mich, 1981, University of
Michigan Press, pp 25–47.
2. Athanasiou AE, Melsen B, Eriksen J:
Concerns, motivations and experience of
orthognathic surgery patients: a retrospective
study of 152 patients. Int J Adult Orthodon
Orthognath Surg 4:47–55, 1989.
3. Bell R, Kiyak HA, Joondeph DR, et al:
Perceptions of facial profile and their
influence on the decision to undergo
orthognathic surgery. Am J Orthod
88:323–332, 1985.
4. Bellucci CC, Kapp-Simon KA: Psychological
considerations in orthognathic surgery. Clin
Plastic Surg 34:e11–e16, 2007.
5. Bennett ME, Phillips CL: Assessment of
health-related quality of life for patients with
severe skeletal disharmony: a review of the
issues. Int J Adult Orthodon Orthognath Surg
14:65, 1999.
6. Berscheid E: An overview of the
psychological effects of physical
attractiveness. In Lucker GW, Ribbons KA,
McNamara JA, editors: Psychological aspects of
facial form, Craniofacial Growth Series
Monograph No. 11, Ann Arbor, Mich,
1981, University of Michigan Press,
pp 1–23.
7. Bertolini F, Russo V, Sansebastiano G:
Pre- and postsurgical psycho-emotional
aspects of the orthognathic surgery patient.
Int J Adult Orthodon Orthognath Surg
15:16–23, 2000.
8. Blinder D, Rotenberg L, Taicher S:
Conversion disorder after maxillofacial
trauma and surgery. Int J Oral Maxillofac
Surg 25:116, 1996.
9. Broder HL: Psychological research of
children with craniofacial anomalies: review,
critique and implications for the future. Cleft
Palate Craniofac J 34:402, 1997.
10. Bull R, Rumsey N: The social psychology of
facial appearance, New York, 1988,
Springer-Verlag.
11. Chen B, Zhang ZK, Wang X: Factors
influencing postoperative satisfaction of
orthognathic surgery patients. Int J Adult
Orthodon Orthognath Surg 17:217–222,
2002.
12. Cheng LHH, Roles D, Telfer MR:
Orthognathic surgery: the patient’s
perspective. Br J Oral Maxillofac Surg
36:261, 1998.
13. Clifford E, Crocker EC, Pope BA:
Psychological findings in the adulthood of
98 cleft lip-palate children. Plast Reconstr
Surg 50:234–237, 1972.
14. Crerand C, Franklin M, Sarwer DB: Body
dysmorphic disorder and cosmetic surgery.
Plast Reconstr Surg 118:167, 2006.
15. Crowell NT, Sazima HJ, Elder ST: Survey of
patients’ attitudes after surgical correction of
prognathism: study of 33 patients. J Oral
Surg 28:818–822, 1970.
16. Cucalon A, Smith RJ: Relationship between
compliance by adolescent orthodontic
patients and performance on psychological
tests. Angle Orthod 60:107, 1990.
17. Cunningham SJ, Hunt NP, Feinmann C:
Psychological aspects of orthognathic
surgery: a review of the literature. Int J
Adult Orthodon Orthognath Surg 10:159,
1995.
18. Cunningham SJ, Feinmann C, Horrocks
EN: Psychological problems following
orthognathic surgery. J Clin Orthod 29:755,
1995.
19. Cunningham SJ, Bryant CJ, Manisali M,
et al: Dysmorphophobia: recent
developments of interest to the maxillofacial
surgeon. Br J Oral Maxillofac Surg 34:368,
1996.
20. Cunningham SJ, Crean SJ, Hunt NP, et al:
Preparation, perceptions and problems: a
long-term follow-up study of orthognathic
surgery. Int J Adult Orthod Orthognath Surg
11:41–47, 1996.
21. Cunningham SJ, Feinmann C: Psychological
assessment of patients requesting
orthognathic surgery and the relevance of
body dysmorphic disorder. Br J Orthod
25:293, 1998.
22. Cunningham SJ, Garratt AM, Hunt NP:
Development of a condition-specific quality
of life measure for patients with dentofacial
deformity: I. Reliability of the instrument.
Community Dent Oral Epidemiol 28:195,
2000.
23. Cunningham SJ, Garratt AM, Hunt NP:
Development of a condition-specific quality
of life measure for patients with dentofacial
deformity: II. Validity and responsiveness
testing. Community Dent Oral Epidemiol
30:81, 2002.
24. De Sousa A: Psychological issues in oral and
maxillofacial reconstructive surgery. J Oral
Maxillofac Surg 46:661, 1998.
25. Eagly AH, Ashmore RD, Makhijani IVIG,
Longo LC: What is beautiful is good, but…:
a meta-analytic review of research on the
physical attractiveness stereotype. Psychol Bull
110:109–128, 1991.
26. Finlay PM, Atkinson JM, Moos KF:
Orthognathic surgery: patient expectations;
psychological profile and satisfaction with
outcome. Br J Oral Maxillofac Surg 33:9–14,
1995.
27. Fitts WH: Manual for the Tennessee
Department of Mental Health Self-Concept
Scale, Nashville, Tenn, 1965, Department of
Mental Health.
28. Flanary CM, Alexander JM: Patient
responses to the orthognathic surgery
experience: factors leading to dissatisfaction.
J Oral Maxillofac Surg 41:770, 1983.
29. Flanary CM, Barnwell GM, Jr, Alexander
JM: Patients’ perception of orthognathic
surgery. Am J Orthod 88:137, 1985.
30. Flanary CM, Barnwell GM, VanSickels JE,
et al: Impact of orthognathic surgery on
normal and abnormal personality
dimensions: a 2-year follow-up study of 61
patients. Am J Orthod Dentofac Orthop
98:313, 1990.
31. Fonsecca RJ, Baily LT, Proffitt WR, et al:
Patient selection for orthognathic surgery. In
Oral and Maxillofacial Surgery, vol 2,
Philadelphia, 2000, Saunders, pp 3–4.
32. Forssell H, Finne K, Forssell K, et al:
Expectations and perceptions regarding
treatment: a prospective study of patients
undergoing orthognathic surgery. Int J Adult
Orthodon Orthognath Surg 13:107, 1998.
33. Frost V, Peterson G: Psychological aspects of
orthognathic surgery: how people respond to
facial change. Oral Surg Oral Med Oral
Pathol 71:538, 1991.
34. Garvill J, Garvill H, Kahnberg KE,
Lundgren S: Psychological factors in
orthognathic surgery. J Craniomaxillofac Surg
20:28–33, 1992.
35. Haimovitz D, Lansky LM, O’Reilly P:
Fluctuations in body satisfaction across
situations. Int J Eat Disord 13:77, 1993.
36. Hakman ECJ: Psychological studies on
orthognathic surgery. In De Beaufort I,
Hilhorst M, Holm S, editors: In the eye of
the beholder. Ethics and medical change of
appearance, Copenhagen, 1996, Scandinavian
University Press, pp 48–75.
37. Harper DC: Children’s attitudes to physical
differences among youth from Western and
non-Western cultures. Cleft Palate Craniofac J
32:114, 1995.
38. Hatch JP, Rugh JD, Clark GM, et al:
Health-related quality of life following
orthognathic surgery. Int J Adult Orthodon
Orthognath Surg 13:67, 1998.
39. Hatch JP, Rugh JD, Bays RA, et al:
Psychological function in orthognathic
surgical patients before and after bilateral
split osteotomy with rigid and wire fixation.
Am J Orthod Dentofacial Orthop 115:536,
1999.
40. Heldt L, Haffke EA, Davis LF: The
psychological and social aspects of
orthognathic treatment. Am J Orthod
82:318, 1982.
41. Holman AR, Brumer S, Ware WH, et al:
The impact of interpersonal support on
patient satisfaction with orthognathic
surgery. J Oral Maxillofac Surg 53:1289,
1995.
42. Hoppenreijs TJM, Hakman ECJ, Van’t Hof
MA, et al: Psychological implications of
surgical-orthodontic treatment in patients
with anterior open bite. Int J Adult Orthodon
Orthognath Surg 14:101–112, 1999.
43. Hunt OT, Johnston CD, Hepper PG, et al:
The psychosocial impact of orthognathic

225
CHAPTER 7  Psychosocial Considerations in the Evaluation and Treatment of Dentofacial Deformities
surgery: a systematic review. Am J Orthod
Dentofac Orthop 120:490, 2001.
44. Hutton CE: Patients’ evaluation of surgical
correction of prognathism: survey of 32
patients. J Oral Surg 25:225–228, 1967.
45. Juggins KJ, Nixon F, Cunningham SJ:
Patient- and clinician-perceived need for
orthognathic surgery. Am J Orthod
Dentofacial Orthop 128:697, 2005.
46. Kiyak HA, Hohl T, Sherrick P, et al: Sex
differences in motives for and outcomes of
orthognathic surgery. J Oral Surg 39:757–
764, 1981.
47. Kiyak HA, McNeill RW, West RA, et al:
Predicting psychologic responses to
orthognathic surgery. J Oral Maxillofac Surg
40:150–155, 1982.
48. Kiyak HA, West RA, Hohl T, et al: The
psychological impact of orthognathic
surgery: a 9-month follow-up. Am J Orthod
81:404–412, 1982.
49. Kiyak HA, Hohl T, West RA, et al:
Psychologic changes in orthognathic surgery
patients: a 24-month follow up. J Oral
Maxillofac Surg 42:506, 1984.
50. Kiyak HA, McNeill RW, West RA: The
emotional impact of orthognathic surgery
and conventional orthodontics. Am J Orthod
88:224, 1985.
51. Kiyak HA, Zeitler DL: Self-assessment of
profile and body image among orthognathic
surgery patients before and two years after
surgery. J Oral Maxillofac Surg 46:365–371,
1988.
52. Lazaridou-Terzoudi T, Kiyak HA, Moore R,
et al: Long-term assessment of psychological
outcome of orthognathic surgery. J Oral
Maxillofac Surg 61:545, 2003.
53. Lee S, McGrath C, Samman N: Impact of
orthognathic surgery on quality of life.
J Oral Maxillofac Surg 66: 1194–1199, 2008.
54. Maine M, Goldberg MH: The role of third
molar surgery in the exacerbation of eating
disorders. J Oral Maxillofac Surg 59:1297–
1300, 2001.
55. Marcusson A, List T, Paulin G, Akerlind I:
Reliability of a multidimensional
questionnaire for adults with treated
complete cleft lip and palate. Scand J Plast
Reconstr Surg Hand Surg 35: 271–278,
2001.
56. Modig M, Andersson L, Ward I: Patients’
perception of improvement after
orthognathic surgery: pilot study. Br J Oral
Maxillofac Surg 44:24, 2006.
57. Montegi E, Hatch JP, Rugh JD, Yamagichi
H: Health-related quality of life and
psychosocial function 5 years after
orthognathic surgery. Am J Orthod
Dentofacial Orthop 124:138, 2003.
58. Murray JE, Mulliken JB, Kaban IB, et al:
Twenty-year experience in maxillofacial
surgery: an evaluation of early surgery on
growth function and body image. Ann Surg
190:320, 1979.
59. Narayanan V, Guhan S, Sreekumar K, et al:
Self-assessment of facial form oral function
before and after orthognathic surgery: a
retrospective study. Indian J Dent Res 19:12,
2008.
60. Newton JT, Minhas G: Exposure to “ideal”
facial images reduces facial satisfaction: an
experimental study. Community Dent Oral
Epidemiol 33:410, 2005.
61. Nurminen L, Pietila T, Vinkka-Puhakka H:
Motivation for and satisfaction with
orthodontic-surgical treatment: a
retrospective study of 28 patients. Eur J
Orthod 21:79, 1999.
62. Oland J, Jensen J, Melsen B: Factors of
importance for the functional outcome in
orthognathic surgery patients: a prospective
study of 118 patients. J Oral Maxillofac Surg
68:2221, 2010.
63. Oland J, Jensen J, Elklit A, et al: Motives for
surgical-orthodontic treatment and effect of
treatment on psychosocial well-being and
satisfaction: a prospective study of 118
patients. J Oral Maxillofac Surg 69:104–113,
2011.
64. Oland J, Jensen J, Papadopoulos MA,
Melsen B: Does skeletal facial profile
influence preoperative motives and
postoperative satisfaction? A prospective
study of 66 surgical-orthodontic patients.
J Oral Maxillofac Surg 69:2025–2032, 2011.
65. O’Regan J, Dewey M, Slade P, Lovius B:
Self-esteem and aesthetics. Br J Orthod
18:111–118, 1991.
66. Ostler S, Kiyak HA: Treatment expectations
versus outcomes among orthognathic surgery
patients. Int J Adult Orthodon Orthognath
Surg 6:247–255, 1991.
67. Ouellette PL: Psychological ramifications of
facial change in relation to orthodontic
treatment and orthognathic surgery. J Oral
Surg 36:787, 1978.
68. Padwa BL, Evans CA, Pillemer FC:
Psychosocial adjustment in children with
hemifacial microsomia and other craniofacial
deformities. Cleft Palate Craniofac J 28:354,
1991.
69. Patel PK, Kapp-Simon KA: Orthognathic
surgery in adolescence: the patient’s
perspective [abstract]. American Association
of Plastic Surgeons 83rd Annual Meeting.
Chicago, 2004.
70. Pavone I, Rispoli A, Acocella A, et al:
Psychological impact of self-image
dissatisfaction after orthognathic surgery: a
case report. World J Orthod 6:141, 2005.
71. Pertschuk MJ, Whitaker LA: Psychosocial
adjustment and craniofacial malformations
in childhood. Plast Reconstr Surg 75:177,
1985.
72. Peter JP, Chinsky RR: Sociological aspects of
cleft palate adults: I. Marriage. Cleft Palate J
11:295–309, 1974.
73. Peterson LJ, Topazian RG: The preoperative
interview and psychological evaluation of the
orthognathic surgery patient. J Oral Surg
32:583, 1974.
74. Phillips C, Hill BJ, Cannac C: The influence
of video imaging on patients’ perceptions
and expectations. Angle Orthod 65:263–270,
1995.
75. Phillips C, Broder HL, Bennett ME:
Dentofacial disharmony: motivations for
seeking treatment. Int J Adult Orthodon
Orthognath Surg 12:7, 1997.
76. Phillips C, Bennett ME, Broder HL:
Dentofacial disharmony: psychological status
of patient seeking a treatment consultation.
Angle Orthod 68:547–566, 1998.
77. Phillips C, Kiyak HA, Bloomquist D, et al:
Perceptions of recovery and satisfaction in
the short term after orthognathic surgery.
J Oral Maxillofac Surg 62:535, 2004.
78. Phillips J, Whitaker LA: The social effects of
craniofacial deformity and its correction.
Cleft Palate J 16:7, 1979.
79. Pillemer FG, Cook KV: The psychosocial
adjustment of pediatric craniofacial patients
after surgery. Cleft Palate J 26:201, 1989.
80. Pope AW, Speltz ML: Research on
psychosocial issues of children with
craniofacial anomalies: Progress and
challenges. Cleft Palate Craniofac J 34:371,
1997.
81. Pope AW, Ward J: Self-perceived facial
appearance and psychosocial adjustment in
preadolescents with craniofacial anomalies.
Cleft Palate Craniofac J 34:396, 1997.
82. Posnick JC, Wallace J: Complex
orthognathic surgery assessment of patient
satisfaction. J Oral Maxillofac Surg 66:934,
2008.
83. Proothi M, Drew SJ, Sachs SS: Motivating
factors for patients undergoing orthognathic
surgery evaluation. J Oral Maxillofac Surg
68:1555–1559, 2010.
84. Ramstad T, Ottem E, Shaw WC:
Psychological adjustment in Norwegian
adults who had undergone standardized
treatment of complete cleft lip and palate: I.
Education, employment and marriage. Scand
J Plast Reconstr Surg Hand Surg 29:251–257,
1995.
85. Rispoli C, Acocella A, Pavone I, et al:
Psychoemotional assessment changes in
patients treated with orthognathic surgery:
pre- and postsurgery report. World J Orthod
5:48, 2004.
86. Rivera SM, Hatch JP, Dolce C, et al:
Patients’ own reasons and patient-perceived
recommendations for orthognathic surgery.
Am J Orthod Dentofacial Orthop 18:134,
2000.
87. Robinson E, Rumsey N, Partridge J: An
evaluation of the impact of social interaction
skills training for facially disfigured people.
Br J Plast Surg 49:281–289, 1996.
88. Sarver DM, Johnston MW, Matukas VJ:
Video imaging for planning and counseling
in orthognathic surgery. J Oral Maxillofac
Surg 46:939–945, 1988.
89. Sarwer DB, Bartlett SP, Whitaker LA, et al:
Adult psychological functioning of
individuals born with craniofacial anomalies.
Plast Reconstr Surg 103:412–418, 1999.
90. Scott AA, Hatch JP, Rugh JD, et al:
Psychosocial predictors of satisfaction among
orthognathic surgery patients. Int J Adult
Orthodon Orthognath Surg 15:7–15, 2000.

226
SECTION 1  Basic Principles and Concepts
91. Secord PF, Jourard SM: The appraisal of
body cathexis: body cathexis and the self.
J Consult Psychol 17:343–347, 1953.
92. Shisslak CM, Crago M, Estes LS: The
spectrum of eating disorders. Int J Eating
Disord 18:209, 1995.
93. Sinko K, Jagsch R, Prechtl V, et al:
Evaluation of esthetic, functional, and
quality of life outcome in adult cleft lip and
palate patients. Cleft Palate Craniofac J
42:355–361, 2005.
94. Slade GD, Spencer AJ: Development and
evaluation of the Oral Health Impact Profile.
Community Dent Health 11:3, 1994.
95. Slade GD: Assessing change in quality of life
using the Oral Health Impact Profile.
Community Dent Oral Epidemiol 26:52,
1998.
96. Stewart TD, Sexton J: Depression: a possible
complication of orthognathic surgery. J Oral
Maxillofac Surg 45:847, 1987
97. Stirling J, Latchford G, Morris DO, et al:
Elective orthognathic treatment decision
making: a survey of patient reasons and
experiences. J Orthod 34:114, 2007.
98. Travess HC, Newton JT, Sandy JR, et al:
The development of a patient-centered
measure of the process and outcome of
combined orthodontic and orthognathic
treatment. J Orthod 31:220, 2004.
99. Upton PM, Sadowsky PL, Sarver DM, et al:
Evaluation of video imaging prediction in
combined maxillary and mandibular
orthognathic surgery. Am J Orthod
Dentofacial Orthop 112:656, 1997.
100. Versnel SL, Plomp RG, Passchier J, et al:
Long-term psychological functioning of
adults with severe congenital facial
disfigurement. Plast Reconstr Surg 129:110–
117, 2012.
101. Wictorin L, Hillerstrom K, Sorensen S:
Biological and psycho-social factors in
patients with malformations of the jaws. I.
A study of 95 patients prior to treatment.
Scand J Plast Reconstr Surg 3:138–143,
1969.
102. Williams AC, Shah H, Sandy JR, et al:
Patients’ motivations for treatment and their
experiences of orthodontic preparation for
orthognathic surgery. J Orthod 32:191,
2005.
103. Williams DM, Bentley R, Cobourne MT,
et al: Psychological characteristics of women
who require orthognathic surgery:
comparison with untreated controls. Br J
Oral Maxillofac Surg 47:191, 2009.
104. Wilmot JJ, Barber HD, Chou DG, et al:
Associations between severity of dentofacial
deformity and motivation for orthodontic-
orthognathic surgery treatment. Angle
Orthod 63:283, 1993.
105. Zhou Y, Hagg U, Rabie AB: Severity of
dentofacial deformity, the motivations and
the outcome of surgery in skeletal Class III
patients. Chin Med J (Engl) 115:1031,
2002.

227

8
Speech, Mastication, and Swallowing
Considerations in the Evaluation and
Treatment of Dentofacial Deformities
JEFFREY C. POSNICK, DMD, MD
• The Neuromuscular Masticatory System
• Mastication Mechanism
• Swallowing Mechanism
• Speech: Mechanism, Formation, and
Assessment
• Effects of Jaw Deformities with Malocclusion
on Speech
• Effects of Successful Orthodontics and
Orthognathic Surgery on Speech
• Conclusions
lips, and the tongue efficiently for effective function (i.e.,
speech, swallowing, and chewing). A neurologic control
system regulates and coordinates the activities of the entire
masticatory system.
The dynamic balance of muscles in the head and neck is
made possible through feedback that is provided by sensory
receptors.10 To create a precise mandibular movement,
input from the various sensory receptors is received by the
central nervous system through the afferent fibers.41 The
brain stem and cortex work together to assimilate and orga­
nize this input, and then provide modulated motor activi­
ties through the efferent nerve fibers.80 Within the brain
stem, neurons control rhythmic muscle activities for effec­
tive breathing, swallowing, and chewing.25 These neurons
are called the central pattern generator (CPG).96 The CPG is
responsible for the timed and integrated activity among
antagonistic muscles that is needed to accomplish these
functions. For example, during chewing, the suprahyoid
and infrahyoid muscles contract at the same time that the
elevator muscles relax; this allows the mouth to open and
accept food. With the bolus of food in the mouth, the CPG
causes contraction of the elevator muscles while relaxing the
suprahyoid and infrahyoid muscles, thereby producing
closure of the mouth onto the food bolus. This chewing
mechanism is repeated until the particles of food are small
enough to be efficiently swallowed. All of this assumes that
the individual has normal functioning of the tongue and
lips, adequate numbers and locations of teeth, and intact
temporomandibular joints and jaws (Fig. 8-1).43 Ideally,
with all of these component structures in place, chewing
can be accomplished without excess stress to any of the
component parts. Although chewing is typically a subcon­
scious activity, it can be brought into conscious control at
any time. Likewise, breathing and swallowing are generally
carried out as subconscious activities, but they can also be
brought under voluntary control to be refined (Table 8-1).
The physiologic and functional mechanisms of human
speech, mastication, and swallowing are essential for an
individual to maintain his or her normal performance levels.
These are highly coordinated and complex actions that are
closely interrelated. These functions are susceptible to physi­
cal impairments, such as the presence of a dentofacial defor­
mity. This chapter will review the mechanisms of normal
speech, mastication, and swallowing. The potential for neg­
ative sequelae that stem from the presence of a jaw defor­
mity with malocclusion and the benefits of successful
reconstruction are also reviewed.11,151
The Neuromuscular Masticatory System
The masticatory system is an integrated complex that is pri­
marily made up of bones, muscles, ligaments, and teeth.
Movement of the structures is neurologically coordinated
for efficient function and for the maintenance of the com­
ponent parts over the individual’s lifetime.1-3 Controlled
contracture and relaxation of the head and neck muscula­
ture are necessary to move the mandible, the soft palate, the

228
SECTION 1  Basic Principles and Concepts
Spine of sphenoid bone
Foramen spinosum
Foramen ovale
Sphenopalatine foramen
Pterygopalatine fossa
Choanae (posterior nares)
Lateral plate
Medial plate
Hamulus
of pterygoid
process
Tuberosity of maxilla
Infratemporal fossa
Alveolar process of maxilla
Pyramidal process
of palatine bone
(Posterior temporalis
fibers retract jaw)
Medial pterygoid
Masseter
Lateral pterygoid
Temporalis
Buccinator
Tongue
Orbicularis oris
Geniohyoid (deep
to other mm.)
Mylohyoid
Digastric (anterior belly)
Assist in
moving
food into
position
Depress
jaw
• Figure 8-1  Mastication is the process of chewing food in preparation for deglutition (swallowing)
and digestion. All muscles of mastication originate on the skull and insert on the mandible. All muscles
of mastication are innervated by the mandibular division of the trigeminal nerve. All muscles of mas­
tication are derivatives of the first pharyngeal arch. Movements of the mandible are classified as
follows:
• Elevation
• Depression
• Protrusion
• Retrusion
• Side-to-side (lateral) excursion
The bones involved include the base of the skull and the mandible. The skull base and the mandible
articulate at the temporomandibular joint between the squamous portion of the temporal bone and
the condyle of the mandible.
The muscles involved in the masticatory process include four paired muscles:
• The masseter
• The temporalis
• The medial pterygoid
• The lateral pterygoid
Although the buccinators are not strictly considered muscles of mastication, they help to keep the
bolus of food against the teeth during this process. The illustrations shown here demonstrate the
masticatory muscles’ bony insertions and locations of insertion as well as their overall anatomy. Netter
illustration from © Elsevier Inc. All rights reserved.

229
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
Temporalis muscle
Parotid duct
Buccinator muscle
Orbicularis oris muscle
Lateral pterygoid muscle
Masseteric nerve
and artery
Insertion of
masseter muscle
Maxillary artery
Buccinator muscle
Parotid duct
Masseter
muscle
Deep part
Superficial part
Temporalis muscle
Temporal fascia
Superficial layer
Deep layer
Insertion of temporalis muscle
to coronoid process of mandible
Articular disc of
temporomandibular joint
• Figure 8-1, cont’d 
Lateral pterygoid muscle
Sphenomandibular ligament
Medial pterygoid muscle
Parotid duct
Buccinator muscle
Pterygomandibular raphe
Superior pharyngeal constrictor muscle
Sphenomandibular ligament
Masseteric nerve
Middle meningeal artery
Auriculotemporal nerve
Maxillary artery
Inferior alveolar nerve
Lingual nerve
Medial pterygoid muscle
Nerve to mylohyoid
Lateral pterygoid plate
Lateral pterygoid muscle
Medial pterygoid muscle
Levator veli palatini muscle
Lateral view
Posterior view
Tensor veli palatini muscle
Cartilaginous part of pharyngotympanic
(auditory) tube

230
SECTION 1  Basic Principles and Concepts
Mastication Mechanism
Mastication is defined as the act of chewing food (Fig. 8-2).
It represents the initial stage of digestion. During mastica­
tion, the food bolus is broken down into small particles for
ease of swallowing. For most, it is considered an enjoyable
activity that involves the senses of taste, touch, and smell.
It is a complex function that requires the involvement of
the muscles, the teeth, and the periodontal supportive struc­
tures. It also requires functioning temporomandibular joints
and jaws, and it makes use of the lips, the cheeks, the
tongue, the palate, and the salivary glands. It is an activity
that is usually automatic and often taken for granted,
although it can be easily brought into voluntary (i.e., con­
scious) control. It is also susceptible to pathologic condi­
tions and damaging habits. Furthermore, modifications of
this system (i.e., compensatory patterns) will be introduced
when component parts are not in proper working order
(e.g., in the presence of dentofacial deformity with
malocclusion).
In the normal setting, mastication is made up of rhyth­
mic, well-controlled separations and closures of the maxil­
lary and mandibular teeth. This activity is under the control
of the CPG, which is located in the brain stem. Each
opening and closing movement of the mandible represents
a chewing stroke.79 The chewing stroke can be divided into
the opening phase and the closing phase. The closing phase
may be further subdivided into the crushing phase and the
grinding phase. During mastication, the chewing stroke is
repeated until the food is broken down into small enough
parts for swallowing. After the food has been incised (usually
with the anterior teeth) and then brought further into the
mouth, the crushing of the bolus is concentrated on the
posterior teeth.
TABLE
8-1 
Muscles of Mastication
Muscle of
Mastication
Origin
Insertion
Main Actions
Masseter:
superficial head
• Inferior border of the
anterior two thirds of
the zygomatic arch
• Angle of mandible
• Inferior and lateral parts
of the mandibular ramus
• Elevates mandible
• Protrudes mandible
• Aids in lateral excursion
of mandible
Masseter: deep
head
• Medial border of the
zygomatic arch
• Inferior border of the
posterior one third of
the zygomatic arch
• Superolateral mandibular
ramus
• Coronoid process
Temporalis
• Temporalis fossa, along
the inferior temporal
line, including the
temporal fascia
• Coronoid process,
extending inferiorly on
the anterior border of
the mandibular ramus
• Elevates mandible
• Protrudes mandible
• Aids in lateral excursion
of mandible
Medial pterygoid:
deep head
• Medial surface of the
lateral pterygoid plate
• Medial surface of the
ramus and the angle of
the mandible
• Elevates mandible
• Protrudes mandible
• Lateral excursion of
mandible
Medial pterygoid:
superficial head
• Maxillary tuberosity
• Medial surface of the
ramus and the angle of
the mandible
• Elevates mandible
• Protrudes mandible
• Lateral excursion of
mandible
Lateral pterygoid:
upper head
• Greater wing of the
sphenoid
• Infratemporal crest
• Articular discs and the
capsule of the
temporomandibular joint
• Depresses mandible
• Protrudes mandible
• Lateral excursion of
mandible
Lateral pterygoid:
lower head
• Lateral surface of the
lateral pterygoid plate
• Pterygoid fovea on the
neck of the condyle
• Depresses mandible
• Protrudes mandible
• Lateral excursion of
mandible

231
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 8-2  Mastication prepares food via “chewing” for deglutition and digestion. The illustrations and legends show
an overview of the process. Netter illustration from © Elsevier Inc. All rights reserved.
Digestion of starch
by salivary amylase
(ptyalin) continues in
stomach until arrested
by gastric acidity. Bolus
temporarily protected
from gastric acid by
previously ingested food
Gastric secretion
stimulated
Bolus
entering
stomach
Pathologically diminished salivary secretion
(as in fever, dehydration, drug action,
Sjögren’s syndrome)
Increased
thirst
Sordes and
parched lips
Food particles progressively
reduced in size and mixed
with saliva. Tongue aids in
mixing process
Saliva
entering
mouth
Incisor teeth (cutting action)
Bicuspid and molar teeth
(grinding action)
Sublingual
gland
Submandibular
gland
Parotid
gland
Aromatic
substances
released
from food
Mesencephalic nucleus V
Sensory nucleus V
From teeth and palate
To muscles of
mastication
From back of tongue
Afferents “report” on
character of food and
progress of mastication
Proprioceptive fibers
“report” on pressure
Bolus of food,
particulated, mixed
with and lubricated
by saliva, passing
down esophagus
Difficulty in
swallowing
“dry” bolus
Gastric emptying facilitated
by smaller size of particles
Vagus nerve carries
secretory and motor
impulses to stomach
Afferents
(other than)
Proprioception
Parasympathetic
efferents
Somatic efferents
Indefinite paths
Dorsal
nucleus
of vagus
Nucleus of
solitary
tract
V
IX
X
Olfa
cto
ry
a
ff
er
e
n
t
s
Fr
om te
eth
and tongue
Key
}

232
SECTION 1  Basic Principles and Concepts
It has been documented that the tooth contact ability,
the number of teeth, and the quality of the teeth influence
the chewing stroke. During mastication, sensory informa­
tion is sent back to the central nervous system.5,158 This
feedback mechanism allows for the alteration of the chewing
stroke in response to the particular food being chewed and
the quality of the anatomic structures that are available for
chewing.65 Generally, with maximum full intercuspation
(i.e., tall cusps, deep fossae, and ideal contacts), a predomi­
nantly vertical chewing stroke is seen. When there is a flat­
tened occlusal surface (e.g., as a result of occlusal equilibrium
or a grinding habit that involves a loss of enamel), a broader
chewing stroke can be documented.54,81 The presence of
malocclusion may produce irregular and less repeatable
chew­ing strokes in the individual.6 Studies document that,
in approximately 75% of subjects, there is a preferred
chewing side.6 Chewing activities normally occur on the
side with the greatest number of pain-free tooth contacts
noticed during lateral glide.
The maximum biting force that can be applied to the
teeth varies from individual to individual.156 With tougher
foods, chewing preferably occurs predominantly on the first
molar and second premolar areas. In general, males can bite
more forcefully than females. Typically, in the presence of
normal anatomy, the maximal amount of force applied to
a molar is several times that which can be applied to an
incisor.60 The maximum biting force generally increases
with age, up to adolescence. Nevertheless, the amount of
force placed on the teeth during mastication varies greatly
from individual to individual.103,114
When food is introduced into the mouth, the lips must
guide and control intake. After the food is in place, the lips
must seal off the oral cavity. The lips are especially necessary
when liquid is being introduced.58 This is more difficult for
the individual with a long face growth pattern that causes
mentalis strain and lip incompetence. When the food is in
the mouth, the tongue plays a major role in maneuvering
the bolus for sufficient chewing. The tongue typically initi­
ates the process of breaking up the food by pressing the
bolus against the hard palate; thus, the presence of an oro­
nasal fistula in a patient with a cleft palate can be problem­
atic. The tongue then pushes the food onto the occlusal
surfaces of the teeth, where it can be effectively crushed
during the chewing stroke. During the opening phase of the
next chewing stroke, the tongue repositions the partially
crushed food again onto the teeth for further breakdown.
While the tongue is repositioning the food that has been
displaced lingually, the buccinator muscle in the cheek
region is compressing the food that has shifted into the
vestibule back over the molars. The displaced food is con­
tinuously repositioned on the occlusal surfaces of the teeth
until the particles are small enough to be swallowed effi­
ciently. The tongue is also used to separate the food particles
that require more chewing (and are therefore replaced over
the molars) from those that are now small enough for swal­
lowing. This sorting process is essential to prevent choking
on large food particles. After the eating process is complete,
the tongue is used to clean the teeth and to remove any food
residue that has been trapped in locations such as the floor
of the mouth (i.e., the sulcus) or in the labial vestibule.
In the presence of normal anatomy, the ingestion of a
bolus of food is made easier by the active lowering of the
mandible, the opening of the lips, and the depression of the
tongue.25 All of these activities increase the size of the oral
cavity to accommodate the bolus that is to be ingested. Not
surprisingly, temporomandibular joint ankylosis or mastica­
tory muscle pain with trismus will limit mouth opening and
alter the process. The ingestion of fluid is usually via sucking
(e.g., with a straw). In this case, the lips remain sealed
around the delivery device, and the exit to the back of the
oral cavity is closed by the tongue and the soft palate. In
the individual with a long face growth pattern (i.e., lip
incompetence and an anterior open bite), this will be more
difficult. The lowering of the mandible and the depression
and retraction of the tongue are accomplished by bracing
the cheeks laterally and the mouth floor inferiorly. These
actions will generate a subatmospheric pressure within the
oral cavity to facilitate the flow of fluids into the oral cavity.
This process will be more difficult in the presence of an
oronasal fistula (i.e., an incompletely repaired cleft palate).
This form of suction is also a useful mechanism for driving
the entry of saliva into the oral cavity from the salivary
glands.112
Swallowing Mechanism
Swallowing is a process that occurs through a series of coor­
dinated muscular contractions that move the bolus of food
from the oral cavity through the esophagus and into the
stomach (Fig. 8-3). It requires voluntary, involuntary, and
reflex muscular activity. The decision to swallow generally
depends on the following: (1) the degree of fineness of the
food (2) the intensity of the taste extracted and (3) the
degree of lubrication of the bolus. During the swallowing
mechanism, the lips are closed to seal the anterior aspect of
the oral cavity. The teeth are brought into their maximum
intercuspal position for the stabilization of the mandible.
With the mandible fixed, the contraction of the suprahyoid
and infrahyoid muscles will control the movement of the
hyoid bone for effective swallowing.
The normal adult swallow involves the use of the teeth
for mandibular stability; this is called the somatic swallow.
When adequate teeth are not present (e.g., in the infant),
the mandible must be braced by other means. In the infant
swallow, which is also called the visceral swallow, the man­
dible is braced by placing the tongue between the dental
arches.
In the normal growing child, as the posterior teeth erupt,
the occluding teeth are able to brace the mandible, and the
transition to an adult swallow occurs. In the presence of
malocclusion, either from a developmental jaw deformity
(i.e., an anterior open bite or a Class II malocclusion with
significant overjet) or from the loss of teeth from either

233
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 8-3  Deglutition or swallowing is a combination of voluntary and involuntary muscle contractions
that move a bolus of food from the oral cavity to the esophagus. These illustrations review the details of
the process. Netter illustration from © Elsevier Inc. All rights reserved.
The tip of the tongue contacts
the anterior part of palate while
the bolus is pushed posteriorly
in a groove between tongue and
palate. The soft palate is drawn
upward as a bulge forms in the
upper part of posterior pharyngeal
wall (Passavant’s ridge) and approaches
the rising soft palate.
The bolus lies in a groove on the dorsal surface
of the tongue created by contraction of
genioglossus and transverse intrinsic mm.
Bolus
Bolus
Transverse
intrinsic musculature
of tongue
Genioglossus
muscles
As tongue gradually
presses more of its
dorsal surface against
the hard palate, the bolus
is pushed posteriorly into
the oropharynx. The soft
palate is drawn superiorly
to contact Passavant’s ridge
and closes off the nasopharynx.
A receptive space is created
in the oropharynx as the root
of the tongue moves slightly
anterior. The stylopharyngeus
and upper pharyngeal constrictor
mm contract to raise the pharyngeal
wall over the bolus.

When the bolus
has reached the
vallecula, the hyoid
and larynx move
superior and anterior
while the epiglottis is
tipped inferiorly. A
“stripping wave” on the
posterior pharyngeal
wall moves inferiorly.
The epiglottis is tipped
inferiorly over the laryngeal
aditus but does not completely
close it. The bolus flows in two
streams around each side of
epiglottis to the pyriform fossae
and unites to enter the esophagus.
A trickle of food may enter
the laryngeal aditus.
Soft
palate
Root of
tongue
Epiglottis
turned
down
Laryngeal
aditus
Bolus
Continued
tumor or trauma, the infant swallow is maintained or reas­
sumed (Fig. 8-4). In the presence of an anterior open bite,
it is necessary for the individual to thrust the tongue forward
to close the gap during the swallowing mechanism. This is
an appropriate compensatory swallowing pattern.
Studies confirm that this repetitive swallowing cycle
occurs approximately 600 times during a 24-hour cycle in
the average individual.33 The general breakdown includes
cycles during eating, cycles between meals while awake, and
cycles during sleep. Lower levels of salivary flow during sleep
result in less need for swallowing.112
Although swallowing is one continuous act, for descrip­
tive purposes, it is divided into three stages.
Swallowing: First Stage
The first stage of swallowing is voluntary. It begins with the
selective separation of the masticated food into a specific
bolus. This task is accomplished primarily by the tongue.
The bolus is positioned on the dorsum of the tongue and
then pressed lightly against the intact hard palate. The tip
of the tongue rests on the hard palate anteriorly, just behind
the incisors. The lips are sealed, and the teeth are brought
together; this essentially dams off the anterior oral cavity.
The presence of the bolus pressed against the mucosa of the
intact hard palate initiates a reflex wave of contraction of
the tongue that pushes the bolus backward. As the bolus
reaches the back of the tongue and with the soft palate now
occluding against the nasopharynx, the bolus is transferred
into the pharynx.
Swallowing: Second Stage
When the bolus has reached the pharynx, a peristaltic wave
caused by the contracture of the pharyngeal constrictor
muscles carries it down the pharynx. To prevent regurgita­
tion into the nasal cavity, the soft palate must rise and touch
the posterior pharyngeal wall, thereby sealing off the nasal

234
SECTION 1  Basic Principles and Concepts
• Figure 8-4  Illustrations of a compensatory swallowing mechanism in an individual with a Class II excess overjet
malocclusion. This illustration is representative of the patient shown in Figure 8-10.
Soft palate
Bolus
Bolus
Bolus
1st
2nd
The soft palate is pulled inferiorly
and approximated to the root of
tongue by contraction of the
palatopharyngeus and pressure
of the descending “stripping wave.”
The oropharyngeal cavity is closed by
contraction of upper pharyngeal
constrictors. Relaxation of the
cricopharyngeus permits entry of the
bolus into the esophagus. A trickle of
food may enter the laryngeal aditus.
Laryngeal vestibule is closed by
approximation of aryepiglottic and ventricular
folds, preventing entry of food beyond aditus
into the larynx.
“Stripping wave” reaches
vallecula and presses
out the last of the bolus.
The cricopharyngeus remains
relaxed and the bolus has
largely passed into the
esophagus.
“Stripping wave” passes
the pharynx and the
epiglottis begins to turn
superiorly as the hyoid
and larynx descend.
Communication with the
nasopharynx is re-established.
All structures of the pharynx
return to their resting position
as the “stripping wave” passes
into the esophagus, pushing
the bolus before it.
Soft palate
Root of tongue
Vallecula
Epiglottis
turned down
(sectioned)
Thyroid cartilage
Aryepiglottic fold
Cricoid cartilage
Ventricle of larynx
• Figure 8-3, cont’d

235
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
airflow to be converted into cyclic puffs of air that then
become sound (Fig. 8-6). The airstream is interrupted by
movements of the jaws, the tongue, the soft palate, and the
lips. These movements change the shape of the vocal tract,
which in turn enables the individual to control the articu­
lated sound and resonance characteristics.4 The pitch of the
voice changes in accordance with adjustments that are made
in the tension of the vocal cords. Voiced sounds incorporate
the vibration of the vocal cords in addition to the placement
of the articulators. Unvoiced sounds are produced by the
interruption of the airstream by the articulators. Voiced
sounds are produced with vocal fold vibration that accom­
panies articulator placement. Vocal tract resonance character­
istics are controlled by the cross-sectional area of various
parts of the vocal tract.36 Examples include the articulation
of the upper lip to the lower lip for the bilabial sounds of
/p/, /b/, and /m/ and the articulation of the tongue to the
alveolar ridge for the production of the lingual-alveolar
sounds /t/, /d/, /n/, /l/, /s/, and /z/.120
Individual articulators (i.e., upper jaw, lower jaw, upper
lip, lower lip, tongue, soft palate, hard palate, upper teeth,
and lower teeth) are used for both the speech mechanism
(Figs. 8-7 and 8-8; Table 8-2) and for the mastication
and swallowing (deglutition) mechanisms (see Figs. 8-1,
8-2, and 8-3).123 Speech sounds are composed of the
approximation of individual articulators within the speech
mechanism and the manner in which the airflow from the
vocal cords is modulated.59 This in turn produces what is
called a phoneme, which is known to most as an isolated
speech sound. A significant feature of articulatory move­
ments is the phenomenon of assimilation in which the
mouth position for an individual phoneme in the utterance
cavity. Simultaneously, the epiglottis must block the pha­
ryngeal airway to the trachea to prevent the food from going
into the larynx or the trachea and ending up in the lungs.
This process of walling off potential openings keeps the food
moving down the esophagus. During this stage of swallow­
ing, the pharyngeal muscular activity opens the pharyngeal
orifices of the eustachian tubes, which would otherwise be
closed.
Swallowing: Third Stage
The third stage of swallowing describes the passing of the
bolus through the length of the esophagus and into the
stomach. Rapid peristaltic waves carry the bolus through
the esophagus. As the bolus reaches the lower esophagus,
the sphincter relaxes, thereby allowing for the entrance
of the bolus into the stomach. Interestingly, in the upper
portion of the esophagus, the muscles are mainly voluntary
and can also be used to return the bolus into the mouth
when necessary for more complete mastication. In the lower
section of the esophagus, the muscles are entirely
involuntary.
Evaluation of Swallowing
When a complaint about swallowing is registered, a special
evaluation may be required. Such an evaluation should
consist of a complete medical history, a detailed description
of the complaint, and a physical examination of the periph­
eral deglutitory motor and sensory system, including trial
swallows under observation. Diagnostic studies—including
videofluorography, manometry, electromyography, and
fiber-optic endoscopy—are indicated in selected cases.
Speech: Mechanism, Formation,
and Assessment
The mechanism of speech is composed of several highly inte­
grated processes (Fig. 8-5)26,31,122:
• Speech initiation, during which the content of the utter­
ance to be spoken is converted into phonemes in the
brain’s language center
• The generation of commands that go from the brain’s
motor center to the speech organs
• Phonation, during which the emission of air sent from
the lungs moves through the vocal tract and causes the
formation of the voice as it moves past the vocal folds
• Articulation, which involves movement by the oral
cavity, the oral pharynx, and the hypopharynx for
the production of speech via this specific set of
motor commands
During human speech production, the airflow that is sent
from the lungs with a constant pressure passes between the
vocal cords; the vibration of the vocal cords causes the
• Figure 8-5  Illustration of a cross section through the head and neck
that shows the pertinent anatomy required to articulate speech.
Vocal cords
Uvula
Posterior
pharyngeal
wall
Nasal cavity
Hard palate
Oral cavity

236
SECTION 1  Basic Principles and Concepts
• Figure 8-6  A view of vocal cords as seen via nasoendoscopic
examination. A, Closed vocal cords (adduction position). B, Open
vocal cords (abduction position).
A
B
incorporates the effects of the mouth position for the pho­
nemes uttered immediately before and after. Interestingly, a
human can imitate the sound of an utterance that he or she
has heard without necessarily being able to speak the lan­
guage of the utterance.66 In other words, the individual can
estimate which mouth movements are necessary to produce
a sound that is similar to the one that he or she has heard.
By convention, the classification of speech sounds is catego­
rized in accordance with their manner and place of produc­
tion (i.e., the location of articulation).
Vocal tract variables include the dynamic voluntary
movements of the vocal organs (e.g., lower jaw, tongue, soft
palate, vocal cords, upper lip, lower lip); these organs and
their movements are influenced by the basic positions of the
organs in relation to each other. The baseline position of
the jaws and teeth vary widely; however, if they are
significantly displaced (i.e., if there is malposition of the
teeth or jaws), this can negatively affect articulation (Fig.
8-9). When the position of a jaws is abnormal (i.e., dento­
facial deformity) and then successfully corrected via ortho­
dontics and orthognathic surgery, including a return of
normal morphology, then the tongue may or may not
respond instantaneously to achieve a more normal utterance
of specific consonant or vowel sounds (see Fig. 8-8).
In general, in the patient with a dentofacial deformity,
the articulators will try to adapt first to the genetically
malpositioned jaws and teeth and then to the corrected
anatomy after successful orthodontics and orthognathic
surgery. It is said that the tongue is the single most impor­
tant articulator, because it is highly mobile and therefore
adaptable to the adjacent vocal organs for the production
of a spectrum of speech sounds, even when the other articu­
lators are abnormally located (e.g., as a result of the malposi­
tion of the teeth and jaws, a palatal fistula, a poorly moving
velum, or widely separated lips). The vocal folds also have
the capacity to adapt when speech pressure leaks out of the
nose. The upper and lower lips, the soft palate, and the
mandible are also mobile but to a more limited degree;
therefore, they are less adaptable components of the vocal
tract.
Speech sounds are generally divided into the categories
of consonant sounds and vowel sounds. The production of
consonant sounds requires the obstruction or partial closure
(i.e., sphinctering) of the airstream at specific sites along
the vocal tract.121 The classifications of consonant sounds
are based on the extent of airstream obstruction, the site
of airstream obstruction, and whether the vocal cords
vibrate.16,17 Vowel sounds are generally produced by the
position of the tongue and lips without airstream obstruc­
tion and with the upper and lower teeth more widely sepa­
rated. All vowel sounds are voiced, and it is for this reason
that vowel sounds are generally less affected by the malpo­
sitioning of the teeth or jaws than consonant sounds are.138
With regard to the consonant sounds, the different
extents of airstream obstruction are generally considered to
fall into the following categories:
• Plosive/stop: Air pressure is stopped within the oral cavity
at a specific location, and it is then suddenly released.
Examples are /p/, /b/, /t/, /d/, /k/, and /g/.
• Fricative: Air pressure is partially blocked or obstructed
within the vocal tract, thereby causing turbulent airflow.
Examples are /f/, /v/, /s/, and /z/.
• Affricative: There is a sequencing of the airstream initially
with complete obstruction (i.e., plosive/stop) followed
by fricative (i.e., partial vocal tract obstruction) at the
same location. Examples are /ch/ and /j/.
• Nasal: Air is allowed to pass freely through the nasal
cavity. Examples are /m/, /n/, and /ng/.
The anatomic locations of the vocal organs that block or
partially block the airflow (i.e., places of articulation)
include the following: bilabial (upper lip to lower lip);

237
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
TABLE
8-2 
Kinesiologic Positions for the Oral and Pharyngeal Musculature during the Articulation
of Speech Sounds
Structural Components of
the Articulatory Valve
Closed Valve
Voiceless
Closed
Valve
Voiced
Constricted
Valve
Voiceless
Constricted
Valve Voiced
Voiced
Nasals
Labiodental (upper teeth and lower lip)
“f”/f/
“v”/v/
Bilabial (lips)
“p”/p/
“b”/b/
“w”/w/
“m”/m/
Linguodental (tongue tip and upper teeth)
“th”/θ/
“th”/ð/
Linguoalveolar (tongue tip and alveolar
ridge)
“t”/t/
“d”/d3/
“s”/s/
“z”/z/
“l”/l/
“n”/n/
Linguopalatal (tongue blade and hard
palate)
“ch”/t∫/
“j”/dℨ/
“sh”/∫/
“zh”/ℨ/
“r”/r/
“y”/j/
Linguovelor (tongue back and velum)
“ng”/r/
Linguo-velor-pharyngeal (tongue back,
velum, and pharyngeal wall)
“k”/k/
“g”/g/
Glottal (glottis)
“h”/h/
labiodental (lower lip to upper teeth); interdental (tongue
between the upper and lower teeth); lingual to palate alveo­
lar (tongue to alveolar process of the upper jaw), lingual to
palate (tongue to hard palate); and glottal (vocal cords to
each other).124
The assessment of speech disorders involves the use of a
number of tests and techniques.23,24,27,32,34,75,109,132,139 Histori­
cally, various tests have been described to assess speech and
how it compares with recognized normative values. These
assessments typically will evaluate sound production in the
word position or within sentences. Tests that are frequently
used for the assessment of speech are found in Box 8-1.
These tests are based on determining errors when the
results are compared with those of normal individuals
during single-word utterances. The Bzoch Error Pattern
Diagnostic Articulation Test further grades each error type
in accordance with its severity. All of these tests fall short
for the assessment of the complexities of dynamic speech.
Among educators and clinicians, there is often a lack of
agreement with regard to a preferred objective method for
the analysis of speech. The majority of the published studies
were carried out to analyze the effects of orthodontics and
orthognathic surgery on speech attempt to document artic­
ulation error rates in a traditional manner by noting sound
production as simply correct or incorrect and by noting
substitutions, distortions, or omissions. Some studies
further describe errors as either visual or auditory in an
attempt to overcome the usual problems associated with
detecting mild sibilant distortions that might not be cap­
tured on audiotape.161
The classic negative effects of a jaw deformity with mal­
occlusion on speech articulation are known.30,35 The speech
benefits of successful orthodontic and surgical correction
will have their most notable effects on consonant articula­
tion within the fricative class, which includes /s/, /z/, and
/f/. It is known that the /s/ sound in particular is highly
sensitive to precise tongue placement and to the accurate
direction of airflow across the incisal edges of the upper and
lower teeth.
The characterization of speech error type is usually
defined as follows:
• Substitution: when one sound is replaced by another
• Omission: when a sound is omitted from a word
altogether
• Distortion: when sound is not produced appropriately
but is still understood
• Visual distortion: when the visual appearance of
making the sound is abnormal but the sound itself is
correct
• Auditory distortion: when the perception of the sound
(what is heard) is abnormal but the appearance (visual
appearance) of the positioning of the anatomy is
correct
• BOX 8-1 
Speech Assessment Tests
• Templin-Darley Screening Test of Articulation
• Iowa Pressure Articulation Test
• Bzoch Error Pattern Diagnostic Articulation Test
• Fisher-Logemann Test of Articulation
• Goldman-Fristoe Test of Articulation

238
SECTION 1  Basic Principles and Concepts
• Figure 8-7  Diagram showing the kinesiologic positions for the oral and pharyngeal musculature during the articulation of speech sounds.
1. Upper teeth
and lower lip
Neutral
3. Tongue tip and
upper teeth
4. Tongue tip and
alveolar ridge
6. Tongue back and velum
7b. Velum and pharyngeal wall
7c. Velum and pharyngeal wall (superior view)
7a. Tongue back, velum,
and pharyngeal wall
5. Tongue blade
and hard palate
8. Glottis
Palatopharyngeus
Velum
Superior constrictor
2. Lips

239
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 8-8  Illustrations that demonstrate the articulation of sounds created by specific positions of the lips, tongue, and teeth in
the presence of harmonious jaws and occlusion. The numbering allows you to refer back to the chart shown in Figure 8-7, B, to cor­
relate the anatomic position of the articulators with the associated speech sounds.
Plosive
P, B (2 in Figure 8-7)
T, D (4 in Figure 8-7)
K, G (7 in Figure 8-7)
F, V (1 in Figure 8-7)
S, Z (4 in Figure 8-7)
Th (3 in Figure 8-7)
M (2 in Figure 8-7)
N (4 in Figure 8-7)
Ng (6 in Figure 8-7)
Ch, J (5 in Figure 8-7)
Fricative
Nasal
Affricative