Orthognathic Surgery

241
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
Or
Or
Or
Orthththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatata hicici Su
Su
Su
Su
Surg
r ery
ry; J.C.
C.
C.
C. Pos
os
os
os
os
osnicicicick
Or
Or
Orththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
g atata hicici Su
Surg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
os
os
o nicicick
Or
Or
Or
Orthththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
g atatata hicicic Su
Su
Surg
r ery; J.C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
o nicicicick
Or
Or
Or
Orthththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatata hicicicicicic Su
Surg
r ery
ry
ry; J.C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
osnicicicick
A
B
• Figure 8-10  A 16-year-old girl arrived with her parents for the surgical evaluation of a developmental
jaw deformity with malocclusion. She was diagnosed with a primary mandibular deficiency, a maxillary
arch constriction, and a Class II excess overjet growth pattern. Attempts at orthodontic growth modi­
fication and camouflage in the past were unsuccessful. There was a lifelong history of obstructed nasal
breathing, heavy snoring, and the suggestion of sleep apnea. The patient experienced difficulty with
chewing, swallowing, speech articulation, breathing, and lip closure/posture. A formal evaluation by a
speech–language pathologist was carried out.
Chewing/swallowing:
• Difficulty with chewing solid, textured food
• Only able to chew on the back teeth
• Frequently swallows foods partially whole, especially raw vegetables and meat
Oral-sensory motor:
• Normal to mild labial weakness during repeated puckering and retraction tasks
• Lingual range of motion within normal limits
• Palatal structures revealed adequate elevation
Articulation:
• Assessed via the Fisher-Logemann Test of Articulation and informally during speech and
conversation
• Misarticulations were identified, including /s/, /sh/, /st/, /z/, /dz/, and /sk/
Continued

242
SECTION 1  Basic Principles and Concepts
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatathicicicicicicicicicic Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
o nicicici k
Or
Or
Or
Or
Or
Or
Or
Or
Orthththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicici Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
osnicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicic 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; J.C.
C.
C Pos
osnicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C. Pos
os
os
osnicicick
C
D
Production of sounds:
• Anterior tongue thrusting is required to facilitate speech sounds in conversation and in contex­
tual speech.
• Imprecision in speech makes her difficult to understand.
• She frequently uses a closed-mouth posture to speak, thereby causing her speech to be
unintelligible for the listener.
Recommendations:
The patient’s presenting jaw deformity and malocclusion interfere with her ability to communicate
information precisely to a listener and to be understood. Orthodontic treatment and orthognathic
surgery are recommended to correct the maxillofacial deformities. If successful, then improvements
in the dysfunctions described should be expected. It is highly doubtful that speech therapy alone could
solve the extent of the deficits.
Treatment
The patient agreed to a combined orthodontic and surgical approach. Mandibular first bicuspid extrac­
tions provided space to orthodontically relieve dental compensation. Surgery included a maxillary Le
Fort I osteotomy (arch expansion and horizontal advancement); bilateral sagittal split ramus osteoto­
mies (horizontal advancement); osseous genioplasty (horizontal advancement); and septoplasty and
inferior turbinate reduction.
A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment. C, Oblique facial views before and after treatment. D, Profile views before and after
treatment.
• Figure 8-10, cont’d

243
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
E
Pre surgery with lower bicuspid extractions
After treatment
F
Arch expansion
E, Occlusal views with orthodontics in progress (mandibular bicuspid extractions) and then after treatment.
F, Articulated dental casts that indicate analytic model planning.
• Figure 8-10, cont’d 
Continued

244
SECTION 1  Basic Principles and Concepts
G
H
G, Computed tomography scans prior to reconstruction confirming non-progressive glenoid fossa and condyle malforma­
tions. H, Lateral cephalometric radiographs before and after surgery.
• Figure 8-10, cont’d

245
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
Or
Or
Or
Or
Or
O thththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatata hicicicic Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C Pos
os
os
os
os
os
os
os
osnick
Or
Or
Or
Or
O thththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatata hicicic Su
Su
Su
S rg
r ery
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
o nicicicick
Or
Orthththththththththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatathicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C.
C.
C Pos
os
os
os
os
o nick
Or
Or
Orthththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gnatatatatatatatatatatatatatatatatathicic Su
Su
S rg
r ery
ry
ry; J.C.
C.
C Pos
os
os
os
osnicicick
A
B
• Figure 8-11  An 18-year-old man arrived with his parents for the surgical evaluation of a develop­
mental jaw deformity with malocclusion. He was diagnosed with a long face Class III anterior open-bite
negative overjet growth pattern. This was due to both a hereditary Class III tendency and a lifelong
obstructed nasal breathing open-mouth posture. The patient described difficulty with chewing, swal­
lowing, speech articulation, breathing, and lip closure/posture. A formal speech–language pathologist’s
evaluation was carried out.
Chewing/swallowing:
• Frequent need to tear food apart before chewing
• Unable to bite into solid, textured food
• Only able to chew on the posterior teeth
• Frequently noted to swallow foods partially whole
• Difficulty with eating meats and breads
Oral-sensory motor:
• Labial motion and strength greatly reduced, especially with puckering and retraction of the
tongue
• Soft palate structure and elevation within normal limits
Articulation:
• Assessed via the Fisher-Logemann Test of Articulation and informally during spontaneous
conversation
• Misarticulations were identified, including /s/, /sh/, /z/, /dz/, /sk/, /ch/, and /s/ blends
Continued

Or
Or
Or
Or
Or
Orthththththth
r ogn
gn
gn
gn
gn
gn
gn
gnatatatatata hicicicic Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry; J.C.
C.
C.
C.
C Pos
os
os
o nicick
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
g atatatatatatatathicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
o nicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatata hicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
os
os
os
os
os
os
os
os
os
os
osnicicicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Orththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatathicicicicicicicic 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; J.C.
C Pos
os
os
osnicicicick
C
D
Production of sounds:
• Production of sounds required anterior tongue thrusting and lateral lisping
• Exhibited imprecision in coarticulation, which often interfered with speech intelligibility
• Speech rate is rapid, with mumbling used as a compensatory feature for communication
• Frequently uses closed-mouth posturing with lack of enunciation, which greatly interfere with
communication
• States that friends, teachers, and parents often comment that they cannot understand his
speech
• Unintelligible speech interferes with daily performance at school and in social situations
• Avoids telephone conversations and hesitates to leave voice messages as a method of
communicating
Recommendations:
The presenting jaw anomalies and malocclusion are responsible for the described findings. Orthodon­
tics and orthognathic surgery are recommended to correct the maxillofacial anatomy. If successful, it
is highly probable that the dysfunction described will resolve.
Treatment
The patient agreed to a combined orthodontic and surgical approach. With the removal of dental
compensation, surgical procedures included a maxillary Le Fort I osteotomy (arch expansion, arch
form correction, horizontal advancement, clockwise rotation, and vertical shortening); bilateral sagittal
split ramus osteotomies (horizontal advancement and counterclockwise rotation); osseous genioplasty
(horizontal advancement); and septoplasty, inferior turbinate reduction, and nasal floor recontouring.
A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment. C, Oblique facial views before and after treatment. D, Profile views before and after
treatment.
• Figure 8-11, cont’d

247
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
E
Prior to treatment
Pre surgery
After treatment
E, Occlusal views before treatment, with orthodontics in progress, and after treatment.
• Figure 8-11, cont’d 
Continued

248
SECTION 1  Basic Principles and Concepts
F
Maxillary clockwise rotation
Mandibular counter-clockwise
rotation
Arch expansion
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radiographs
before and after treatment.
• Figure 8-11, cont’d

249
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
Or
Or
Or
Or
Or
O thththththth
r ogn
gn
gn
gn
gn
g atata hic Su
Su
S rg
r ery
ry; J.C.
C.
C Pos
os
os
os
os
os
o nicicicici k
Or
Or
Or
Orththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
g ata hicicici Su
Su
Surg
r ery
ry; J.C.
C.
C Pos
os
os
osnicicici k
Or
Or
Or
Or
O thththth
r ogn
gn
gn
gn
gnatatata hicic Su
Surg
r ery
r ; J.C.
C. Pos
os
os
os
os
os
os
osnicicicick
Or
Or
Or
Or
Orthththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatathicic Su
Surg
r ery
ry
ry
ry; J.C. Pos
os
os
os
os
os
os
os
os
osnicicici k
A
B
• Figure 8-12  A 16-year-old girl arrived with her parents for the evaluation of a developmental jaw
deformity with malocclusion. She was diagnosed with a long face Class II anterior open-bite growth
pattern. She had undergone years of orthodontic growth modification and camouflage treatment,
without success. Her dentofacial deformity was found to affect speech, chewing, swallowing, breath­
ing, and lip closure/posture. A formal speech–language pathologist’s evaluation was carried out.
Chewing/swallowing:
• Only able to chew on the posterior teeth
• Malocclusion results in frequently swallowing food whole
• Noted to frequently have food falling out of her mouth secondary to malocclusion
Oral-sensory motor:
• Mild labial weakness
• Demonstrates anterior carriage of the tongue at rest
• Tends to hold oral cavity in a closed posture during speech
Articulation:
• Assessed via the Fisher-Logemann Test of Articulation and informally during conversation
• Misarticulations were identified, including /s/, /sh/, /z/, /dz/, /z/, /sk/, and /st/
Continued

250
SECTION 1  Basic Principles and Concepts
Or
Or
Or
Or
Or
Or
O ththththththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatathicicicicicicicicicici Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C. Pos
os
os
os
o nicicick
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
Orththththththththththththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C. Pos
os
os
o nicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththththththtr ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatata hicicicicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
osn cicicici k
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
Orthththththththththththththththththththththththththththththththththththththththththththththththththththtr 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
g atatatatatatatatatatatatatatata hicicicicicicicicicicicicicicici 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; J.C.
C.
C.
C.
C Pos
os
os
o nicici k
C
D
Production of sounds:
• Sound production is with anterior tongue thrusting and lateral lisping during contextual speech
• Exhibits imprecise coarticulation, which interferes with speech intelligibility
• Speech rate is often fast, which compounds the difficulties with articulatory precision (i.e.,
perceived mumbling)
• Occasional final consonant deletions were noted
Recommendations:
The correction of the presenting abnormal jaw morphology and dental malposition is recommended,
if feasible, through orthodontics and orthognathic surgery.
Treatment
Further orthodontic (dental) decompensation in combination with orthognathic surgery was planned.
The procedures included a maxillary Le Fort I osteotomy (vertical intrusion, horizontal advancement,
and counterclockwise rotation); bilateral sagittal split ramus osteotomies (horizontal advancement and
counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); and
septoplasty, inferior turbinate reduction, and nasal floor recontouring.
A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment. C, Oblique facial views before and after treatment. D, Profile views before and after
treatment.
• Figure 8-12, cont’d

251
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
F
G
Maxillary counter
clockwise rotation
Mandibular
counter-clockwise
rotation
E
Pre surgery
After treatment
E, Occlusal views before surgery and then after treatment. F, Articulated dental casts that indicate analytic
model planning. G, Lateral cephalometric radiographs before and after surgery.
• Figure 8-12, cont’d

252
SECTION 1  Basic Principles and Concepts
Unfortunately, many of the published studies that set out
to evaluate speech aspects after the orthodontic and surgical
correction of the initial jaw deformity or malocclusion
include too few subjects, have inadequate controls, mix
varied patterns of dental and jaw deformities, and lack a
standardization of the sampling times before and after treat­
ment.* Some of the published studies seem to lack an
understanding of the expected postoperative convalescence,
during which short-term speech disability is to be expected.
Definitive speech evaluation should occur after adequate
healing (i.e., 3 to 6 months) and with documentation of
the level of success of the correction of the jaw deformity
and malocclusion. As a result of these study shortcomings,
there is a need for the further investigation of the speech
effects of jaw and dental corrections with 1) larger samples
of homogenous patterns of jaw deformity and malocclusion
2) standardized treatment protocols 3) the confirmation of
the actual correction of jaw dysmorphology and malocclu­
sion 4) the setting of agreed-upon speech sampling param­
eters 5) interobserver and intraobserver error testing of
speech evaluations and 6) appropriate statistical analysis.
Cause and Effect Relationships
If the upper and lower lips cannot easily close together—as
is frequently observed in patients with Angle Class III nega­
tive overjet skeletal patterns (e.g., maxillary deficiency with
relative mandibular excess; see Fig. 8-11) or in those with
classic long face growth patterns with Class II anterior
open-bite malocclusion (e.g., maxillary vertical excess with
mandibular deficiency; see Fig. 8-12)—then bilabial sounds
(e.g., words such as pill, baby, and man) cannot be normally
formed.55,95,97,104,136 These sounds will then be attempted
through labiodental articulation. If the lower lip cannot
contact the upper incisors (e.g., long face growth pattern
with Class II anterior open-bite malocclusion or maxillary
deficiency with mandibular excess negative overjet), then
labiodental sounds (e.g., words such as five and vein) will
be affected. Compensation will be attempted with bilabial
sounds. If the tongue has difficulty reaching the lingual
alveolar ridge of the maxilla (e.g., with moderate to severe
Class II mandibular retrognathia), if the airstream cannot
be correctly directed to the edges of the incisors (e.g., with
an anterior open bite), or if the tongue is too far from the
anterior aspect of the lower jaw (e.g., with Class III man­
dibular excess), then sibilant sounds (e.g., words such as
sun, zoo, ship, chair, judge, and measure) will be affected
(see Fig. 8-10).
Interestingly, from a speech perspective, some individu­
als are able to adapt to their dental or jaw defects more
effectively than others. The individual’s ability to alter the
airflow over the incisors or through other articulation points
is necessary to effectively compensate for anatomic
Chapter 20).46,61,157 There were less articulation errors
found in patients with Angle Class II primary mandibular
deficiency malocclusions (see Chapter 19) and in patients
with conditions that involve jaw asymmetry without
significant malocclusion (i.e., mild hemifacial microsomia;
see Chapter 28).67 Voice disorders were more frequently
seen with closed-bite malocclusion as compared with
open-bite malocclusion. Closed-bite jaw deformities are
generally associated with adequate overjet and often with a
deep overbite (i.e., the short face growth pattern; see
Chapter 23).50
Patients with Class III skeletal patterns show distinct
differences with regard to the consonant fricatives (/f/ and
/s/) as compared with normal controls.73 Distortion type
speech errors are also frequently associated with this type of
malocclusion. This is especially true for patients with com­
bined acoustic and visual errors. The speech sounds that are
most commonly affected in the presence of malocclusion
are sibilant sounds and bilabial (i.e., upper lip to lower lip)
sounds. Errors in bilabial sounds are generally found in
individuals with wide lip separation, such as those with
maxillary deficiency in combination with mandibular excess
or long face growth patterns (i.e., vertical maxillary excess
and mandibular deficiency).87
Class II mandibular retrusion with excess overjet is likely
to produce significant bilabial errors (see Fig. 8-10). Patients
with Class II mandibular retrognathia also frequently show
misarticulation errors (e.g., with the sound /r/). It is known
that individuals with mild to moderate Class II mandibular
retrusion are frequently able to adapt by posturing their
lower jaw forward (i.e., by having a dual bite) to maintain
control of their speech. This compensatory jaw position
mechanism tends to break down with rapid speech or when
the individual is otherwise fatigued.130 As a result of the
inherent anatomic barriers, it is not possible for patients
with maxillary deficiencies or mandibular excesses with sig­
nificant negative overjet to posture their lower jaw posteri­
orly as a method of speech compensation (see Fig. 8-11).147
This makes the production of the /s/ sound difficult for
most individuals with Class III malocclusions.133
Published reports indicate that, for a majority of the
individuals studied, the orthodontic and surgical correc­
tion of the baseline jaw deformity and malocclu­sion
either eliminates or dramatically reduces articulation
errors.95,97,106,107,113,127,146 A minority of the study patients
report little change and occasionally speech deterioration.
This lack of success in some patients is most likely attribut­
able to 1) initial errors in dental or jaw diagnosis; 2) the
incomplete initial correction of the dental or jaw deformity
3) or long-term skeletal or dental relapse with a return of
the abnormal dental or jaw position. The inability of an
individual with normal neuromotor ability to favorably
adapt to the corrected dental and jaw relationships is
not the most common reason for a lack of speech improve­
ment. Nevertheless, some individuals will be in need of
speech articulation retraining after corrective surgery and
orthodontics.
*References 8, 21, 18, 28, 29, 40, 42, 44, 45, 74, 106, 113, 126, 127,
131, 134, 135, 137, 146, 148, 150

253
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
(e.g., maxillary deficiency with relative mandibular excess)
achieved the maximum improvement in labiodental scores
after successful orthodontic and surgical correction.
Ruscello and colleagues studied the speech characteris­
tics of 20 individuals who were scheduled to undergo
orthognathic surgery for the correction of a variety of den­
tofacial deformities.106,107 They underwent speech evalua­
tion before and at intervals for up to 6 months after surgery.
Speech assessment at each interval included the Templin-
Darley Screening Test of Articulation, a 60-item nonsense
syllable task, the Deep Test of Articulation, and the Rainbow
Passage. Sixty percent of the patients with jaw deformities
demonstrated preoperative articulation errors. The majority
of those who were exhibiting preoperative articulation
errors had documented improvements after surgery. None
of the patients experienced a deterioration in their articula­
tion after surgery at the close of the study.
Kummer and colleagues studied 16 skeletal Class III
patients before and after Le Fort I maxillary advancement.71
Seven of the 16 study patients were adolescents with repaired
cleft lip and palate. Each patient underwent preoperative
and postoperative speech evaluations and a multi-view vid­
eofluoroscopic speech study. Patients were evaluated before
surgery as well as 3 and 6 months after surgery. The Templin-
Darley Screening Test of Articulation was given, and articu­
lation, resonance, and nasal emission were judged at each
time interval. Eleven of 16 patients (69%) demonstrated
articulation errors before surgery. After surgery, 7 of these
11 (64%) patients (4 without clefts and 3 with clefts)
showed a decrease in the number of misarticulation speech
sounds. None of the patients showed deteriorations in artic­
ulation after surgery.
Vallino studied the articulation, voice, resonance,
hearing sensitivity, and middle-ear function of 34 individu­
als before and at intervals (i.e., at 3, 6, 9, and 12 months)
after they underwent orthognathic surgery.129 Thirty of the
34 patients (88%) exhibited articulation errors before
surgery. The most frequent sibilant errors were /s/ and /z/,
followed by /j/, /zh/, /ch/, and /sh/. The errors were pre­
dominantly distortions of both the visual and acoustic
types. After surgery, articulation generally improved spon­
taneously, without the need for speech training or interven­
tion. Most of the preoperative articulation errors were
eliminated by 3 months after surgery. In a minority of the
study patients, a gradual decline in some of these improve­
ments was measured at 12 months after surgery. This could
be explained by either a relapse of the initial satisfactory
occlusion and jaw correction or a limited sustained adapta­
tion of speech ability in some individuals. Interestingly,
voice, resonance, and hearing sensitivity were not altered by
the surgeries that were carried out.
Xue and colleagues carried out a study to compare vocal
tract configuration in males with skeletal Class III maloc­
clusion (n = 8) with that of their normally developed Class
I counterparts (n = 8).157 The goal of these researchers was
to investigate the concomitant acoustic changes caused by
any alterations in the vocal tract configuration that were
variations in the teeth and jaws. Marked deformities such
as severe Class III maxillary deficiency (see Fig. 8-11), severe
long face growth pattern (i.e., anterior open bite with men­
talis strain; see Fig. 8-12), and severe Class II mandibular
retrognathia with the inability to posture the jaw forward
(see Fig. 8-10) are examples of situations in which compen­
sation is not possible and speech articulation is noticeably
affected. With successful orthodontics and jaw surgery,
improved positioning of the teeth, jaws, lips, tongue, and
soft palate results in ease of articulation to accomplish effec­
tive speech.28,74,126,131,137
It is not surprising that vowel sounds are less frequently
disturbed by a jaw disproportion or malocclusion. Physio­
logically, the major difference between vowel sounds and
consonant sounds is that consonant sounds require signifi­
cant constriction of the airflow within the vocal tract,
whereas vowel sounds are formed by the tongue being posi­
tioned to only partially constrict the airflow.143 Therefore,
consonant sounds are more dependent on an exact position­
ing of the teeth with respect to each other and the lips with
respect to each other (i.e., complete valve closure). Conso­
nant sounds are more affected by jaw deformities such as
Class III maxillary deficiency; long face anterior open bite;
and severe Class II mandibular retrusion. These abnormal
skeletal and occlusal patterns significantly interfere with the
production of speech sounds. However, each individual’s
speech system has variable adaptive ability. The adaptability
primarily comes from the stretching of the lips (i.e., men­
talis strain); the stretching of the tongue to extended posi­
tions; the posturing of the lower jaw forward (i.e., centric
relation to the centric occlusal slide); and the ability to alter
the airflow force across the valves and sphincters. The ability
of an individual to control these factors is also dependent
on the speed of speech and the amount and length of con­
tinuous speech required.
Effects of Successful Orthodontics and
Orthognathic Surgery on Speech
Effects on Speech Articulation: Review of
the Literature
A study by Witzel and colleagues examined the articula­
tion of 41 individuals before and after orthognathic surgery
that was carried out to improve facial aesthetics and to
correct the occlusion.150 The investigators found a direct
relationship between the pretreatment degree of mandibular
retrognathia and the confirmed speech articulation errors.
Twenty-two of 29 (76%) of the study patients had docu­
mented articulation errors before surgery; these included
errors in sibilant production, labiodental sounds, and bila­
bial sounds. After surgery, significant improvement in the
mean total articulation score for each patient was docu­
mented. There was also significant improvement in the sibi­
lant sounds for all groups and in the mean bilabial scores
of patients with mandibular retrognathia. Individuals with
a Class III skeletal pattern and significant negative overjet

254
SECTION 1  Basic Principles and Concepts
Effects on Velopharyngeal Function:
Review of the Literature
Velopharyngeal insufficiency (VPI) is the hallmark sign
of the negative speech effects among individuals who
are born with cleft palates.7,12,22,52,76,91 The basic etiology
of VPI in the repaired or unrepaired cleft palate is dys­
function of the soft palate (Fig. 8-13).13,19,20,51,101,111
The muscular anatomy that is affected by clefting
includes both the elevators of the soft palate (i.e., the mus­
culus uvulus and the levator veli palatini) and the antago­
nists to the elevators (i.e., the palatoglossus and the
palatopharyngeus).56,69,70,116-118,145,160 VPI involves the inad­
equate closure of the velum to the pharyngeal walls while
speaking.78,108,141,142 VPI results in increased nasal air escape
with increased nasal resonance that can be heard.72,88,159
Resonance disorders include both hypernasality and hypo­
nasality.77 When there is improper control of airflow across
the velopharyngeal (VP) sphincter, hypernasality can occur,
with increased nasal resonance occurring during the pro­
duction of vowel sounds.84,153,154 Hyponasality is defined as
a reduction in normal nasal resonance as a result of the
blockage of airflow within the nasal cavity.92,104 A review of
the literature is helpful to better understand the effects of
Le Fort I osteotomy with advancement on VP function.*
In 1969, Jabaley and Edgerton were the first to report
about the potential for changes in the spatial relationship
of the soft palate to the pharyngeal wall as a result of maxil­
lary Le Fort I advancement.63 They described an 18-year-old
patient without clefting who underwent a Le Fort I oste­
otomy with advancement. They stated that there was “no
adverse alteration of velopharyngeal function accompany­
ing the maxillary advancement.”63
In 1976, Schwarz and Gruner reported about 40 patients
who were undergoing Le Fort I osteotomy with reposition­
ing (31 out of 40 with repaired cleft palate).113 The authors
concluded that the “subjective evaluation of velopharyngeal
function and nasality in the cleft palate patients showed no
relationship between the degree of hypernasality before or
after the Le Fort I advancement.”113
Witzel and Munro discussed a 16-year-old patient with
a repaired unilateral cleft lip and palate who presented to
them with maxillary hypoplasia and malocclusion.149 Before
surgery, this patient’s VP valving mechanism showed only
touch closure of the soft palate against the posterior pha­
ryngeal wall. Two months after Le Fort I osteotomy (10 mm
of advancement and 4 mm of vertical lengthening), his
speech evaluation revealed marked hypernasality through­
out connected discourse. The authors concluded that “max­
illary advancement may have a disastrous effect on the
velopharyngeal valving mechanism.”149 They recommended
that “all patients undergoing this procedure should have
detailed clinical investigation of speech and velopharyngeal
function pre- and postoperatively.”149
identified. The findings of the study confirmed that young
adolescents with Class III malocclusion had different vocal
tract configurations than their counterparts with normal
occlusion. The differences occurred in the oral cavity only.
The individuals with Class III malocclusion had signifi­
cantly longer oral length and larger oral volume than their
counterparts in the control group. They surmised that the
Class III dentofacial deformity restricted lip protrusion
during the production of /u/, thereby contributing to the
significantly higher resonating frequency (first formant or
F1) of /u/ as compared with that of normal controls.
A review of these studies indicate that a majority of
individuals who present with moderate or severe jaw defor­
mity and malocclusion will demonstrate articulation errors
during speech. The pattern of jaw deformity (i.e., Class II,
Class III, open bite, or long face) will predict the pattern of
specific articulation errors. Some individuals will have a
greater ability to adapt to their dentofacial deformity to
achieve relatively normal articulation.
Distortions are the most frequently reported errors,
which occur in association with malpositioning of the jaws
and teeth. They are of more concern than substitutions or
omissions. Individuals will attempt to adapt, but their
speech production will not always be within acceptable
phonetic boundaries. The most frequent speech sound
errors are of the /s/ speech sounds, which are sibilants pro­
duced in the alveolar part of the palate with the tongue
resting in this region. This type of sibilant distortion error
can occur with a spectrum of jaw deformities (e.g., man­
dibular retrognathic Class II).
*References 9, 14, 15, 38, 45, 47-49, 64, 68, 71, 82, 83, 85, 98, 102,
110, 125, 128, 129, 144, 149, 152, 155
NOTE:  Residual misarticulations may become
learned behavior patterns. If this occurs, a few speech
treatment sessions may be required for complete
correction during contextural speech production. We
have found that adults more frequently than adolescents
benefit from speech therapy sessions after successful
surgery and orthodontics.
In general, individuals who present with articulation
errors caused by dentofacial deformity with malocclusion
are expected to achieve improved speech function after suc­
cessful jaw surgery and orthodontics. This assumes that the
individual articulators are placed in sufficient proximity to
each other. Published studies indicate that 80% to 90% of
individuals will find positive improvement in their articu­
lation after the vocal organs are correctly positioned. Inter­
estingly, approximately 10% of individuals are found to be
either unchanged or to show some negative effects in speech
articulation after jaw surgery. Possible explanations for this
small failure rate include errors in jaw or dental diagnoses;
unsatisfactory surgical or dental execution; skeletal or dental
relapse; effects of neurosensory deterior­ation; or the inabil­
ity of the individual to adapt over the long term.

Or
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Orththththththth
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Su
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A
B
A
• Figure 8-13  A 15-year-old boy was born with bilateral cleft lip and palate. Previous cleft surgery
included bilateral cleft lip repair (3 months of age); cleft palate repair (12 months of age); and alveolar
bone grafting (8 years of age). The patient has maxillary deficiency and secondary deformities of the
mandible, and there is chronic nasal obstruction (i.e., septal deviation, inferior turbinate hypertrophy,
and nasal floor irregularities). There is a severe Class III negative overjet malocclusion. Orthodontic
(dental) decompensation has been carried out in preparation for jaw and intranasal surgery. The
patient’s current maxillofacial findings affect speech, chewing, swallowing, breathing, and lip closure/
posture. A formal speech–language pathologist’s evaluation was carried out.
Chewing/swallowing:
• Able to chew on posterior teeth only
• Occasional nasopharyngeal leakage (into the nose) when drinking milk
Oral-sensory motor:
• Maxillary hypoplasia with Class III malocclusion
• Exhibits mild lip weakness with protrusion and retraction
• Lingual movements appear adequate
• Ability to elevate the soft palate is suspect
Articulation:
• Assessed via the Fisher-Logemann Test of Articulation and during informal conversation
• Misarticulations were identified, including /s/, /sh/, /z/, /dz/, /sk/, and /st/
Production of sounds:
• Sibilant sounds were noted to involve anterior tongue thrusting and lateral lisping during con­
textual speech
• Exhibits imprecision in coarticulation of speech, which interferes with speech intelligibility
• Unintelligible speech is frequently noted, with mumbling
Continued

256
SECTION 1  Basic Principles and Concepts
Or
Or
Or
Or
Orthththththththtr ogn
gn
gn
gn
gn
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gn
gn
gnatatatatatatatatathicicicicicicic Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
o nicicicicicicici k
Or
Orthththththththth
r ogn
gn
gn
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gnatatatatatatatatatata hicicicicicicicicic Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C.
C.
C.
C Pos
os
o nicici k
Or
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O thththththththththththtr ogn
gn
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gnatatatatatata hicicicicicicicicici Su
Su
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r ery
ry
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ry; J.C.
C.
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C. Pos
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osnicicicicicick
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g atatatatatatatatatatatatathicicicicicicicicicicicicicic Su
Su
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ry
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ry; J.C.
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C
D
Nasopharyngeal examination:
• Nasal emission under right nares observed during non-nasal speech sounds
• Soft palate motion weak
• Shortened palate during non-nasal speech production of phrases and single words
• Good lateral wall movements bilaterally
Recommendations:
• Exhibits sound misarticulations associated with jaw anomaly and malocclusion
• Misarticulations affect speech function during routine conversation
• Forced to use anterior tongue thrusting and lateral lisping, which distort speech and affect
perception of intelligence
• Rated as having inadequate velopharyngeal closure before jaw reconstruction
• Reassess 3 to 6 months after jaw surgery, with anticipated need for a pharyngeal flap
Treatment
Further orthodontic (dental) decompensation in combination with orthognathic surgery was planned.
The procedures included maxillary Le Fort I osteotomy (vertical intrusion, horizontal advancement, and
counterclockwise rotation); bilateral sagittal split ramus osteotomies (horizontal advancement and
counterclockwise rotation); osseous genioplasty (vertical shortening and horizontal advancement); and
septoplasty, inferior turbinate reduction, and nasal floor recontouring.
A, Frontal views in repose before and after treatment. B, Frontal views with smile before and after
treatment. C, Oblique facial views before and after treatment. D, Profile views before and after
treatment.
• Figure 8-13, cont’d

257
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
E
After bone grafting in mixed dentition
Pre orthognathic surgery
After treatment
E, Occlusal views before surgery and then after treatment.
• Figure 8-13, cont’d 
Continued

258
SECTION 1  Basic Principles and Concepts
F
G
Maxillary clockwise rotation
Arch expansion
F, Articulated dental casts that indicate analytic model planning. G, Lateral cephalometric radio­
graphs before and after surgery. Six months after successful jaw and intranasal reconstruction; a nasoendoscopic speech
assessment confirmed the need for a tailor-designed pharyngeal flap.
• Figure 8-13, cont’d 
Epker and Wolford observed that adolescent patients
with repaired clefts, maxillary deficiency, and preoperative
VPI became worse after Le Fort I advancement.29 The
authors stated that individuals with only borderline VP
closure may demonstrate notable VPI after maxillary oste­
otomy, particularly if the advancement exceeds 10 mm.
Bralley and Schoeny reported about a 19-year-old patient
with a submucous cleft palate and maxillary deficiency who
showed no change in nasality after Le Fort I advancement.9
Schendel and colleagues evaluated 21 patients without clefts
before and after maxillary Le Fort I osteotomy to assess VP
closure.110 They did this through speech evaluation, lateral
cephalometric radiography, and nasopharyngoscopy, and
they found no change in VP competence after Le Fort I
advancement.
Witzel described a sample of 41 patients without
cleft palate and 50 patients with repaired cleft palate (bilat­
eral, unilateral, or isolated) who underwent Le Fort I maxil­
lary advancement.152 The results indicated that patients
without cleft palate have a very low risk of deterioration of
VP function. Patients with a repaired cleft palate who had
adequate VP function before Le Fort I advancement were
also at lower risk. However, 11 of 15 of the study patients
with a repaired cleft palate and a preoperative rating of
borderline VP closure acquired surgically induced symp­
tomatic VPI after Le Fort I advancement. Patients who were
considered to have inadequate VP closure before surgery
remained so after surgery. For most patients, the extent of
preoperative competence of the VP sphincter before Le Fort
I advancement predicted the competence of the VP sphinc­
ter after surgery (as documented by videofluoroscopy and
nasoendoscopy).
Kummer and colleagues reported on VP function in
two different patient groups: those with repaired clefts and
those without clefts who underwent maxillary Le Fort I
advancement with or without vertical change.71 The mea­
sured change in VP function was not clinically significant.
They concluded that “Le Fort I maxillary osteotomy has a
negligible effect on velopharyngeal function in both cleft
and non-cleft cases.”71
Vallino discussed 34 patients without clefts before and
at intervals after orthognathic surgery that included Le Fort
I osteotomy.129 The VP port area was measured in the study
patients before and at intervals (i.e., 3, 6, 9, and 12 months)
after Le Fort I osteotomy. The estimation of the size of the
VP port area was obtained with the pressure-flow technique

259
CHAPTER 8  Speech, Mastication, and Swallowing Considerations in the Evaluation and Treatment of Dentofacial Deformities
Both before and after Le Fort I osteotomy, VP function
is rated as adequate, borderline, or inadequate:
• Adequate function is defined as normal nasal resonance,
normal nasal air emission, and adequate VP closure
during speech.
• Borderline function is defined as normal nasal resonance
or clinically insignificant hypernasality, inaudible nasal
air emission (via mirror test), and borderline or marginal
VP closure during speech. Patients with this level of
functioning usually have small pinhole gaps in the VP
valve through which bubbles, barium, or mucus is
observed during videofluoroscopy, nasoendoscopy, or
both.
• Inadequate function is defined as clinically significant
hypernasal resonance, nasal air emission, and VP insuf­
ficiency during speech.
Patients without clefting and those with repaired cleft
palates who present with maxillary deficiency and adequate
preoperative VP closure seem to have enough adaptability
in the pharyngeal and soft palate muscles to maintain VP
closure after Le Fort I advancement. In general, patients
with either a repaired cleft palate or those who have under­
gone uvulopalatopharyngoplasty and who have only bor­
derline VP closure do not have the same adaptability of the
soft palate musculature to achieve valve closure after Le Fort
I advancement. Thus, they are at higher risk for the develop­
ment of clinical VPI. Patients with repaired cleft palates and
maxillary deficiency or those with obstructive sleep apnea
who have undergone uvulopalatopharyngoplasty and who
are considered to have inadequate VP closure before Le Fort
I advancement are expected to have the same degree of poor
closure after surgery.
Conclusions
When managing a dentofacial deformity with malocclu­
sion, the achievement of a successful outcome and a high
level of patient satisfaction requires a thorough understand­
ing of issues related to speech, mastication, and
swallowing.
A review of the literature shows significant associations
between misarticulated speech and Angle Class II, Angle
Class III, and anterior open-bite malocclusions. As long as
the other aspects of the speech mechanism are not at fault,
the correction of misarticulations through successful ortho­
dontics and jaw surgery is the rule.
A competent VP valve is also an important aspect for the
production of intelligible speech. The individual with a
repaired cleft palate and maxillary deficiency who is only
able to achieve borderline VP closure is at higher risk for
the development of VP insufficiency after Le Fort I
advancement.
With interdisciplinary evaluation that takes into account
speech, mastication and swallowing, the most effective care
can be rendered to the individual with a jaw deformity and
malocclusion.
described by Warren and Dubois.139 All study patients dem­
onstrated VP port areas that measured between 0 and
0.49 cm2 both before and after surgery across all speech
tasks, which indicated adequate VP competence. The author
concluded that the Le Fort I osteotomies carried out in
patients without clefts did not alter the VP valve or cause
hypernasal speech.
Watzke and colleagues evaluated VP function with the
use of aerodynamic testing before and at least 1 year after
Le Fort I maxillary advancement in 24 adolescents with
repaired cleft palates.144 Five of these patients (23%) dem­
onstrated VP deterioration, whereas another five (23%)
showed improvement after Le Fort I advancement. Interest­
ingly, those patients with a pharyngeal flap in place had a
higher incidence of improved VP function after surgery. Of
the five (23%) that showed VP deterioration, four had
adequate VP function and one had borderline VP function
preoperatively. Fourteen (46%) of the patients with clefts
showed no significant change in VP function as a result of
Le Fort I advancement.
Janulewicz and colleagues completed a retrospective
study that evaluated VP function in patients with repaired
cleft lips and palates (N = 54) who underwent maxillary Le
Fort I advancement.64 The authors documented a significant
deterioration of VP function in many of the patients with
clefts after Le Fort I advancement. There was also an increase
in hypernasality, which further supported the findings of
VP deterioration in a subgroup of the patients with repaired
clefts after Le Fort I advancement. The authors also found
improvements in hyponasality as compared with in preop­
erative values, which was attributed to a decrease in nasal
airflow obstruction after maxillary advancement.
Velopharyngeal Evaluation Among Individuals
with Repaired Cleft Palates and Maxillary
Deficiencies Undergoing Le Fort I
Advancement
A variety of methods for the assessment of VP function have
been described.57,62,86,89,90,93,94,99,100,105,115,119,140,152 A protocol
for the evaluation of patients undergoing orthognathic
surgery has been advanced by the American Cleft Palate-
Craniofacial Association in Parameters for Evaluation and
Treatment of Patients with Cleft Lip/Palate or Other Cranio­
facial Anomalies (American Cleft Palate-Craniofacial Asso­
ciation, Revised edition 2009 ).
Witzel also developed a protocol for the evaluation of
VP function in adolescents and adults after palate repair to
anticipate alterations in the VP sphincter after maxillary Le
Fort I osteotomy.154 She recommends a routine speech
assessment that includes instrumentation evaluation of VP
function, preferably with nasoendoscopy or, as a second
choice, videofluoroscopy. After surgery and sufficient time
for healing (i.e., 6 to 12 months), a final assessment of
articulation and VP function can be carried out. At that
time, if VP function is inadequate, definitive management
can go forward (e.g., pharyngeal flap surgery or the revision
of a flap that is already in place).

260
SECTION 1  Basic Principles and Concepts
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264

9
Temporomandibular Disorders: Effects
of Occlusion, Orthodontic Treatment,
and Orthognathic Surgery
JEFFREY C. POSNICK, DMD, MD
• Incidence of Temporomandibular Disorders
in the General Population and the Basic
Treatment Approach
• Mandibular Range of Motion
• Review of Occlusal Factors and Association
with Temporomandibular Disorders
• Occlusal Conditions More Frequently
Associated with Temporomandibular
Disorders
• Orthodontic Treatment and Its Effects on
Temporomandibular Disorders
• Association of Jaw Deformities, Orthognathic
Surgery, and Temporomandibular Disorders
• Brief Overview of Okeson’s Thinking About
Temporomandibular Disorders and the
Effects of Occlusion
• Personal Thoughts About the Role of Open
Joint Procedures for Temporomandibular
Disorders
• Conclusions
average of 55% demonstrates at least one clinical sign.*
Schiffman and colleagues completed a cross-sectional epi­
demiologic study that indicated that, at any given time,
between 40% and 75% of individuals who were not
currently seeking treatment had at least one sign of TMD,
and about one third of individuals reported at least one
symptom of TMD.296 Mongini and colleagues documented
a prevalence of TMD symptoms in children and teenagers
of 12% and 20%, respectively.210 Wanman and colleagues
showed an incidence of joint noise in young adults in their
late teens to be as high as 17.5% over a 2-year period.345
TMDs remain a frequent cause of visits to primary care
physicians, otolaryngologists, internists, and pediatricians.
Despite the high incidence of TMDs, their natural history
suggests that, in up to 40% of patients, symptoms resolve
spontaneously.296
TMD includes various signs and symptoms of the tem­
poromandibular joint (TMJ), the masticatory muscles, and
related structures (Figs. 9-1 through 9-8). These may include
a spectrum of referred head and neck pain; joint noise (e.g.,
popping, clicking, crepitus); reduced or altered mandibular
range of movement as a result of muscle spasm or disc
displacement; condylar head erosion; and direct pain on
palpation of either the TMJ or the masticatory muscles. The
signs and symptoms associated with TMDs can also lead to
misdiagnosis.16,112,171,216,342
A wide variety of often contradictory “conservative”
treatment modalities (i.e., non-invasive or potentially
Incidence of Temporomandibular
Disorders in the General Population
and the Basic Treatment Approach
The prevalence of temporomandibular disorders (TMDs) in
the general population as reported in the literature varies
widely. It is estimated that an average of 32% of the popula­
tion reports at least one symptom of TMD, whereas an
*References 22, 24, 39, 40, 50, 80, 81, 83, 94, 95, 116-118, 120, 122,
126, 139, 147, 148, 151, 161, 170, 173, 175-177, 181, 183, 190-195,
199, 207, 214, 218, 220-221, 223, 244, 251, 252, 262, 264, 270, 277,
300, 301, 319, 326, 343, 345, 348
Text continued on p. 269

265
CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
• Figure 9-1  A, Intraoral frontal view of dentition juxtaposed with the underlying alveolar bone. B, Intraoral lateral view of dentition juxtaposed
with the underlying alveolar bone. From Okeson JP: Management of temporomandibular disorders and occlusion, St. Louis, 2012, Elsevier,
p 3, Figures 1-1, A and B, 1-3, and 1-4.
A1
A2
B1
B2
• Figure 9-2  Lateral view of the craniofacial skeleton. From Okeson JP: Management
of temporomandibular disorders and occlusion, St. Louis, 2012, Elsevier, p 4, Figure 1-5.
Parietal
bone
Occipital
bone
Mandible
Zygomatic bone
Maxilla
Nasal bone
Sphenoid
bone
Temporal
bone
Frontal bone

266
SECTION 1  Basic Principles and Concepts
• Figure 9-3  Bony structures (components) of the temporomandibular joint. MF, Mandibular fossa; AE, articular eminence;
STF, squamotympanic fissure. From Okeson JP: Management of temporomandibular disorders and occlusion, St. Louis, 2012,
Elsevier, p 4, Figure 1-12.
MF
AE
AE
AE
MF
STF
• Figure 9-4  Anterior cross-sectional view of the articular disc, the fossa, and the condyle. A, Illustration. B, Cadaver speci­
men. The disc adapts to the morphology of the fossa and the condyle. LP, Lateral pole; MP, medial pole. From Okeson JP:
Management of temporomandibular disorders and occlusion, St. Louis, 2012, Elsevier, p 8, Figure 1-14.
DISC
MP
LP
B
A
LP
MP
DISC

267
CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
• Figure 9-5  A, Lateral view illustrations and B, cadaver specimen views of normal movement of the condyle and disc during vertical mouth
opening. As the disc moves out of the fossa, it rotates posteriorly on the condyle. First, rotational movement occurs (predominantly in the lower
joint space). After that, translation takes place (predominantly in the superior joint space) as mouth opening continues. A from Okeson JP:
Management of temporomandibular disorders and occlusion, St. Louis, 2012, Elsevier, p 17, Figure 1-30. B courtesy Terry Tanaka, MD, San
Diego, Calif.
A
B

268
SECTION 1  Basic Principles and Concepts
• Figure 9-6  Illustrations of the normal functional movement of the condyle and disc during the full range of opening and closing. The
disc is rotated posteriorly on the condyle as the condyle is translated anteriorly out of the fossa. The closing movement is the exact
opposite of the opening movement. From Okeson JP: Management of temporomandibular disorders and occlusion, St. Louis, 2012,
Elsevier, p 19, Figure 1-31.
1
5
2
8
3
7
4
6

269
CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
• Figure 9-7  Illustration of rotational movement of the mandible. This
movement occurs with the condyles in the terminal hinge position. This
pretranslation opening will occur until the anterior teeth are approxi­
mately 20 to 25 mm apart. From Okeson JP: Management of tem­
poromandibular disorders and occlusion, St. Louis, 2012, Elsevier,
p 64, Figure 4-7.
• Figure 9-8  The second stage of movement during mouth opening
is illustrated. Note that the condyle is translated down the articular
eminence as the mouth rotates open to its maximum limit. From
Okeson JP: Management of temporomandibular disorders and occlu­
sion, St. Louis, 2012, Elsevier, p 64, Figure 4-8.
reversible) have been recommended to alleviate the
symptoms of TMD and to prevent recurrence.* Enthusiasm
by clinicians for the direct surgical alteration of the struc­
tures that comprise the TMJ to treat TMD have waxed
and waned over the past half century.60,71,141,143,200,222,241,344
Occlusal factors (i.e., degrees of malocclusion) are
often claimed to be associated with TMD. Although it is
sometimes stated that orthodontic treatment increases the
prevalence of TMD, it is also claimed that orthodontic
maneuvers (for at least some types of malocclusion)
may reduce the signs and symptoms of TMD. Studies
document that the correction of a baseline jaw defor­
mity
with malocclusion through orthodontics and
orthognathic surgery improves the presenting TMD in the
majority of the treated patients, whereas a minority get
worse.6,29,31,67,102,131,152,232,236,347,349,356,359 This is described in
greater detail later in this chapter.
Mandibular Range of Motion
The expected normal mandibular range of motion and
inter-incisor mouth opening is discussed periodically in the
literature.9,70,93,115,146,179,197,234,235,249,308,309,311-313,315,316,318 Even
a 6-year-old child can often open the mouth to a maximum
40 mm or more. Measurements of maximum vertical
mouth opening with and without discomfort are considered
useful parameters of TMJ health. A restricted mouth
opening is considered by many to be a distance of less than
40 mm. Only 1.2% of young adults open their mouths less
than 40 mm. However, 15% of the healthy elderly popula­
tion open their mouths less than 40 mm. Any lateral or
protrusive movement of less than 8 mm is considered
restricted, although the significance of this measurement is
unclear.
Review of Occlusal Factors
and Association with
Temporomandibular Disorders
Clinicians from a spectrum of medical and dental specialties
often consider malocclusion to be the major etiologic
factor of TMD.† An assumed strong association between
TMD and the malpositioning of the teeth serves as one
reason why the diagnosis and treatment of TMD is gener­
ally considered within the purview of dentistry. Many of
the therapeutic options for the treatment of TMD are
based on the idea of “normalizing” or “neutralizing” the
*References 10, 13, 20, 30, 53, 65, 72, 82, 91, 97, 113, 119, 142, 204-
206, 213, 219, 238, 266, 297, 324, 328, 336, 338, 339, 360
†References 1, 4, 5, 8, 11, 12, 14, 15, 17, 21, 23, 26-28, 37, 38, 41, 43,
44, 51, 56-58, 63, 64, 78, 79, 85-88, 92, 99-101, 106, 114, 125, 129,
130, 132, 133, 136, 140, 149, 153, 162, 163, 178, 186, 188, 196, 198,
201, 202, 208-210, 215, 217, 233, 239, 242, 243, 246, 248, 250, 254-
261, 263, 265, 269, 278, 280, 283-287, 298, 299, 302-307, 310, 314,
317, 321, 327, 333, 337, 341, 346, 351, 357

270
SECTION 1  Basic Principles and Concepts
occlusion.135,355 Common treatment approaches to do so
include the reversible use of an occlusal appliance or defini­
tive techniques such as occlusal adjustment (equilibration),
restorative dentistry, orthodontics, and orthognathic
surgery. Concurrently, it is also true that either the onset of
TMD or the worsening of current symptoms is frequently
blamed on any one of the previously mentioned treatment
regimens.
The dental literature contains clinical studies and reports
that claim there are causal relationships between occlusal
factors and the symptoms and signs associated with TMD.
Egermark-Eriksson and colleagues examined 402 children
and reported an association between signs and symptoms
of TMD, specific malocclusions (i.e., Class II, Class III,
anterior crossbite, and anterior open bite), and occlusal
supra-contacts.87 Brandt studied 1342 children and found
a correlation between TMD and degrees of overbite (deep
and open) and overjet.33 Nilner examined 749 teenagers and
young adults and reported an association with centric rela­
tion (CR)–centric occlusion (CO) discrepancies (i.e., slides),
balancing-side contact slides, and symptoms and signs of
TMD.220 Confusion in the literature arises as independent
research studies have drawn contrary conclusions. DeBo­
ever and colleagues examined 135 individuals with signs
and symptoms of TMD and found no specific associations
with malocclusion.59 Gunn and colleagues similarly found
no association between TMD and occlusion in 151 migrant
children that they studied.121 Dworkin and colleagues
examined 592 individuals within a specific health mainte­
nance organization and found no association between TMD
signs and symptoms and specific occlusions.80
In their review article, Seligman and Pullinger pointed
out that the majority of existing clinical research (up to
that point in time) did not support a clear relationship
between occlusion and TMD symptoms.302 They further
clarified that the majority of published research relied
on symptom-based data rather than discrete disease classi­
fications. Seligman pointed out that symptoms like joint
sounds (e.g., popping, clicking, crepitus) and pain (e.g., in
the TMJ region and the masticatory system) lack specific­
ity.303 In addition, most published studies did not differen­
tiate between TMD diagnostic categories (e.g., disc
displacement, myalgia, TMJ osteoarthritis). Most published
studies also suffered from a lack of or an inadequate control
group. Seligman and colleagues attempted to avoid these
shortcomings by completing a multifactorial analysis of the
risks and relative odds of an individual having a TMD as a
function of 1 of 11 common occlusal features.259,304 They
looked for correlations between each of these 11 specific
occlusal factors (Box 9-1) and 1 of 6 TMJ diagnostic catego­
ries (Box 9-2), including asymptomatic normal controls
without TMD.259
The asymptomatic control subjects (N = 147) were con­
sidered the reference standard because they were without
current symptoms or signs of TMD and because they had
no history of TMD. Occlusal findings in the symptomatic
group showed wide variations, including the following:
*Data from Pullinger AG, Seligman DA, Gornbein JA: A multiple logistic
regression analysis of the risk and relative odds of temporomandibular
disorders as a function of common occlusal features. J Dent Res
72:968–979, 1993.
• BOX 9-1 
Occlusal Features and Factors to Consider
in TMD*
1. Anterior open bite
2. Maxillary lingual posterior crossbite
3. Retruded centric position–inter-contact position slide
length
4. Retruded centric position–inter-contact position slide
asymmetry
5. Unilateral retruded centric position contact
6. Overbite
7. Overjet
8. Dental midline discrepancy
9. Number of missing posterior teeth
10. First molar relationships (i.e., the greater of the
mesiodistal maxillary discrepancies at the first molar
location)
11. Right versus left first molar position asymmetry
*Data from Pullinger AG, Seligman DA, Gornbein JA: A multiple logistic
regression analysis of the risk and relative odds of temporomandibular
disorders as a function of common occlusal features. J Dent Res
72:968–979, 1993.
• BOX 9-2 
Temporomandibular Joint Diagnostic Categories
to Consider in TMD*
1. Disc displacement with reduction (N = 81)
2. Disc displacement without reduction (N = 48)
3. Temporomandibular joint osteoarthrosis with disc
displacement history (N = 75)
4. Primary osteoarthrosis (N = 85)
5. Myalgia only (N = 124)
6. Asymptomatic normals (N = 147)
• Overjets ranging from –1 to +6 mm
• Overbites ranging from –2 to +10 mm
• Midline discrepancies of up to 5 mm
• Anteroposterior molar relationships from –6 to +6 mm
• Molar asymmetries of 0 to 6 mm
• CR–CO slides of up to 2 mm
There were also a wide variety of crossbites, asymmetrical
slides, posterior contacts, and severe attrition facets in the
control group. Interestingly, no anterior open bites were
found in the control group.
The authors concluded that what have been traditionally
considered malocclusions cannot be used to define or

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CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
Overjet (>6 to 7 mm)
In the patients that were studied, an overjet of more than
4 mm was more likely to be associated with osteoarthritis.
Only when the overjet was more than 6 mm was there an
association with disc displacement. The occurrence of a
progressive overjet in adults would be suggestive of active
condylysis. It was not stated in what percentage of those
individuals with significant overjet (i.e., >6 to 7 mm) the
occlusal feature was part of a developmental jaw deformity
rather than occurring secondarily only after condylysis with
a loss of condylar height.
Centric Relation–Centric Occlusion Slides
Limited occlusal slides (i.e., 1 mm) were common in all
patient groups, including the normal controls. CR–CO
slides of more than 2 mm were only found in the patients
with TMDs. Pullinger found that larger slides were fre­
quently associated with osteoarthritis of the condylar head.
He questioned the advisability of the clinicians’ automatic
attempt to “relieve” the occlusal slides in all individuals—
whether by irreversible (e.g., occlusal equilibration, ortho­
dontics, surgery, restorative dentistry) or reversible (e.g.,
occlusal splints) means—because the observed slide may be
either adaptive or inconsequential.260
predict either individuals with TMD or those who are or
will become asymptomatic. No single occlusal factor was
able to differentiate a TMD patient from a healthy subject.
The authors did identify four specific occlusal features that
occurred mainly in individuals who were symptomatic with
TMD (see diagnostic categories 1 through 5) and that were
rarely found in those who were asymptomatic for TMD (see
diagnostic category 6). The occlusal features that primarily
occurred in individuals with symptomatic TMD included
the following:
1. The presence of a skeletal anterior open bite
2. CR-CO slides of more than 2 mm
3. Overjets of more than 4 mm
4. Five or more missing and unreplaced posterior teeth
Pullinger and colleagues concluded that occlusion
cannot be considered the most important factor in the defi­
nition of TMD but that specific occlusal factors do make
biologic contributions to TMD and thus cannot be
ignored.254-261 In most individuals, they observed that the
human biologic system will adapt to a variety of malocclu­
sions in an attempt to achieve TMJ stability. The authors
surmised that some occlusal features will place greater
adaptive demands on the individual’s biologic system than
others. Although most individuals are able to compensate
for their occlusal disharmony without problems, adaptation
for others may lead to a greater risk for TMD. On the
basis of this data, the authors stressed the importance of
five occlusal conditions, which in isolation or combination
are more likely to reach the threshold that exceeds adapta­
tion for an individual and therefore results in TMJ dysfunc­
tion. The high-risk malocclusions are discussed later in
this chapter.
Occlusal Conditions More
Frequently Associated with
Temporomandibular Disorders
Anterior Open Bite
Research by Pullinger and colleagues showed a strong
relationship between osteoarthritis of the condylar head
with a loss of condylar height and an anterior open-bite
malocclusion.254-261 Interestingly, anterior open bite was
not commonly associated with disc displacement disorders
with or without reduction. Myalgia (i.e., masticatory muscle
discomfort) was also a frequent symptom among patients
with an anterior open bite. It is not stated in what percent­
age of individuals the anterior open-bite malocclusion
occurred only secondarily as a result of osteoarthritis
followed by a loss of condylar height with clockwise
rotation of the mandible. Therefore, it is unclear what per­
centage of the examined individuals with anterior
open bites had these finding as part of a developmental
jaw deformity.
NOTE:  The studies by Pullinger and colleagues
seem to confirm that the occlusal features of anterior
open bites; overjets of more than 6 mm; and CR–CO
slides of more than 2 mm are frequently seen in
conjunction with osteoarthritis (i.e., loss of condylar
height) and less commonly seen with disc displacement
disease. Unfortunately, it is not clearly stated which came
first: a developmental deformity with malocclusion and
then osteoarthritis or condylysis with the loss of
posterior facial height that results in a secondary jaw
deformity with malocclusion.
Unilateral Maxillary (Lingual) Crossbite
The occlusal feature of unilateral maxillary crossbite occurs
in about 10% of the adult population, and it is frequently
found in association with TMJ disc displacement with or
without disc reduction. Approximately 25% of the patients
with non-reducing disc displacements were found to have
unilateral maxillary lingual crossbites. This indicated to
Pullinger and colleagues that disc displacement may be a
biologic adaptive response of the individual to a unilateral
maxillary lingual crossbite.260 The investigators theorized
that these individuals may later be prone to osteoarthritis.
They suggested that the orthodontic treatment of a unilat­
eral crossbite discovered during childhood should be con­
sidered as a preventative measure to reduce the adaptive
demands on the masticatory system. They did not come to
the same conclusion for the correction of a longstanding

272
SECTION 1  Basic Principles and Concepts
of) the osteoarthritic changes. Interestingly, when open
bites are observed in children, they are rarely associated
with TMJ symptoms. In the pediatric population, the
majority of observed open bites represent a developmental
jaw deformity rather than a result of osteoarthritis. Never­
theless, it is recommended that, when either a child or an
adult is found to have an anterior open bite, radiographic
analysis of the condylar head should be undertaken to check
for osteoarthritic changes.
Orthodontic Treatment and Its Effects
on Temporomandibular Disorders
Review of the Literature
The relationships among malocclusion, orthodontic treat­
ment to improve the occlusion, and the effects on TMD is
discussed frequently in the literature.* A spectrum of orth­
odontic treatment philosophies has been championed by
individual practitioners on the basis of presumed effects on
TMD. The longitudinal nature of orthodontic treatment,
which is often carried out over several years, means that a
changing TMD history would also be expected in a control
group that is not simultaneously undergoing orthodontic
treatment. Therefore, the occurrence of joint noise (e.g.,
popping, clicking) or myalgia (i.e., masticatory muscle dis­
comfort) during orthodontic treatment may either be the
result of the treatment or consistent with the natural history
of the untreated individual.
Sadowsky and colleagues reported on 75 adult study
patients who had undergone orthodontic treatment with
full appliances during adolescence at least 10 years earlier.290
The treated group was compared with a group of 75 similar
adults with untreated malocclusions. The authors also went
on to increase both their control and subject groups and to
report these additional findings several years later.291 In the
two sequenced studies, respectively, 15% to 21% of the
treated subjects presented with one or more signs of TMD
(e.g., joint noise), and 29% to 42% had at least one or more
symptoms of TMD. There were no statistically significant
differences between the treated and untreated (control)
groups.
Larsson and colleagues evaluated 23 individuals who
had undergone orthodontic treatment during adolescence
at least 10 years earlier.172 Mild TMD was recorded in 8 out
of 23 (35%) of the patients, whereas only 1 (4%) had severe
TMD. The authors compared this with published epide­
miologic controls and stated that there was no difference in
the incidence of TMD in the treated group versus the
control group.
Dahl and colleagues examined 51 subjects 5 years after
the completion of orthodontic treatment and compared
them with an untreated control group.54 The authors found
unilateral posterior crossbite in an adult, because skeletal
adaptation would have already occurred. Unfortunately, the
investigators did not clarify if the crossbites in their study
patients were the result of developmental jaw deformities
(e.g., asymmetrical mandibular excess) or simply due to the
malpositioning of the teeth. They did not specifically
comment on whether orthognathic surgery should be
carried out in conjunction with orthodontics (if needed) in
young adults to correct the presenting malocclusion as a
way to prevent the progression of TMD.
Missing Posterior Teeth (≥5)
The investigators found that, when five or more posterior
teeth were missing, the incidence of TMD increased. This
includes TMD categories of both osteoarthritis and disc
displacement with or without osteoarthritis. Pullinger and
colleagues further claimed that, when two or four of the
“posterior teeth” (bicuspids) were removed as part of an
orthodontic treatment protocol, there was a negligible effect
on TMD.260 Other studies carried out by Kayser156 and
Witter354 have also documented acceptable masticatory
function after bicuspid extractions and orthodontic treat­
ment without increased signs and symptoms of TMD.
*References 2, 3, 19, 34, 35, 42, 45-49, 52, 68, 69, 84, 89, 90, 104,
107-109, 127, 134, 137, 138, 150, 155, 159, 164, 168, 169, 182, 184,
185, 203, 224, 237, 240, 245, 253, 268, 271-276, 279, 281, 282, 288-
291, 323, 325, 329-332, 334, 352, 358
NOTE:  The multifactorial analysis of occlusal factors
and TMD disease categories carried out by Pullinger and
colleagues showed that, except for the few clearly
defined occlusal features described previously, there was
a low probability of a malocclusion being associated
with TMD. Seligman and colleagues estimated that the
overall contribution of occlusal factors for the defining of
patients with TMD was only in the range of 10% to
20%.302 The corollary is that 80% to 90% of the causative
factors cannot be explained by patients’ presenting
malocclusions.
In the Pullinger and Seligman study, it must be assumed
that many of the significant overjets observed in the adult
subjects were secondary deformities after condylar resorp­
tion (i.e., condylysis).260 The authors did not present evi­
dence to suggest that the presence of significant overbite or
overjet plays a role in the pathophysiology of non-arthritic
disorders of the TMJ, and they did not show that it was a
causative factor in the observed osteoarthritis. They do
believe that a combination of unilateral retruded centric
position in the presence of a clinically apparent retruded
centric position–inter-contact position slide may encourage
TMJ disc displacement but that unilateral retruded centric
position per se is not associated with TMD. They found
that lost molar support (i.e., 4 or 5 posterior teeth) may be
associated with osteoarthrosis. They concluded that a dental
midline discrepancy is not a predictor of TMD develop­
ment during adulthood. Anterior open bite is frequent in
the presence of condylysis or osteoarthritic changes in the
TMJ, but it is probably the result of (rather than the cause

273
CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
Orthodontic Treatment Undertaken
Specifically to Relieve
Temporomandibular Disorders
In everyday dental practice, the establishment of a preferred
intra-arch morphologic relationship of the teeth and then
the achievement of a satisfactory inter-arch relationship of
the teeth in one jaw to those in the other jaw (i.e., occlu­
sion) serves as the basis of treatment objectives. According
to a review of the literature, the establishment of a “normal”
occlusion through orthodontic mechanics or via other
dental means carried out for the purpose of eliminating or
preventing the worsening of TMD does not seem war­
ranted. Pullinger and Seligman have stated five potential
exceptions to this, which were described previously in this
chapter.255-261 McNamara and colleagues also stated that
prudent basic dental treatment objectives will generally
include the establishment of the six keys to ideal occlusion
as advocated by Andrews, when feasible; the establishment
of a limited CR–CO slide (i.e., <2 mm); the limiting of an
anterior open bite; the alleviation of significant overjet (i.e.,
>6 to 7 mm); the limiting of unilateral maxillary lingual
crossbites in children; and the establishment of a stable
posterior occlusion.
Orthodontic Treatment Undertaken
Specifically to Prevent
Temporomandibular Disorders
The literature also contains studies that suggest that specific
orthodontic maneuvers are effective for the prevention of
TMD. The studies by Magnusson and colleagues187-192 and
the study by Egermark and colleagues89 suggest pre­ventative
TMD advantages related to orthodontic occlusal correc­
tions. At 5 and 10 years, these investigators reevaluated a
group of 402 children and adolescents who had originally
undergone a full course of orthodontic treatment. The
Helkimo Index was used to measure clinical signs of TMD
in the now older age group (i.e., ≥25 years old). Interest­
ingly, the Helkimo Index outcome was lower in those who
had undergone orthodontic treatment as compared with the
control group. The studies by Dahl and colleagues and
Sadowsky and colleagues also demonstrated a trend
(although not a statistically significant one) toward the
decreased prevalence of TMD signs and symptoms in
orthodontically treated patients.53,290,291 These studies would
require further confirmation before accepting them as cred­
ible indications of a cause-and-effect relationship.
Summary of Effects of Orthodontic Treatment
on Temporomandibular Disorders
McNamara, Seligman, and Okeson summarize their under­
standing of the relationship between orthodontic treatment
and TMDs as follows203:
1. Signs and symptoms of TMD do occur in healthy
individuals.
no statistical differences in TMD between the two groups.
The number of subjects in both groups who had at least one
mild TMD symptom was relatively high (70% in the treated
group versus 90% in the untreated group). Mild symptoms
(e.g., joint noise), masticatory muscle fatigue, and stiffness
in the lower jaw were frequently observed in both groups.
A study by Smith and Freer examined 87 individuals
who were treated with full orthodontic bracketing during
adolescence.320 The treatment group (N = 87) was com­
pared with an untreated control group (N = 28). Four years
after treatment ended, TMD symptoms were found in 21%
of the treated group and 14% of the control group; this was
not found to be statistically significant. The one symptom
that was statistically more common in the treatment group
was a “soft click” (64% of the treated group versus 36% of
the untreated group).
Rendell and colleagues examined 462 individuals (90%
adolescents and 10% adults) who were undergoing orth­
odontic treatment in a graduate orthodontic dental school
clinic.267 With the use of a modified Helkimo Index, only
11 of the patients presented with TMD signs or symptoms
before treatment. Of the other 451 patients, during the
18-month study, none developed TMD signs or symptoms.
For those with preexisting TMD signs or symptoms (N =
11), there was no consistent change in the level of pain or
dysfunction reported during treatment.
Kremenak and colleagues reported pretreatment and
posttreatment TMD examination data from 109 patients
who were treated with full orthodontics.166,167 The Helkimo
Index scores were also compared. No statistically significant
differences were noted between the subjects’ pretreatment
and posttreatment scores. Ninety percent of the patients
had Helkimo Index scores that either remained the same or
improved, and 10% of the treated patients had scores that
worsened. The authors concluded that the orthodontic
treatment provided to their patients was not an important
etiologic factor for the development of TMD.
Hirata and colleagues examined 102 individuals before
and after orthodontic treatment for signs and symptoms of
TMD.128 They compared their treatment group with 41
untreated controls who were matched for age. The incidence
of TMD for the treatment and control groups was not
statistically significantly different.
Studies have also been carried out to evaluate specific
orthodontic treatment maneuvers and their relationship to
TMD symptoms and signs. The studied orthodontic
maneuvers include the type of orthodontic mechanics used;
extraction versus non-extraction therapy; orthodontic treat­
ment and posterior condylar displacement; and orthodontic
treatment focused on classic gnathologic principles.
NOTE:  In the studies that were reviewed, no
consistent benefits or causative factors of TMD were
identified on the basis of any specific orthodontic
treatment maneuvers carried out in the treatment group
as compared with controls.

274
SECTION 1  Basic Principles and Concepts
signs and symptoms have been examined in clinical studies
for the past several decades.* The quality of the research and
therefore the value of the conclusions vary. There are just
three longitudinal prospective controlled clinical trial
studies that have been carried out to assess the effects of
orthognathic surgery on TMD: the studies by Onizawa and
colleagues,232 Panula and colleagues,236 and Dervis and
colleagues.67
The study by Onizawa and colleagues sought to evalu­
ate changes in the symptoms of TMD after orthognathic
surgery.232 TMJ symptoms in preoperative orthognathic
patients (N = 30) were compared with those of healthy
control volunteers (N = 30). Changes in TMD symptoms
were evaluated in both groups at 3- and 6-month postopera­
tive intervals. The authors found no significant differences
in the incidence of TMJ sounds, deviation of mouth
opening, or tenderness on direct palpation of the TMJ
and masticatory muscles between patients who were sched­
uled to undergo orthognathic surgery and control volun­
teers. The treatment group did not report TMJ symptoms
significantly more often than the control subjects. At both
the 3- and 6-month postoperative intervals, half or more of
the treatment group showed no change in TMJ sounds,
deviation of mouth opening, or tenderness on palpation of
the TMJ or masticatory muscles. At each evaluation time
frame, some individuals in both the control group and the
study group exhibited improvement in TMJ symptoms,
whereas others showed a change for the worse. Findings of
postoperative TMJ sounds were observed to be associated
with a reduction of mandibular mobility (i.e., mouth
opening). The authors concluded that TMD symptoms
did not always show improvement after surgical correction
and that, for some patients, the symptoms changed for
the worse.
Panula and colleagues carried out research to study the
effects of orthognathic surgery on TMJ dysfunction.236
They completed a prospective follow-up study to examine
the influence of orthognathic procedures for the correction
of dentofacial deformities on signs and symptoms of TMJ
dysfunction. Sixty consecutive patients with dentofacial
deformities were examined preoperatively and then twice
after orthognathic surgery. The Helkimo Anamnestic and
Dysfunction Indices were also given as a questionnaire, and
the results were used as part of the determination. The
prevalence of headache was also assessed. The average
follow-up was 4 years after the initial preoperative examina­
tion. A group (N = 20) with a similar type and grade of
dentofacial deformity who elected not to undergo surgical
correction or any other occlusal therapy served as the control
group. The majority of the treatment group (73%) was
found to have signs and symptoms of TMJ dysfunction or
TMD during the preoperative examination. At the final
2. Signs and symptoms of TMD increase with age, particu­
larly during adolescence.
3. Orthodontic treatment performed during adolescence
generally does not increase or decrease the odds of devel­
oping TMD later in life.
4. The extraction of teeth as part of an orthodontic treat­
ment plan does not increase the risk of TMD.
5. There is no elevated risk for TMD associated with
any particular type of conventional orthodontic
mechanics.
6. Although a stable occlusion is a reasonable orthodontic
treatment goal, the inability to achieve a specific gnatho­
logic ideal occlusion does not result in TMD signs or
symptoms.
7. No specific method of TMD prevention has been dem­
onstrated to be effective.
8. When more severe TMD signs and symptoms are
present, simple forms of treatment can alleviate them in
most patients.
*References 6, 7, 25, 32, 33, 36, 55, 61, 62, 66, 67, 96, 98, 103, 105,
110, 111, 123, 124, 131, 144, 145, 154, 157, 158, 160, 174, 180, 187,
189, 211, 225, 226, 232, 236, 247, 292-295, 322, 335, 340, 347, 349,
350, 353, 356, 359
NOTE:  McNamara, Seligman, and Okeson suggest
that until reliable criteria are developed for the
treatment of TMD, the dental and medical professions
should be encouraged to manage presenting TMJ
symptoms with reversible therapies and to only consider
permanent alterations in the occlusion (for the specific
purpose of treating or preventing TMD) in patients with
very unique circumstances. This is in agreement with the
National Institure of Health conference guidelines which
states that reversible therapies should be used in the
primary treatment of TMD219
A summary of evidence-based systematic reviews of
TMDs was carried out by Rinchuse and McMinn.283 Their
systematic review resulted in the following conclusions:
1. Occlusion, which was once considered the primary and
sole cause of TMD, now at best is recognized as having
a secondary role in causing it.
2. Conventional orthodontic treatment that improves the
occlusion does not cause TMD.
3. The use of occlusal adjustments in orthodontic patients
has no evidence-based support for the treatment of
TMD.
4. There is evidence-based support for the use of occlusal
splints and biofeedback for the treatment of TMD.
Association of Jaw Deformities,
Orthognathic Surgery, and
Temporomandibular Disorders
Review of the Literature
The association of a jaw deformity with malocclusion and
the effects of orthodontic and surgical correction on TMD

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CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
3. Despite the trend for diminished signs and symptoms of
TMD after orthognathic surgery and orthodontics, indi­
viduals did not always show improvement; for some, the
symptoms changed for the worse.
4. After orthognathic surgery and orthodontic treatment,
a decrease in masticatory muscle tenderness was fre­
quent. A decrease in joint tenderness on palpation was
also a common occurrence.
5. In one of the three studies reviewed, a decrease in
maximum mouth opening was observed, but this was
not found to be of clinical importance.
There are other less rigorous reports and studies that can
be found in the literature that also analyze the effects of
orthodontics and orthognathic surgery carried out for the
correction of dentofacial deformities on TMD, including
the following:
Karabouta and colleagues reviewed 280 individuals with
different patterns of mandibular deformities (e.g., progna­
thism, retrognathia, open bite, asymmetry) who underwent
orthognathic surgery that included sagittal split ramus oste­
otomies of the mandible. Before surgery, the patients were
found to present subjective or objective TMJ dysfunction
symptoms with an incidence of 41%.154 After surgery, the
incidence of such symptoms in the same patients was
reduced to 11%. Individuals with no preoperative TMJ
dysfunction symptoms developed such symptoms with an
incidence of 4% after surgery.
White and colleagues set out to review the prevalence
of TMD in patients with dentofacial deformities who were
undergoing orthognathic surgery.349 Preoperatively, 49% of
their study group presented with TMD. After orthognathic
surgery, in the symptomatic patients, 89% had improved
temporomandibular function, 3% were unchanged, and
8% developed increased symptoms. Of the preoperative
asymptomatic patients, 8% developed TMD after surgery.
In the study group, TMD was significantly greater in
patients with Class II skeletal deformities as compared with
those with Class III tendencies. Overall, temporomandibu­
lar function generally improved in both treatment groups
(i.e., Class II and Class III) after successful surgery.
Hori and colleagues reported three individual (non-
consecutive) cases in which there was a worsening of preex­
isting TMJ dysfunction after sagittal split ramus osteotomy
of the mandible and 6 weeks of intermaxillary fixation.131
All three of their patients initially presented specifically
seeking treatment of malocclusion for the relief of TMD.
All three patients had active TMD before and after their
orthognathic procedures.
Aghabeigi and colleagues studied the effect of orthogna­
thic surgery on the TMJ of patients who presented with an
anterior open bite.6 This was a retrospective survey study of
patients (N = 83) who presented with an anterior open bite
who then underwent orthognathic surgery. The preopera­
tive prevalence of head and neck pain was 32%, TMJ dys­
function was found in 40% of patients, and limited mouth
postsurgery examination (i.e., 4 years after surgery), the
prevalence of TMD had been reduced to 60%. There was
also a dramatic improvement in the prevalence of headache,
which was initially experienced by 63% of patients and
reduced to 25% of patients at the final visit. The authors
concluded that signs and symptoms of TMD, including
pain (headache) levels, could be reduced with orthognathic
treatment. The risk of an orthognathic patient experiencing
new TMD was extremely low. No association could be
shown between TMD and any specific type or magnitude
of dentofacial deformity.
A study was conducted by Dervis and colleagues with
the objective of looking at the long-term prevalence of
TMD in individuals with a dentofacial deformity who then
underwent orthognathic surgery as compared with a control
group.67 Signs and symptoms of TMD in both the dento­
facial deformity patients and the control group were evalu­
ated before surgery, 1 week after release of intermaxillary
fixation, and 1 and 2 years after surgery with the use of the
Helkimo Anamnestic and Dysfunction Indices. At both the
initial preoperative examination and the final examination
(i.e., 2 years after surgery), signs and symptoms of TMD in
the patients who were undergoing orthognathic surgery
were compared with those of healthy control subjects. The
lengths of condylar pathways during opening and with
lateral and protrusive movements were also evaluated with
the use of axiography. A statistically significant reduction of
TMD symptoms and signs 2 years after surgery as com­
pared with before surgery was found. Interestingly, at the
initial examination, the patients with dentofacial deformi­
ties who were scheduled to undergo orthognathic surgery
did not report TMD signs and symptoms with a greater
frequency than other healthy control subjects. At the final
examination (i.e., 2 years after surgery), greater improve­
ments in TMD symptoms in the patients who had under­
gone orthognathic surgery were found as compared with
healthy control subjects. The authors also found a statisti­
cally significant decrease in masticatory muscle tenderness
after surgery. The authors concluded that the “functional
status” of the TMJ can be improved with orthognathic
surgery. There was no clear association between TMD
symptoms and a specific type or pattern of dentofacial
deformity.
When comparing and contrasting the three published
longitudinal prospective controlled studies that were con­
ducted to determine the effects of orthognathic procedures
on TMD symptoms and signs (i.e., Onizawa and col­
leagues,232 Panula and colleagues,236 and Dervis and col­
leagues67), several observations can be made:
1. Patients with dentofacial deformities who were sched­
uled to undergo orthognathic surgery were not found to
have significant differences in their TMD signs and
symptoms as compared with patients in the control
groups.
2. After orthognathic surgery and orthodontics, signs and
symptoms related to TMD were frequently improved.

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SECTION 1  Basic Principles and Concepts
have a high probability of the significant worsening of TMJ
dysfunction after surgery. This reported high incidence of
TMD and condylar resorption after orthognathic surgery is
contrary to all other studies reported in the literature.
Borstlap and colleagues reported about a consecutive
series of individuals who were scheduled to undergo sagittal
split ramus osteotomies for both Class II mandibular ret­
rognathism and Class III mandibular prognathism.31
Patients were reviewed preoperatively, immediately postop­
eratively, and at 3, 6, and 24 months postoperatively. Any
signs and symptoms of TMD were documented, including
clicking, preauricular pain, maximum mouth opening, pro­
trusive movements, and lateral excursions. The authors
documented that 56% of the patients with preexisting
TMD had relief of their signs and symptoms. Interestingly,
22% of individuals without preexisting TMD went on to
develop clinical signs or symptoms after surgery.
Bock and colleagues studied the importance of temporo­
mandibular function as a factor in the achievement of
patient satisfaction after orthognathic surgery.29 The authors’
orthognathic surgery patients (N = 102) were examined at
an average of 47 months after surgery. The average age of
their patients was 24 years. A patient satisfaction question­
naire and other modalities were reviewed, including the
Helkimo Index, clinical findings, nerve function parame­
ters, and the incidence of intraoperative and postoperative
complications. The results of their study showed that 91%
of patients were satisfied or very satisfied with their overall
orthognathic results. Answers to the questionnaires revealed
that only 79% of patients would undergo treatment again
(i.e., 21% of the patients would not). Statistically significant
differences were found in the Helkimo Index and in the
pain reported both in the TMJs and with jaw movements
between the satisfied and dissatisfied postoperative patients.
The authors surmised that the 21% of patients who would
not undergo treatment again were more likely to have a
greater degree of TMD and limitations with regard to man­
dibular range of movement. Statistically significant differ­
ences were found between those who were satisfied and
those who were dissatisfied with surgery on the basis of their
Helkimo Indices. Those with pain on palpation in the TMJ
region and those with pain experienced during motion of
the mandible were more likely to be overall dissatisfied with
the treatment. The persistence of postoperative symptoms
of TMD, including pain, was the single most important
correlation with low patient satisfaction.
Frey and colleagues studied the effects of mandibular
advancement procedures and counterclockwise rotation on
signs and symptoms of TMD.102 The study patients were
followed for a minimum of 2 years after orthognathic
surgery. A series of patients with Angle Class II malocclu­
sions (N = 127) who were undergoing sagittal split ramus
osteotomies with advancement and counterclockwise rota­
tion of the mandible were studied to evaluate signs and
symptoms of TMD at specific intervals after surgery. The
results of the study indicate that counterclockwise rotation
of the mandible was associated with more masticatory
opening was found in 7%. The overall prevalence of TMJ
signs and symptoms was not found to be significantly dif­
ferent after orthognathic surgery. In the study group, an
abnormal psychological profile was the most significant
factor associated with the presence and persistence of TMJ
pain. The authors concluded that orthognathic surgery does
not significantly influence TMD in patients with anterior
open bites. Female patients—particularly those with abnor­
mal psychological profile—were at higher risk for persistent
postoperative TMJ pain.
Westermark and colleagues studied a consecutive series of
individuals to understand the effects of orthognathic surgery
on the signs and symptoms of TMD.347 The authors sent a
survey questionnaire to a consecutive series of patients (N
= 1516) who initially presented with dentofacial deformities
and who then underwent orthognathic surgeries that were
performed by a group of experienced surgeons at a single
institution. The survey was given at least 2 years after
surgery. The questions asked in the survey related to joint
pain, chewing pain, joint noise, grinding, daytime head­
ache, and morning headache. Preoperatively, 43% of the
patients reported subjective symptoms of TMD; postopera­
tively, 28% of the patients did. This difference suggested an
overall beneficial effect of orthognathic surgery on TMD
signs and symptoms. Patients with Class II skeletal deformi­
ties did not improve as much as with those with Class III
skeletal prognathism.
Yamada and colleagues studied the incidence of condylar
morphologic change, disc displacement, and signs and
symptoms of TMD in individuals set to undergo orthogna­
thic surgery.359 The study showed preoperative condylar
morphologic change (unilateral or bilateral) in 36% of the
subjects and in 24% of each joint. Preoperative disc dis­
placement (unilateral or bilateral) was seen in 41% of the
subjects and in 30% of each joint. The percentage of con­
dylar morphologic change and disc displacement was higher
for individuals with anterior open-bite skeletal Class II
growth patterns and lower for patients with skeletal Class
III deformities.
Wolford and colleagues studied changes in TMD after
orthognathic surgery in a series of 25 patients who were
scheduled to undergo bimaxillary surgery.356 They used
magnetic resonance imaging and clinical verification of
TMJ articular disc displacement. This was a retrospective
evaluation with an average follow up of 2.2 years. Presurgi­
cally, 16% of the patients had only TMJ pain, 64% had
only TMJ sounds, and 20% had both TMJ pain and sounds.
Postoperatively, 24% of the patients had only TMJ pain,
16% had only TMJ sounds, and 60% had both TMJ pain
and sounds. Thirty-six percent of the patients had TMJ
pain preoperatively; this jumped to 84% after surgery. In
addition, the authors claimed that 6 out of 25 of their
patients (24%) developed condylar resorption postopera­
tively, thereby explaining the high incidence of observed
Class II open-bite malocclusion. The authors demonstrated
that patients with preexisting TMJ dysfunction who undergo
bimaxillary osteotomies via the techniques that they used

277
CHAPTER 9  Temporomandibular Disorders: Effects of Occlusion, Orthodontic Treatment, and Orthognathic Surgery
knee pathology in anticipation of improved function and
relief of pain have varied but are currently without consen­
sus. Therefore, a randomized clinical trial that included a
placebo group was designed by Moseley and colleagues to
address this controversy. To blind the placebo group, a
sham surgical procedure was designed as part of the study.
The placebo subjects were given a general or regional anes­
thetic, and incisions were made; however, the arthroscope
was not inserted into the joint, and no therapeutic proce­
dure was carried out. The results of the study were that
neither treatment group (i.e., lysis and lavage or arthro­
plasty) offered improved clinical outcomes as compared
with the placebo group for osteoarthritis. As a consequence
of this evidence-based study, many orthopedic surgeons
have changed treatment recommendations for their
patients. In any case, Medicare (i.e., the U.S. government
medical insurance plan for the elderly) made a decision
that it would no longer cover arthroscopy for osteoarthritis
of the knee. Restorative dentists, orthodontists, and orthogna­
thic surgeons should remain circumspect when advising
patients regarding irreversible treatment specifically for the
purpose of relieving TMD.
Brief Overview of Okeson’s Thinking
About Temporomandibular Disorders
and the Effects of Occlusion
Okeson believes that, during the normal use of the mastica­
tory system, either local or systemic events can occur that
may influence function.165,227-231 Each individual has a
varied ability to tolerate these events without any adverse
head and neck effects. It is likely that an individual’s
tolerance can be influenced by these local or systemic
factors. When an event exceeds the individual’s physiologic
tolerance, the system begins to reveal changes. Each com­
ponent of the masticatory system can tolerate a certain
amount of change. When functional change exceeds a criti­
cal level, alteration of the tissues begins. The tissue break­
down site is generally seen in the structure with the least
tolerance. Therefore, the breakdown site varies from indi­
vidual to individual. This is influenced by factors such as
the individual’s unique maxillofacial morphology, previous
head and neck trauma, and local tissue conditions. The
weakest link in the masticatory system will break first
(i.e. masticatory muscles, TMJs, supporting structures of
the teeth, the teeth themselves). Typically, the weakest struc­
tures in the system are the masticatory muscles; this is
evidenced by muscle tenderness and pain during mandibu­
lar movements.
When the TMJs are the weakened structures in the
system, the individual may experience joint tenderness and
pain. The TMJ can also produce sounds such as clicking or
grating. When the individual has increased muscle activity
(e.g., bruxism, grinding), then the next weakest link is fre­
quently either the supporting structures of the teeth (i.e.,
the periodontium) or the teeth themselves. The teeth may
muscle tenderness early after surgery, especially in those
who were undergoing more than 7 mm of advancement.
The combination of extensive mandibular advancement
with counterclockwise rotation was also associated with
increased TMD symptoms early after surgery. Interestingly,
all TMJ symptoms declined by 2 years after surgery. The
authors conclude that surgical advancement and counter­
clockwise rotation of the mandible (i.e., sagittal split ramus
osteotomy) is associated with a slight increase in masticatory
muscle discomfort during initial recovery. All symptomatol­
ogy tended to decline over time, which suggests that the
amount of advancement and the amount of mandibular
counterclockwise rotation should not be considered as risk
factors for the long-term development of TMD in patients
without preexisting symptoms.
Jung and colleagues retrospectively evaluated the effects of
bilateral intraoral vertical ramus osteotomies with setback
for the management of Class III skeletal patterns on symp­
toms that are associated with TMD.152 Patients were evalu­
ated preoperatively and at intervals (i.e., 1, 3, 6, 12, 18, and
24 months) after surgery for specific parameters, including
mouth opening, clicking, and TMJ pain. The authors
reported that 94% of those with preoperative joint noise
achieved resolution. After surgery, 8% of individuals who
were free of noise before surgery developed joint noise after­
ward. On average, mouth opening was 50 mm before
surgery and 49 mm 6 months after surgery. Joints that were
free of pain before surgery remained so. Those individuals
with preoperative TMJ pain remained free of pain at 18
months. The authors concluded that bilateral intraoral ver­
tical ramus osteotomy with setback as a method of manag­
ing Class III skeletal deformities was also effective for the
relief of undesirable TMJ symptoms (e.g., joint noise, pain)
without negatively affecting mouth opening.
Additional thoughts Concerning Effects
of Orthodontics and Orthognathic Surgery
on Temporomandibular Disorders
It may not be correct to conclude that orthodontic treat­
ment and orthognathic surgery carried out for the correc­
tion of a presenting jaw deformity with malocclusion are
the responsible factors for any observed reduction or reso­
lution of TMD signs and symptoms.18 During the decades
that have passed since McCarty and Farrar first defined the
diagnoses of internal derangement of the TMJ and then
described a disc repositioning procedure to treat it, quality
research to evaluate their recommended treatment has been
scant.200 The experience of orthopedic surgeons with regard
to the treatment of derangements of the knee should
remind us of the need for clinical practice to be based on
sound supporting evidence. Moseley and colleagues carried
out a controlled clinical trial of arthroscopic surgery (i.e.,
lysis and lavage or arthroplasty) for osteoarthritis of the
knee that should give us pause when considering irrevers­
ible TMD treatment.212 Clinician opinions regarding the
effectiveness of lysis and lavage or arthroplasty to manage

278
SECTION 1  Basic Principles and Concepts
A critical review of the literature suggests that outcomes
for open TMJ procedures are often unpredictable and may
result in further TMD.73-77 The success rate for “redo” open
joint surgery is even less favorable. Among the criteria for
an open joint procedure are the following: that the clinician
must be confident that the source of the pain or dysfunction
is arising from within the joint; that the appropriate use of
conservative measures has failed; that the current symptoms
are intolerable to a patient who is psychosocially stable; and
that a significant long-term success rate for the selected
open joint procedure in the specific patient can be assured.
Although an intracapsular lavage procedure with or
without limited debridement and lysis of adhesions to
relieve inflammation and improve function may be rela­
tively benign in experienced hands, disc repositioning and
discectomy have generally proven to be of little statistical
value as compared with conservative measures. The techni­
cal simplicity of disc repositioning and discectomy proce­
dures has lured many clinicians into offering them as
standard options; however, a significant long-term success
rate has not been documented.
The overall approach to TMD should aim to avoid
further harm to the joint and err on the side of appropriate
conservative management to relieve symptoms and to
achieve or maintain reasonable function for the long term.
Conclusions
It is estimated that an average of 32% of the population
will report at least one symptom of TMD and that an
average of 55% will demonstrate at least one clinical sign.
Historically, clinicians from a spectrum of medical and
dental specialties have considered occlusion to be the major
etiologic factor for TMD. A review of the literature suggests
that the overall contribution of occlusal factors to identify­
ing patients with TMD to only be in the range of 10% to
20%. The corollary is that 80% to 90% of the causative
factors among patients with TMD cannot be explained by
those patients’ occlusions.
The National Institude of Health conference guidelines
state that reversible therapies should be used for the primary
treatment of TMD. Despite these words of caution, studies
document that, for whatever combination of reasons, the
correction of an individual’s developmental jaw deformity
and malocclusion through successful orthodontics and
orthognathic surgery tends to have a positive effect on pre­
existing TMD in the majority of patients, whereas a minor­
ity of patients will get worse.
show mobility or wear (e.g., loss of enamel, breakdown of
restorations, fracture). Emotional stress seems to be a major
influence on bruxing activity.
According to Okeson, the occlusal condition can influ­
ence TMDs by way of two mechanisms. One mechanism
relates to the introduction of acute changes in the occlusal
condition (e.g., recent restorative dentistry with an uneven
alteration of the occlusal surfaces). Acute changes can lead
to a muscle co-contraction response that leads to a condi­
tion of muscle pain. Typically, in these circumstances, new
muscle engrams are developed, and the patient adapts with
little consequence. A second mechanism relates to a more
longstanding variation in the occlusal condition. In these
conditions, maximum intercuspation (i.e., centric occlu­
sion) results in the instability of the masticatory system
(e.g., a CR–CO discrepancy). The orthopedic instability is
not likely to withstand significant compressive loading
forces on the TMJs. Dental therapy (i.e., the alteration of
the occlusion) will only be helpful for the relief of TMDs
when it effectively relieves one of these conditions (i.e., the
muscle co-contraction response or the orthopedic instability
accompanied by loading forces).
Dr. Okeson concludes that, in general, conventional
orthodontic treatment is not an effective method for the
prevention of TMD. As a corollary, a review of the literature
suggests that patients who receive conventional orthodontic
therapy are at no greater risk for the development of TMD
than those who do not. According to Dr. Okeson’s work,
any dental or surgical procedure that produces an occlusal
condition that is not in harmony with a musculoskeletal
stable position of the joint can—but does not necessarily—
predispose the individual to these problems. Alternatively,
dental or surgical procedures that reduce one of these occlu­
sal conditions and restore harmony may improve the mas­
ticatory system.
Personal Thoughts About the Role of
Open Joint Procedures for
Temporomandibular Disorders
Unanswered questions remain: What is the appropriate
treatment for an individual with a persistent symptomatic
intracapsular TMJ disorder that has either not resolved
spontaneously or not responded to conservative therapy? In
these cases, what are the best studies to use to confirm the
diagnosis and then select the appropriate treatment
intervention?
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10
Nasal Airway Considerations
• Frequent Causes of Chronic Obstructive Nasal
Breathing
• The Effects of Respiratory Pattern and Jaw
Posture on Maxillofacial Growth
• Simultaneous Management of Chronic
Obstructed Nasal Breathing and the
Presenting Dentofacial Deformity
• Approaching the Nasal Airway Through
Le Fort I Down-Fracture
• Management of Residual Postoperative Nasal
Obstruction
• Effects of Maxillary Arch Expansion and Nasal
Floor Recontouring on the Airway
• Comprehensive Approach to Chronic Nasal
Airway Obstruction
• Case Presentation
• Conclusions
“Irregularities of the teeth being so frequently associated
with some pathologic obstruction of the nasal passages or
nasopharynx, this fact should ever be present in the
operator’s mind and suitable examination being made;
and in case [as is often found] the oral deformity be
complicated by the presence of hypertrophied faucal tonsils,
adenoid hypertrophies in the vault of the pharynx, or
obstruction of the nasal passages, the orthodontist’s work
can only be made complete by the assistance of a
rhinologist and laryngologist.” 2
—EDWARD H. ANGLE, MD, DDS (1907)
“The nasal fossae are bounded by the maxillary bones and
by bones attached to the maxillae; therefore deformities of
maxillary bones are bound to influence the size, shape and
patency of the nasal fossae. Nasal obstruction may be due
directly to deformity or to lack of development of the
maxillae. Any [intranasal] bony [obstructions] are
removed [surgically] until ample breathing space is
established. If nasal obstruction is due simply to lack of
size of the nasal fossae and there are erupted [permanent]
molar teeth [on each side], then the treatment consists
of placing a jackscrew across the mouth from one
upper molar to the other. As the screw is spread, the
intermaxillary suture opens, the maxillae separate, and the
nasal obstruction is relieved.” 10
—VILRAY PAPIN BLAIR, AM, MD, FACS (1914)
Frequent Causes of Chronic Obstructive
Nasal Breathing
Nasal septoplasty is a generic descriptor of the surgical cor­
rection of septal thickenings and deflections frequently carried
out to improve nasal airflow and sinus drainage (Figs. 10-1
and 10-2).3,7,20,30,52,53,57,75,80,88,89,91,93,94 Enlarged inferior turbi­
nates also commonly obstruct nasal breathing and interfere
The efficiency of care for the individual with a dentofacial
deformity requires the collaborative management of any
presenting upper airway obstruction, facial dysmorphology,
and malocclusion or dental rehabilitative needs. At the time
of orthognathic surgery, the surgeon has an opportunity to
further contribute to the patient’s quality of life by seam­
lessly addressing any longstanding breathing and sinus
drainage difficulties that coexist with the jaw deformity.
Breathing difficulties may range from isolated symptomatic
nasal airway obstruction to obstructive sleep apnea and
should not be overlooked. The impact and frequency of the
combined occurrence of nasal obstruction, sinus disease,
and maxillary deformity have been recognized and discussed
in established literature for well over 100 years:
in the Evaluation and Treatment
of Dentofacial Deformities
JEFFREY C. POSNICK, DMD, MD

288
SECTION 1  Basic Principles and Concepts
• Figure 10-1  A, Three-dimensional maxillofacial and coronal section computed tomog­
raphy scan views of a child with mandibular deficiency during late mixed dentition.
B, Three-dimensional maxillofacial and coronal section computed tomography scan
views of a teenager with maxillary deficiency and relative mandibular excess. For both
patients, the scans indicate a deviated nasal septum in combination with enlarged
inferior turbinates, with an expected increase in nasal airway resistance and diminished
breathing space.
A
B
with sinus drainage (Fig. 10-3). Hypertrophic inferior tur­
binates that are only minimally responsive to medical treat­
ment are best managed by partial (surgical) reduction.8,23,77
A tight nasal inlet or constricted pyriform apertures occur
in conjunction with a narrow maxillary arch (Fig.
10-4).58,86,90,95 An elevated floor of the nose is a frequent
finding in the presence of anterior vertical maxillary excess
(i.e., long face growth pattern) (Fig. 10-5).63,81,112 A scarred
nasal vestibule seen with a repaired cleft nasal malformation
may be another cause of persistent nasal obstruction (Fig.
10-6). Nasal septal deformities, inferior turbinate enlarge­
ment, a tight nasal inlet, and an elevated nasal floor all
commonly coexist with maxillary deformities (Figs. 10-7
and 10-8).1,12-14 Favorable access to the nasal septum, the
inferior turbinates, the pyriform apertures, and the nasal
floor to correct these airway obstructions and deformities is
possible through the Le Fort I down-fracture osteotomy
that is commonly used in orthognathic surgery (Figs. 10-9,
10-10, and 10-11).82-85
Maxillofacial literature has traditionally addressed
aspects of nasal obstruction, nasal anatomy, and sinus
drainage in the patient who is undergoing orthogna­
thic surgery, but often only in subjective and limited
ways.8,18,24,27,32,33,36,38,55,56,71,73,74,76,103,104,107 Authors tradition­
ally discuss the effects of Le Fort I osteotomies on nasal
morphology (i.e., aesthetics) and occasionally recommend
adjunctive soft-tissue techniques in the hopes of limiting
suboptimal aesthetics (e.g., the alar cinch stitch).37 Little
consideration is given to either baseline upper airway find­
ings or how the maxillary surgery may affect long-term nasal
breathing. Warren and colleagues discusses issues of nasal
airway changes after Le Fort I osteotomy with maxillary

289
CHAPTER 10  Nasal Airway Considerations in the Evaluation and Treatment of Dentofacial Deformities
• Figure 10-2  Sagittal midfacial illustration and coronal section computed tomography scan view of the skeletal (vomer
and perpendicular plate of ethmoid) and cartilage (quadrangular) components of the septum of the nose. The computed
tomography scan view indicates deviation and buckling of the septum, which obstructs the left side of the nose. Modified
from an original illustration by Bill Winn.
Septal deviation
Nasal bones
Quadrangular
cartilage
Vomer
Perpendicular plate,
ethmoid bone
• Figure 10-3  Sagittal midfacial illustration and coronal section computed tomography scan showing an axial view
of the turbinates. The CT scan view indicates asymmetrical inferior turbinate hypertrophy. Modified from an original
illustration by Bill Winn.
Inferior turbinate hypertrophy
Supreme
Superior
Middle
Inferior
Sphenoid
sinus
Opening of
nasolacrimal duct
impaction, advancement, and transverse widening.108 They
used a pressure flow meter to assess nasal airway breathing
before and after maxillary osteotomies.21,29 Turvey and col­
leagues recognized preexisting nasal obstruction in many of
their orthognathic patients.103 They suggested methods of
avoiding adverse effects on nasal airway resistance that may
result from Le Fort I maxillary osteotomy procedures.104
Moses and coworkers reported about a series of patients
who were treated for nasal obstruction and sinus drainage
difficulties after Le Fort I maxillary procedures were carried
out for long face growth patterns (e.g., vertical maxillary
excess with anterior open bite).71 They concluded that Le
Fort I impaction frequently aggravates preexisting nasal
airway obstruction and sinus disease. Williams and col­
leagues examined the nasal airway function (breathing)
in a consecutive series of subjects (n = 50) before and 5
months after undergoing (1) Le Fort I osteotomy with
advancement and vertical lengthening (2) maxillary seg­
mentation with transverse expansion (14 of 50 subjects,
28%); and (3) recontouring of the nasal floor and pyriform
rims with a rotary drill. Despite these favorable nasal airway
surgical maneuvers, when ignoring potential pathology of
the septum (e.g., buckling and deviation) and the inferior
Text continued on p. 295