Cẩm Nang Điều Trị Chỉnh Hình Hàm Mặt (Tiếp Cận Đa Chuyên Khoa)

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Handbook of Orthognathic Treatment
surgery, a dose of 10 mg p.r.n. which may be repeated
every 4 hours to control pain. Appropriate precau­
tions should be taken with the use of opiates. The use
of long acting local anaesthesia during surgery would
also reduce postoperative pain.
7.10.4  General postoperative care
Airway and breathing
It is essential to ensure that the airway is not ob­
structed following surgery. The reduction of oxygen
saturation in the blood, increased respiratory rates
and unequal expansion of the right and left lobes
of the lung are the manifestations of respiratory
obstruction (Figure 7.20). Antero-posterior chest
radiographs should be taken to confirm the diagno­
sis. Aspiration of blood into the main bronchus may
cause partial collapse of the affected position of the
lung. The application of 100% oxygen, nebulizers
and starting physiotherapy are essential. In some
cases aspiration of the blood clot using brochoscope
may be essential.
Circulation
Loss of blood and fluids should be monitored care­
fully preoperatively and during the first 24 hours
following surgery.
The application of urinary catheter is indicated in
long surgical procedure to monitor fluid balance. The
use of antiemetic medications as Metoclopromide
10 mg would reduce vomiting which is distressing to
patients and another cause for fluid loss. The intra­
venous infusion with Hartmann’s solution would
maintain fluid balance in addition to blood transfu­
d.  Electro-cardio gram and chest radiograph are
required for elderly patients or as deemed neces­
sary according to the medical history.
e. Despite the fact that blood transfusion is unlikely
following orthognathic surgery it is safe to group
and save blood before complex orthognathic
procedure.
f. The preoperative use of low molecular weight
heparin to avoid the risk of deep venous throm­
bosis would depend on the age, sex, BMI of the
patients as well as smoking habit, expected length
of the surgical and the need for iliac crest bone
graft.
7.10.3  Operative considerations
Minimise blood loss
Operative blood loss can be significantly reduced
with hypotensive anaesthesia and the application of
local anaesthesia with Adrenalin 1/80.000. The use of
antifibrinolytic agents and the use of bipolar dia­
thermy would minimise blood loss.
Minimise facial swelling (Antioedema)
Dexamethasone 8mg (Solumderon 250mg) is given
IV with the anaesthetic induction, this is repeated 6
hourly for the first 24 hours following surgery. The
intramuscular injection of a long acting steroid,
Depomedron 80mg, four hours after the last dose of
Dexamethasone would further reduce postoperative
facial swelling and facilitate recovery during this
crucial stage.
Pain
Subcutaneous or intravenous administration of an
opiate (morphine) may start immediately following
Figure 7.20  AP chest radiograph
showing the unequal expansion of
the right and left lobes of the lung
due to respiratory obstruction and full
expansion of both sides following
physiotherapy.

Basic orthognathic surgical procedures
139
reactions the soft callus is populated with cells of
osteogenic lineage to start bone formation between
the distracted segments. Ilizarov popularised distrac­
tion osteogenesis in long bones (Figure 7.21a) and
this method is used nowadays for lengthening the
jaw bones. The following are the basic principles of
this method for bone lengthening:
1. Bone cut
This should be performed at the site where bone
lengthening is required. The direction of the osteot­
omy line influences the pattern of bone formation.
The periosteum should be kept intact tomaintain the
blood supply and give the maximum osteogenic
potential to the site of distraction.
2. Vector of distraction
This is the pre-planned direction of separating the
two bony segments. Based on the vector distraction
osteogenesis could be mono-directional (antero-
posterior (Figure 7.21b), vertical (Figure 7.21c) or
medio-lateral (Figure 7.21d)), bi-directional (Figure
7.21e), or multi-directional (Figure 7.21f).
3. Latency period
This is the time interval following the osteotomy and
before starting distraction to allow the formation of
healthy blood clot and soft callus. This is usually
between four and seven days dependent on the type
of bone and the age of the patient.
4. Rate of distraction
This is the magnitude of separating the bone seg­
ments which is usually 1 mm/day. This also depends
sion as may be deemed necessary due to a significant
drop in the haemoglobin level.
Antibiotics
The use of intravenous antibiotics during a stay in
the hospital would minimise postoperative infection
especially in cases when bone grafts has been applied.
The use of postoperative antibiotics is limited to
grafted cases.
Feeding
Patients are encouraged to take clear fluids orally for
a few hours following surgery. Hartmann’s solution
may be continued for the first 24 hours to maintain
patients’ hydration. Patients are then instructed to
keep on fluids and soft diet for the first few days fol­
lowing surgery. A highly caloretic blended diet should
always be considered, Chlorhexidine 0.2% mouth
rinse should commence as soon as possible and main­
taining oral hygiene using a soft narrow tooth brush
is recommended.
7.11  Distraction osteogeneis
The method depends on a gradual and controlled
separation of two bony segments at a rate of 1 mm/
day. This creates an active metabolic environment for
formation of a healthy callus between the segments.
Through a cascade of osteogenic and haematopoietic
Figure 7.21a  Ilizarove device for
lengthening of bone by distraction
osteogenesis.
Figure 7.21b  Intra-oral distraction
device for antero-posterior
lengthening of the mandible.

140
Handbook of Orthognathic Treatment
Figure 7.21d  Mono-direction distraction of the body of
the mandible in medio-lateral direction.
Figure 7.21e  Bi-directional ditrsction osteogenesis to
lengthen the bertical height of the ramus and the
natero-posterior length of the body of the mandible.
Figure 7.21f  Multi-directional distraction osteogeneis
which allows moulding of the callus vertically, horizontally
and medio-laterally.
Figure 7.21c  Mono-direction vertical distraction of the
ramus of the mandible.
on the age of the patient and osteogenic potential of
the distracted tissue.
5. Frequency
This represents the number of steps/increments
required to achieve the distraction rate. In most of the
cases it is split into 0.5 mm every 12 hours. Increasing
the frequency of distraction and the number of incre­
ments would improve the quality of bone formation.
6. Retention period
After completion of the required lengthening of the
bone segment the distraction device is left in place
to allow the consolidation and remodelling of the
bone between the segments. This retention period is
dependent on the magnitude of distraction, the
patient’s age, and the quality of the formed bone.
This retention period is usually four times the length
of the active distraction phase.
7.11.1  Mandibular distraction osteogenesis
Indications
1. Severe mandibular retrognathism or hypoplasia
beyond the scope of advancement using a conven­
tional sagittal split osteotomy.
2. Deficiency of the vertical ramus height.
3. Mandibular asymmetry due to unilateral shortness
of the vertical height of the ramus or deficiency of
the antero-posterior length of the body of the
mandible in one side.
4. Narrow mandibular width.

Basic orthognathic surgical procedures
141
Figure 7.22a  Radiographs showing
the lengthening of the right vertical
height of the ramus using unilateral
extra-oral distraction osteogenesis and
the achieved correction of facial
asymmetry.
5. Following condylectomy to create a new condylar
process.
6. Segmental mandibular defect.
7. The need to avoid the harvest of autogenous bone
graft.
Mandibular lengthening by distraction osteogene­
sis can be achieved by using extra-oral devices, uni­
laterally (Figure 7.22a), or bilaterally (Figure 7.22b).
The main complications associated with extra oral
devices are the scarring, potential facial nerve
Figure 7.22b  Lateral cephalograph and profile photograph before and after correction of severe mandibular deficiency
using extra-oral bilateral mandibular distraction osteogenesis.

142
Handbook of Orthognathic Treatment
Figure 7.23  Bi-directional intra-oral distraction osteogenesis, one rod is used for antero-posterior distraction and the
other for the vertical adjustment.
Figure 7.24a  Postero-anterior
radiographs and facial photographs
before and after correction of facial
asymmetry due to deficiency of the
berticla height of the right ramus
using automatic continuous
distraction osteogenesis. Source:
Ayoub, A.F., Richardson, W. and
Barbenel, J.C. (2005) Mandibular
elongation by automatic distraction
osteogenesis: the first application in
humans. Brit J Oral Maxillofac Surgery,
43, 324–328. Reproduced with
permission of Elsevier.
damage, infection from the transcutaneous pins, lack
of acceptance by patients and finally the difficulty
that patients face socially. However, they offer the
advantage of better control of the distraction vector.
The use of intraoral devices (Figure 7.23) may inter­
fere with the application of oral hygiene measures
and patient co-operation is essential to avoid infec­
tion at the surgical site. Mandibular lengthening has
also been achieved using automatic continuous dis­
traction osteogenesis (Figures 7.24a, 7.24b), this

Basic orthognathic surgical procedures
143
Figure 7.24b  Panoramic radiographs before and after completion of the automatic continuous distraction osteogenesis
for correction of mandibular asymmetry. Source: Ayoub, A.F., Richardson, W. and Barbenel, J.C. (2005) Mandibular
elongation by automatic distraction osteogenesis: the first application in humans. Brit J Oral Maxillofac Surg, 43, 324–328.
Reproduced with permission of Elsevier.
Figure 7.25a  A case of cleft lip and
palate showing maxillary hypolasia
and collapse of the dental arch.
Source: Jayade et al. (2006).
Reproduced with permission of
Elsevier.
approach has the advantage of multi-incremental dis­
traction without patients’ interference.
7.11.2  Maxillary distraction
Distraction osteogenesis is an efficient method for
advancing the maxilla at a Le Fort I level.
Indications
1. Cleft lip & palate cases (Figure 7.25a) due to exces­
sive scar formation of the lip and/or the palate, as
well as the limited bone stock in width and height.
2. In non-cleft cases where the magnitude of maxil­
lary advancement osteotomy is beyond the con­
ventional Le Fort I osteotomy.
3. Eliminate the need for bone graft in cases which
require significant maxillary advancement more
than 10 mm.
4. In children to avoid the use of internal fixation
using metal plates which would interfere with
facial growth.
Extra-oral distraction osteogenesis (Figure 7.25b)
usually achieves satisfactory stability (Figure 7.25c).
The stability of maxillary advancement is improved
with distraction osteogenesis due to the gradual
expansion of the soft tissue envelop throughout the
course of treatment.
7.11.3  Compression bifocal and multifocal
distraction osteogenesis
Distraction osteogeneis can be successfully utilised to
reconstruct segmental bone defect. An osteo-
periosteal bone segment (transport disc) is cut and
gradually distracted across the defect. The tissue is
Figure 7.25b  The application of the Glasgow Extra-oral
Distraction (GED) device for correction of maxillary
hypoplasi. Source: Jayade et al. (2006). Reproduced with
permission of Elsevier.

144
Handbook of Orthognathic Treatment
between the two transport discs would be gradually
compressed until they meet together at the centre of
the defect, the method has been used successfully for
reconstruction of mandibular continuity defect and
improved the facial appearance (Figure 7.26). Fresh­
ening the edges of the transport discs as they meet
may be required to achieve complete bone union.
compressed mesial to the transport disc and the soft
callus is distracted distal to the disc. Tri-focal distrac­
tion is achieved by cutting two transport discs, one
proximal to and one distal to the segmental defect
(Figure 7.26). Bone will be formed by distraction
osteogenesis between each of the transport discs and
its adjacent bone segment. In addition, the tissue
Figure 7.25c  Radiographic and
photographic appearance of the face
after completion of maxillary
distraction osteogenesis. Source:
Jayade et al. (2006). Reproduced with
permission of Elsevier.
Figure 7.26  Preoperative and postoperative panoramic radiographs, and intra-oral photograph showing the mandibular
continuity defect and its reconstruction by tri-focal intra-oral distraction osteogenesis using two transport discs and its
impact on improving facial appearance.

Basic orthognathic surgical procedures
145
the frequency of distraction. Clinical Orthopedics, 239,
263–285.
Jayade, V., Ayoub, A.F., Khambay, B.S., Walker, F.S., Gopal­
akrishnan, K., Malik, N.A., Srivastava, D.S., Pradhan, D.R.
(2006) Skeletal stability after correction of maxillary hypo­
plasia by Glasgow extra-oral distraction device. British
Journal of Oral Maxillofacial Surgery, 44, 301–307.
Kole, H. (1995) Surgical operations on the alveolar ridge to
correct occlusal deformities. Oral Surgery, 12, 413.
Le Fort, R. (1901) Etude experimentale sur les fractures de la
machoire superieure. Rev Chir, 23, 208–227.
Obwegeser, H. (1965) Eingriffe an Oberkiefer zue Korrektur
des progenen Zustandsbildes. Zahnheilk, 75, 365–374.
Precious, D.S., Goodday, R.H., Bourget, L. and Skulsky, F.G.
(1993) Pterygoid plate fracture in Le Fort I osteotomy with
and without pterygoid chisel: A computed tomography
scan evaluation of 58 patients. Journal of Oral Maxillofacial
Surgery, 51, 151–153.
Shoji, T., Muto, T., Takahashi, M., Akizuki, K. and Tsuchida,
Y. (2012) The stability of alar cinch suture after Le Fort 1
mandibular oteotomonies in Japanese patients with class
III mild occlusions. British Journal of Oral Maxillofacial
Surgery, 50, 361–365.
Snyder, C., Levine, G.A., Swanson, H.M. and Brownie, E.Z.J.
(1973) Mandibular link by gradual distraction. Plastic
Reconstruction Surgery, 51, 506–508.
Turvey, T.A. (1985) Intraoperative complications of sagittal
split osteotomy of the mandibular ramus: Incidence and
management. Journal of Oral Maxillofacial Surgery, 43,
504–509.
Wassmund, M. (1935) Lehrbuch der Probleschen Chirurgie des
Mundes und der Kiefer, vol 1. Leipzig: Meuser.
Wunderer, S. (1962) Die Prognathie operation mittels frontal
gastieltem maxillofragment. Ost Z Stomatol, 59, 98.
7.12  Further reading
Ayoub, A.F. and Richardson, W. (2001) A new device for
micro-incremental automatic distraction osteogenesis.
British Journal of Oral Maxillofacial Surgery, 39, 353–
355.
Bell, W.H. (1977) Correction of maxillary excess by anterior
maxillary osteotomy. Journal of Oral Surgery, 43, 323–
332.
Collins, P. and Epker, B.N. (1982) Alar base cinch: A tech­
nique for prevention of alar base flaring secondary to
maxillary surgery. Oral Surgery Oral Medicine Oral Pathology
Journal, 53, 549–553.
Cupar, I. (1954) Die Chirurgie behandling der form und
stellingsveren drungen des oberkiefers. Ostmatol, 51, 565.
Dal Pont, G. (1961) Retromolar osteotomy for the correction
of prognathism. Journal of Oral Surgery Anesthesia and Hos­
pital Dental Service, 19, 42–47.
Hall, H.D. (1992) Intraoral vertical ramus osteotomy. In: Bell,
W.H. (ed.). Modern Practice in Orthognathic and Reconstruc­
tive Surgery. Mandibular Prognathism. Philadelphia: Saun­
ders, 1992.
Hunsuck, E.A. (1968) A modified intraoral splitting tech­
nique for the correction of mandibular prognathism.
Journal of Oral Surgery, 26, 249–250.
Ilizarov, G.A. (1988) The principles of the Ilizarov method.
Bulletin Hospital for Joint Diseases Orthopedicas Institute, 48,
1–11.
Ilizarov, G. (1989) The tension-stress effect on the genesis
and growth of tissues. Part 1 The influence of stability of
fixation and soft tissue preservation. Clinical Orthopedics
Related Research, 238, 249–281.
Ilizarov, G.A. (1989) The tension-stress effect on the genesis
and growth of tissues. Part 2 The influence of the rate and

Intended learning outcomes
By the end of this chapter the reader should:
• Have an understanding of the usage and
indications for standard and high level
osteotomies and the principles of timing for
surgery.
• Have an explanation of the basic surgical
procedures and the principles behind them.
• Recognise the surgical limitations, risks and
possible complications that can occur.
• Have an understanding of the reasons for long
term follow up and the necessity for repeat
procedures as a result of failure of growth after
birth.
• Have a basic knowledge for information to
patients searching for treatment.
High level osteotomies
8
Chapter overview
Intended learning outcomes, 146
8.1
Introduction, 146
8.2
Indications, 146
8.2.1 The Le Fort II osteotomy, 146
8.2.2 The Le Fort III osteotomy, 147
8.3
Timing of surgery, 148
8.4
Special investigations, 148
8.5
Le Fort II surgical procedure, 148
8.6
Le Fort III surgical procedure, 149
8.6.1 Indications, 149
8.7
Advantages and disadvantages of
subcranial Le Fort III osteotomy, 152
8.8
Complications related to anatomy of
area, 152
8.9
Other facial deformities, 153
8.9.1 Treacher Collins Syndrome, 153
8.9.2 Craniofacial (hemifacial) microsomia, 153
8.10  Further reading, 154
have a small place in the repertoire of the maxillofa­
cial surgeon primarily for the correction of craniofa­
cial and asymmetric deformity. The principal ones are
the Le Fort II and Le Fort III osteotomies outlined
here.
Le Fort II and III osteotomies are based on the
fracture lines which occur following trauma and
these have been modified over the last 40 years to
correct congenital deformities of the midface. They
also may be used for post traumatic, secondary cleft
and iatrogenic deformities (e.g. post radiotherapy)
and they can be extensively modified to correct
asymmetric deformity and for localised osteotomies
in the craniofacial area.
8.2  Indications
8.2.1  The Le Fort II osteotomy (Figures 8.1a,
8.1b)
This is most effective where there is central midface
(naso-maxillary) hypoplasia with both anteroposte­
rior and vertical deficiency without significant
orbital hypoplasia or ocular proptosis. There may be
146
8.1  Introduction
There are a variety of osteotomies that may be used
in the midface for the correction of deformity which
Handbook of Orthognathic Treatment: A team approach, First Edition. Ashraf Ayoub, Balvinder Khambay, Philip Benington,
Lyndia Green, Khursheed Moos, and Fraser Walker.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.

High level osteotomies
147
the base of skull and the coronal sutures are affected.
Many milder degree cases may be corrected by a sub­
cranial procedure. This can also be used for untreated
post-traumatic deformity and for major craniofacial
clefting defects. An additional Le Fort I osteotomy
is often required to increase the maxillary vertical
dimension or to improve the dental occlusion.
(The Kufner modification where the nasoethmoidal
complex is left in its original position and the malars
and maxillae are advanced is occasionally helpful but
often it is difficult to obtain a good dental occlusion,
and it is then better to do two malar osteotomies with
a separate Le Fort I procedure.)
The Le Fort III osteotomy is widely used either
subcranially or transcranially for deformities associ­
ated with the craniosynostotic syndromes of Crouzon,
a degree of telecanthus or hypertelorism. It is most
effective in von Binder’s syndrome (maxillo-nasal
dysplasia), (Figure 8.2) and post traumatic cases
(Figure 8.3). When there is infraorbital hypoplasia
the procedure may be extended laterally, but there is
a risk of damage to the infraorbital nerve. It is most
useful for cases with a short hypoplastic nose, with
moderate vertical and anteroposterior deficiency.
8.2.2  The Le Fort III osteotomy
This is primarily indicated for total midface hypopla­
sia, where there is deficiency affecting maxillae,
malars and nasoethmoidal complex, especially in the
presence of exorbitism. This is typically seen in syn­
dromic and non-syndromic craniosynostosis, where
Figure 8.1   Le Fort osteotomy cuts.
a)
b)
Figure 8.2  von Binder syndrome pre- and post-op.
a)
b)
Figure 8.3  Malunited fracture corrected by Le Fort II
osteotomy.
a)
b)

148
Handbook of Orthognathic Treatment
three-dimensional, axial and coronal cuts is neces­
sary. Any suspected or identified intracranial prob­
lems are additionally likely to require magnetic
resonance imaging as well as the usual postero-
anterior and lateral cephalograms for orthognathic
planning purposes. If there is asymmetry of any sig­
nificance then stereolithography is helpful. Intraoral
dental views may be required as well as an orthopan­
tomograph and dental models. From the general
medical point of view a chest x-ray, routine haema­
tology and biochemistry would be appropriate as
well as a preoperative neurosurgical and anaesthetic
assessment and a check for other systemic disease.
A team approach is adopted for all orthognathic
cases.
8.5  Le Fort II surgical procedure
(a) Approach
An intraoral incision from right to left malar but­
tresses as for the Le Fort I osteotomy is made. Muco­
periosteal flaps are raised to expose the infraorbital
margins and the nasomaxillary area and the whole
of the pyriform aperture. Bilateral oblique canthal
(medial) incisions are made through skin onto the
frontal process of the maxillae just lateral to the
external angular veins. The subperiosteal stripping is
continued over the bridge of the nose, elevating the
soft tissues well into the orbits without damaging the
infraorbital nerves, nasolacrimal ducts and lacrimal
sacs.
(b)  Osteotomy-bone cuts, mobilisation and
reconstruction
The bone cuts are made with burs starting midway
between the infraorbital nerve and naso-lacrimal
duct on each side slightly obliquely and inferiorly
then horizontally across the zygomatic buttresses to
the pterygo-maxillary junctions on both sides (Figure
8.1). Via the canthal incision a bur cut is made
through the infraorbital margin and is then extended
medially behind the naso-lacrimal duct with a small
chisel. The bur cut is completed medially through the
lateral wall of the naso-ethmoid elevating the soft
tissues with an Aufricht retractor and across the
bridge of the nose below the fronto-nasal suture to
join a similar cut from the opposite side. The medial
canthi remain intact and attached to the elevated
periosteum. A curved Tessier chisel is then directed
inferiorly through the canthal incision on one side
to section the nasal septum and vomer completing
the cut into the nasopharynx, at the same time
checking its position in the nasopharynx. The lower
Apert, Carpenter, Pfeiffer and Saethre-Chotzen. Care
needs to be taken when there is only slight exoph­
thalmos associated with major midface hypoplasia
which is sometimes seen in Apert’s syndrome. Any
major advancement with distraction osteogenesis
can lead to enophthalmos and then bone grafting of
the orbits will be necessary. Distraction osteogenesis
is particularly useful for severe maxillary retrusive
deformity, as it largely avoids the necessity for exten­
sive bone grafting. The latter is difficult to do when
the child is very young, that is, between 1 and 5 years
when surgery is necessary at that stage.
8.3  Timing of surgery
If surgery is to be carried out for aesthetic reasons
this is best done at the end of the growth period
(females 17 to 18 years and males 18 to 19 years) as
a single procedure with pre and post surgical ortho­
dontic care. However in most syndromic cases early
release of cranial sutures is required between 8 and
15 months of age to allow the brain to grow. It
triples its volume in the first year, after that there is
only a small increase in its size. Premature suture
closure will lead to raised intracranial pressure, brain
damage and loss of vision. Early surgery for release
of cranial sutures and frontal (supraorbital) advance­
ment is then required. Following this the facial
deformity appears much worse and sometimes this
is complicated by postnasal choanal atresia accom­
panying the midface retrusion with airway problems
and obstructive sleep apnoea. Early (<18 months)
midface advancement surgery is difficult with poor
control of the facial bones and it is better if possible
to wait until 5 to 10 years. A tracheostomy or a
CPAP machine may be required to improve the
airway until surgery is carried out. Prior to any early
surgery, it is essential to exclude other congenital
anomalies, for example, cardiac, respiratory and
neurological and to check the family history espe­
cially for other recessive and dominant conditions.
A psychological assessment of children and young
adults should always be considered before this type
of surgery.
8.4  Special investigations
Prior to surgery a neurological check for raised intrac­
ranial pressure should be made with CT/MRI scan­
ning. CT scanning of the mid- and upper face with

High level osteotomies
149
to insert a columella strut attached to the wing
shaped bone graft, to give a nasal tip projection. From
the frontonasal suture area a long bony strut can be
inserted through a small midline vertical fronto­
nasal incision. This is fixed into position with a small
mini or micro plate. Standard skin and mucoperio­
steal closures are then carried out.
8.6  Le Fort III surgical procedure
8.6.1  Indications
Total midface advancement and midface lengthening
with onlay bone grafting is usually applicable. If
craniectomy and cranial suture release or other
intracranial procedures are required a transcranial
approach is to be used (but this is not considered
here), otherwise if no intracranial intervention is
required the approach should be subcranial. Accom­
panying midface lengthening frequently requires a Le
Fort I osteotomy which can be carried out sequen­
tially. These procedures are used primarily for syndro­
mic craniofacial synostosis and occasionally for other
deformities, for example, achondroplasia and post-
traumatic deformity (Figure 8.4).
(a) Approach
Essentially the approach is made via a long coronal
incision carried down low into the preauricular area.
To reduce the significant scar in the hairline a
zigzag incision is widely used down to the temporal
fascia laterally and to the pericranium coronally. The
portion of the pterygoid plates are separated from the
maxillae with Tessier chisels. With Rowe’s disimpac­
tion forceps the midface is mobilised, taking care to
avoid tearing the naso-lacrimal ducts. This can be
difficult in post-traumatic and secondary cleft
deformities. In that case Smith spreaders can be
helpful in the zygomatic buttress areas and for
advancement Tessier mobilisers. The maxillary denti­
tion is checked into its new position with an inter-
occlusal wafer and the vertical and horizontal
positions are fixed using two mini plates on each side.
Some trimming of bone in the nasal bridge area is
usually required and small bone grafts are inserted at
the infraorbital margins, nasal bridge, medial orbital
and anterior maxillary osteotomy sites. With major
shifts inferiorly and anteriorly it can be helpful to use
pin fixation with a Levant frame attached to an upper
arch bar to fix the maxilla correctly in space then
applying plates and bone grafts after which the pin
fixation may be removed before soft tissue closure.
(c) Other reconstructive procedures
For secondary cleft deformity bone grafting of the
pyriform aperture and nasolabial areas may be
required before closure of the nasal and oral cavities.
In von Binder’s syndrome, the bony deficiency in the
nasal sill area is corrected following extensive muco­
periosteal elevation of the nasal floor and nasolabial
areas which often requires periosteal release and cuts
to allow insertion of a wing shaped bone graft (cranial
or ileal) to provide an anterior nasal spine when this
is absent. The columella skin is sectioned vertically
Figure 8.4  Crouzon deformity
requiring a Le Fort III correction.
a)
c)
b)

150
Handbook of Orthognathic Treatment
these cuts infraorbitally on each side down towards
the infraorbital fissures. The cut may then be picked
up through the transconjunctival incision and taken
across the orbital floor avoiding damage to the
infraorbital nerves to just posterior to the lacrimal
sac. The nasal bones are cut across at or close to the
frontonasal suture directing the bur cut slightly infe­
riorly to avoid entering the cribriform plate area and
passing intracranially. The cuts in the nasoethmoidal
areas are then directed inferiorly through the medial
wall of the orbit to pick up the infraorbital cut,
making sure to avoid any damage to the nasolacrimal
apparatus. This is usually abnormally positioned in a
funnel shaped antero-medial wall defect. A curved
Tessier chisel is passed through the frontonasal bone
cut and is directed firmly downwards and slightly
backwards to section the septum, guided by a tran­
soral finger in the nasopharynx to avoid damage
there. The pterygoid plates are separated from the
back of the maxilla with a curved Tessier chisel
through the vestibular incisions. In young children
this may be more easily achieved from above by
passing the chisel under the zygomatic arch and pro­
tecting it with a finger.
(c) Mobilisation
Mobilisation of the midface is carried out with Rowe’s
disimpaction forceps, sometimes considerable but
controlled force is required assisted by using chisels
in the osteotomy sites especially the frontonasal/
frontozygomatic areas and Smith spreaders applied
in the zygomatic buttress areas can be helpful. For
advancement of the midface Tessier mobilisers are
used in the retromolar areas on both sides. Care of the
airway is essential at this stage as bleeding is some­
times significant. Slight figure of eight movements of
pericranium is then incised 2–3 cm above the supraor­
bital ridge from the temporal fascia from one side to
the other and then the pericranium is elevated into
the orbits tunnelling to expose both malar com­
plexes, the zygomatic arches and the nasoethmoid.
The supraorbital nerves are freed from the superior
orbits with a small chisel and the nasoethmoidal
complex is exposed with a midline vertical periosteal
incision, then laterally into the orbits, the lateral
canthi are marked with a suture. The medial canthi
are elevated subperiosteally from the naso-orbital
ethmoidal complex, followed by extensive periorbital
stripping to include the orbital floor. If this is difficult
it can be accessed inferiorly through a lower transcon­
junctival approach. The temporalis muscles are
stripped subperiosteally out of the temporal fossae
but not detached. To give better access to the zygo­
matic arches the outer layer of the temporal fascia is
split laterally avoiding the facial nerve (temporal
branch) and the arch is exposed through the fat.
Additional access to the malar complex is through
two vestibular mucoperiosteal incisions in the molar
regions to approach the pterygo-maxillary junctions
on both sides.
(b) Bones cuts
The malar bones may be either mobilised entirely
with the maxillae or be sagittally split, the former is
easier especially when they are small in the young
child (Figure 8.5). The temporal fossa is very shallow
and it is essential when making lateral orbital cuts to
avoid entering the middle cranial fossae. The zygo­
matic arches are sectioned through the suture or just
posterior to the main body of each malar. The lateral
orbits are sectioned through the frontozygomatic
sutures then down the lateral orbital wall extending
Figure 8.5  Le Fort III bone cuts.
a)
b)

High level osteotomies
151
Two cranial suction drains are placed over the
frontal bones. The pericranium and temporal fascia
are closed on both sides with subcutaneous resorb­
able sutures followed by replacement of the coronal
flap taking care to suture the galea back into place
and Raney clips are used to close the coronal skin
incision (Figure 8.7, Figure 8.8).
the midface with Rowe’s disimpaction forceps can be
helpful during mobilisation and disimpaction.
Excessive tension on the globes must be avoided,
often indicated by slowing of the pulse rate. Once the
midface is free, intermaxillary fixation with an inte­
rocclusal splint provides an intraoperative rest period
for stabilisation of the patient.
(d) Reconstruction
This can be carried out either by distraction osteo­
genesis at 2–3 days following the insertion and use
of a distraction device which will advance the midface
and nasoethmoidal complex (Figure 8.6). This may
be fixed to the teeth and superiorly to the nasoeth­
moidal complex in the young adult. The alternative
is to manually advance the midface stabilising the
occlusion and the vertical position of the face with
intermaxillary fixation and titanium mini plates at
the frontozygomatic suture, zygomatic arches and at
the frontonasal osteotomy site. Cranial bone graft is
used to fill in defects in the lateral orbits, orbital floor,
medial orbit, frontonasal area and zygomatic arches.
The cranial bone graft is normally harvested from the
outer plate of the parietal bones. Following this the
intermaxillary fixation is removed.
The medial canthi are identified through a small
horizontal incision of the skin at the medial canthus.
A fine wire is passed through and around the canthal
ligament and both ends are then passed through a
fine cannula or needle posterosuperiorly to the
opposite medial orbit and are attached to a micro
plate placed vertically from the supraorbital ridge.
This is repeated on the other side. This allows the
canthus to correctly position slightly more posteri­
orly and superiorly and then a further screw may be
placed in the plate to fix their position posteriorly
and vertically from the supraorbital ridge. This is
repeated on the other side.
The lateral canthi are picked up by a fine wire
passed through the lateral canthi from the skin
surface on each side which is then passed back
through the skin to be attached laterally to the
supraorbital ridge on each side. Throughout, protec­
tion of the eyes must be maintained often with a
Frost suture. Forced duction testing of globe move­
ments is essential to avoid subsequent diplopia and
to ensure there is no prolapse of orbital contents into
any floor defect. Prior to this where there has been
gross proptosis, the periorbita should be cut circum­
ferentially to allow the orbital fat to flow into the
enlarged orbits. Any orbital dystopia or orbital asym­
metry should be corrected or dealt with prior to
closure and defects in the orbital walls are filled with
cranial bone graft.
Figure 8.7  Apert deformity pre- and post-op.
a)
b)
Figure 8.6  Crouzon deformity pre- and post-op
distraction.
a)
b)
Figure 8.8  Apert deformity pre- and post-op.
a)
b)

152
Handbook of Orthognathic Treatment
• much shorter operation, lowers infection risk,
frontal sinuses not involved;
• if early surgery at 11–12 years is undertaken.
This can be repeated at the end of growth
period.
8.8  Complications related to anatomy
of area
1. Persisting deformity – asymmetry; relapse – inad­
equate mobilisation and poor fixation, temporal
hollowing – failing to advance a portion of tem­
poralis muscle onto the lateral orbit during closure.
2. Orbital complications
(a) diplopia due to muscle trapping with bone
grafts or just poor ocular muscle development
this may require ophthalmic – ocular muscle
surgery.
(b)  blindness due to “trauma” or retrobulbar
haemorrhage.
(c) en- or exophthalmos – failure to manage sat­
isfactorily the orbital contents.
(d) ptosis – often initially present but masked by
exophthalmos – will require upper lid reduc­
tion and some levator surgery.
(e) corneal ulceration. Failing to protect the globe
intra- and post-operatively.
3. Canthal drift
(a) failure to correct fully telecanthus especially
when the ligaments are rudimentary.
(b) failure to find/reposition lateral canthi – nor­
mally requires slight over correction.
4. Cranial – CSF leak and meningitis – inadvertent
communication in the cribriform plate area.
5. Damage to cranial nerves
(a) damage of nerves to extraocular muscles may
lead to diplopia of III IV VI nerves and this
may be due to narrowing of the superior
orbital fissure.
(b) damage to olfactory nerves I loss of sense of
smell and to optic nerves II leads to blindness.
(c) anaesthesia – as a result of damage to infra and
supraorbital
nerves
as
well
as
to
the
zygomaticofacial/temporal nerves, V- first and
second branches leads to anaesthesia.
(d) facial weakness – rarely damage to temporal
branches of VII.
6. Lacrimal – glands rarely affected, but risk of
damage to nasolacrimal apparatus, notably the
duct and sac – can lead to epiphora and recurrent
dacryocystitis.
If there is significant shortage of midface height,
this is usually best corrected by a Le Fort I osteotomy
which should be undertaken after completion of the
Le Fort III through a standard vestibular incision.
Separation is easy and the vertical defects are filled
with bone graft after plating of the maxilla. Again
cranial or ileal grafts are commonly used. The ves­
tibular incision is then closed in the standard way
after checking the vertical and horizontal dimen­
sional changes using an inter-occlusal splint. The
intermaxillary fixation may then be released.
Occasionally onlays of bone graft over the malars
are required. These can be inserted after the Le Fort I
osteotomy and may be fixed with screws or plates and
screws.
If any surgery to the mandible is required, this
should be done at this stage.
Prophylactic antibiotics and high dose steroids for
a short period are normally given to reduce swelling
and the risk of infection. Appropriate eye monitoring
and protection is required.
Modifications: consideration should be given to
the Kufner procedure and the use of bilateral malar
osteotomies, onlay bone grafts, reduction of promi­
nent supraorbital ridges, reshaping of orbital margins
at a later stage. Also minor degrees of hypertelorism
and telecanthus may be corrected. Nasal lengthening
and increased prominence of the nasoethmoidal
complex with a bone strut is commonly undertaken.
Correction of orbital dystopia in association with Le
Fort III osteotomy especially when associated with a
plagiocephaly requires a transcranial approach to
obtain an optimal result.
8.7  Advantages and disadvantages of
subcranial Le Fort III osteotomy
(a) Disadvantages
• does not correct deformity of the superior orbit
and frontal area;
• any severity of orbital dystopia and hyperte­
lorism cannot be corrected;
• difficult to correct significant asymmetry or
plagiocephaly. For this a transcranial procedure
is required.
(b) Advantages
• less risk of infection;
• reduced risk of intracranial complications, CSF
leak, meningitis, anosmia;
• no need for neurosurgical intervention or dural
repair;

High level osteotomies
153
to the individual. This is usually accompanied by
ocular defects, superolateral orbital dermoid cysts
and vertebral anomalies as well as bilateral conduc­
tive deafness. The unilateral deformity is very varia­
ble and principally affects the ear and mandible as
well as adjacent soft tissues which are hypoplastic. It
may involve the midface with hypoplasia extending
into the orbit with poor ocular development, appear­
ance and function. The muscles of mastication are
normally hypoplastic on the affected side and the
salivary glands may be absent or small in size.
The defect may also affect the temporal bone and the
pinna on the affected side and in severe cases it may
be absent or grossly hypoplastic and there may be
agenesis of the external auditory meatus and middle
ear. There are ear tags commonly unilateral macros­
tomia and a clefting defect of the lip commissure
may be present. This is accompanied by a three-
dimensional failure of growth of the facial structures
on the affected side which is very variable in relation
to site and extent.
Use of the Pruzansky classification is helpful if the
deformity is primarily mandibular in giving guidance
to the surgeon as to the best surgical options. Type 1
can be treated by osteotomy surgery, Type 2a often
by distraction osteogenesis, Type 2b often with a
costo-chondral graft, and Type 3 by a full reconstruc­
tion of the condyle. This takes no account of soft
tissue defects or other facial bone defects and for that
the OMENS classification may prove to be more
helpful (Figure 8.10).
Treatment is based on reconstruction of the man­
dible and the ear, correction of the asymmetry which
may be complicated sometimes by a facial nerve
paresis from birth. Orbital reconstruction and midface
surgery is commonly required because of vertical and
horizontal hypoplasia. Distraction is often helpful
7. Nasal – problems with obstruction synechiae
(fibrous bands), infection of paranasal sinuses and
unsatisfactory appearances.
8. Dental – malocclusion, anterior open bite and
trismus – as a result of inaccurate planning, failure
to fully mobilise the midface and unstable ortho­
dontic treatment.
8.9  Other facial deformities
8.9.1  Treacher Collins Syndrome
This is a dominant hereditary disorder with variable
penetrance sometimes occurring sporadically. It is
typified by clefting defects of the zygomatic arches
and either the infraorbital or lateral orbital margins
which is accompanied by severe bilateral malar hypo­
plasia with an antimongoloid slant to the eyes. There
is also poor mandibular development affecting the
condyles and causing severe mandibular retrusion
and retrogenia, with short mandibular rami and
marked antegomial notching. There is also a variable
degree of maxillary hypoplasia and sometimes a cleft
palate and a poor nasal airway. Pinna formation is
bilaterally poor with a crumpled appearance and
there is an auditory conduction defect as a result of
failure of first and second branchial arch structures
to develop normally. In early life obstructive sleep
apnoea may be a prominent feature requiring early
tracheostomy and very early mandibular advance­
ment by distraction osteogenesis. Colobomata affect­
ing eyes and lower lids and absent cilia are frequently
seen. For the older child, osteotomy surgery with
malar bone grafting, closure of the cleft defects and
onlay bone grafting are frequently required. Man­
dibular and genial advancement will routinely be
required at an age dependent on the expression of
the syndrome with gross underdevelopment of the
auditory and pinna development. Bilateral bone
anchored hearing aids will be required and if ear
reconstruction is not feasible, bone anchored pros­
thetic ears should be constructed (Figure 8.9).
8.9.2  Craniofacial (hemifacial) microsomia
This is the second most common facial deformity
after cleft lip and palate and will only be considered
briefly here in relation to the midface and mandible.
It occurs sporadically with no hereditary basis and it
is a very variable first and second arch developmental
deformity. Rarely is it bilateral in Goldenhar’s syn­
drome, which gives a more symmetrical appearance
Figure 8.9  Treacher Collins deformity.
a)
b)

154
Handbook of Orthognathic Treatment
Murray, J.E., Kaban, L.B., Mulliken, J.B. and Evans, C.A.
(1985) Analysis and treatment of hemifacial microsomia.
In Carroni, E.P. (ed.) Craniofacial Surgery. Little, Brown,
Boston, pp.377–390.
Tulasne, J.F. and Tessier, P.L. (1986) Results of the Tessier
integral procedure for correction of Treacher Collins Syn­
drome. Cleft Palate Journal 23(suppl), 40–49.
Ward, P., Booth, S., Schendel, A. and Hausamen, J-E. (1999)
Maxillofacial Surgery, Churchill Livingstone: London.
and may be repeated to increase the bone volume
otherwise large defects may be reconstructed by the
use of composite free flaps commonly the deep cir­
cumflex iliac, arterial flap with bone, muscle, fat and
skin, the latter of which may be removed at a later
stage. There is still considerable discussion over the
timing of treatment and its nature. Rarely is there any
intracranial involvement.
8.10  Further reading
Kerawala, C. and Newlands, C. (2010) Oxford Specialist Hand­
books in Surgery. Oxford University Press.
Figure 8.10  (a) & (b) Preoperative appearance, (c) & (d) show immediate postoperative and final facial appearance at
5 years.
a)
b)
c)
d)

Case reports
9
155
Handbook of Orthognathic Treatment: A team approach, First Edition. Ashraf Ayoub, Balvinder Khambay, Philip Benington,
Lyndia Green, Khursheed Moos, and Fraser Walker.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
9.1  Class II, division 2 malocclusion, 157
9.2  Vertical maxillary excess, 160
9.3  Class III malocclusion, 163
9.4  Mandibular asymmetry with 3D planning, 166
9.5  Anterior open bite, 170
9.6  Class II, division 1 with hypodontia, 173

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Case 9.1 
Class II, division 2 malocclusion
Presentation
Caucasian male, 27 years old with a clear medical
history.
No psychological contra-indications to treatment.
Patient’s concerns
Functional:
• Deep and traumatic overbite.
Aesthetic:
• Lower jaw too far back.
• “Collapsed” lower face.
Facial features (Figure 9.1.1)
Antero-posterior:
• Class II skeletal jaw relationship.
• Mandibular retrusion.
• Increased naso-labial angle.
• Progenia.
Vertical:
• Upper incisor show slightly reduced.
• Reduced lower anterior face height.
• Acute labio-mental fold.
• Reduced gonial angle.
• Shallow mandibular plane.
Transverse:
• No obvious facial asymmetry.
Intra-oral features (Figure 9.1.2a)
Dentition:
• Upper incisors retroclined and severely crowded.
• Lower incisors of average inclination and aligned.
• Accentuated lower curve of Spee.
Occlusion:
• Severe class II, division 2 incisor relationship.
• Overbite 100%, complete and traumatic.
Figure 9.1.1  Frontal view of the face
at rest (a) shows the reduced lower
anterior face height. A smiling view
(b) suggests slightly reduced upper
incisor show. The profile view (c)
shows a deep labiomental fold
accompanied by progenia and the
characteristic features of a short facial
type.
a)
b)
c)
Figure 9.1.2  Intra-orally the upper incisors are retroclined (a), but the presence of severe crowding is favourable for
enabling proclination as part of orthodontic decompensation (b).
a)
b)
157

158
Handbook of Orthognathic Treatment
The surgical plan was finalised, with the aid of
model surgery and photo-cephalometric software, as
follows:
• Le Fort I anterior downgraft (2 mm) and posterior
impaction 2 mm producing some backward (clock­
wise) rotation of the maxilla. No advancement was
possible due to the limitation of mandibular
advancement to approximately 10 mm.
• Bilateral sagittal split mandibular advancement
10 mm to three-point landing (Figure 9.1.5a).
• Vertical augmentation genioplasty 3 mm.
Treatment outcome (Figures 9.1.4–9.1.7)
The fact that maxillary advancement was not possi­
ble meant that no advancement of the upper lip
• Overjet minimal.
• Buccal segments greater than a full unit class II
bilaterally.
Initial combined plan
Desired soft tissue changes and provisional
dento-skeletal movements
1. Upper incisor and maxillary position.
Reduce naso-labial angle and increase incisor
show:
• Normalise inclination of upper incisors.
• Downgraft anterior maxilla by 2 mm.
2. Occlusion and mandibular position.
Advance the mandible by about 10 mm, improve
lip posture and increase LAFH:
• Advance mandible 10 mm (BSSO).
• Correct occlusion to “three-point landing”.
3. Maxillo-mandibular complex rotation.
Steepen mandibular and occlusal planes:
• Clockwise rotation.
4. Chin position.
Achieve optimal vertical proportions and profile
balance.
• Vertically augment the chin (genioplasty).
Key objectives of pre-surgical orthodontic
treatment
• Procline upper incisors beyond their normal incli­
nation, to compensate for the planned backward
maxillary rotation.
• Maintain lower incisor inclination, since backward
surgical rotation of the mandible will procline
them effectively, relative to the true vertical plane.
• Achieve 10–11 mm overjet (this will allow 10 mm
mandibular advancement).
• Maintain lower curve of Spee to allow “three-point
landing”.
• Expand maxillary arch to coordinate arches if
possible.
Final surgical plan
On completion of pre-surgical orthodontics (Figures
9.1.2b and 9.1.3):
• The upper incisors were at greater than normal
inclination (120°).
• The overjet was 11 mm.
• The lower curve of Spee was largely maintained.
• The fit of the occlusion was acceptable, but it was
not possible to achieve ideal transverse arch coor­
dination orthodontically.
Figure 9.1.3  Superimposition of pre-treatment (red) and
pre-surgical (blue) cephalometric tracings shows that the
severely retroclined upper incisors were fully
decompensated. (Produced using OPAL, British
Orthodontic Society).
Figure 9.1.4  End of treatment views illustrate that a good
improvement in the vertical facial proportions (a) and
soft tissue profile (b) were achieved.
a)
b)

Case reports
159
Figure 9.1.5  (a) The “three-point landing” shortly after surgery and (b) the final occlusion, following debond of
orthodontic appliances. The lateral open bites were largely closed through a combination of vertical extrusion of the
posterior teeth and settling of the overbite.
a)
b)
Figure 9.1.6  Cephalometric superimposition of pre-
surgical (red) and post-surgical (blue) lateral
cephalograms. Both the maxilla and the mandibular body
have been rotated downwards and backwards (clockwise),
resulting in a steepening of the occlusal and mandibular
planes. A vertical augmentation genioplasty has been
carried out to achieve optimal vertical proportions.
(Produced using OPAL, British Orthodontic Society).
Figure 9.1.7  The vertical position and inclination of the
upper incisors are aesthetically pleasing on smiling.
occured. Some rotation of the maxillo-mandibular
complex was acheived with a corresponding steepen­
ing of the mandibular plane. The occlusion was
largely corrected and dental aesthetics were very
satisfactory.

Figure 9.2.1  Frontal view of the face
at rest (a) and on smiling (b)
showing the increased lower anterior
face height, the presence of vertical
maxillary excess and a short upper lip.
The profile view (c) confirms that
there is a high FMPA and a downward
and backward rotation of the
mandible.
b)
a)
c)
Presentation
Caucasian female, 16 years old with a clear medical
history.
No psychological contra-indications to treatment.
Patient’s concerns
Functional:
• Some minor problems chewing.
• Lips do not meet together easily.
Aesthetic:
• Too much gum on show when smiling.
• Lower jaw too far back.
Facial features (Figure 9.2.1)
Antero-posterior:
• Class II skeletal jaw relationship.
• Mild maxillary deficiency.
• Increased naso-labial angle.
• Mandibular deficiency.
Vertical:
• Vertical maxillary excess with excessive gingival
display both at rest and on smiling.
• Short upper lip.
• Increased lower anterior face height.
Case 9.2 
Vertical maxillary excess
160
• Steep mandibular plane.
• Retrogenia with obtuse labio-mental fold.
Transverse:
• No obvious asymmetry.
Intra-oral features (prior to orthodontic
treatment)
Dentition:
• Upper incisors upright and mildly crowded.
• Lower incisors of average inclination and mildly
crowded.
Occlusion:
• Class II, division 1 incisor relationship.
• Overjet 8 mm.
• Buccal segments a full unit class II bilaterally.
Initial combined plan
Desired soft tissue changes and provisional
dento-skeletal movements
1. Upper incisor and maxillary position.
Reduce gingival display at rest and on smiling.
Lengthen upper lip as much as possible.
Increase the prominence of the para-nasal regions
by 2–3 mm.

Case reports
161
• The upper incisor inclinations were still slightly
upright.
• The overjet was 8 mm.
• Arch coordination was good.
The final surgical moves, planned with the aid of
model surgery and photo-cephalometric software,
were as follows:
• Le Fort I maxillary impaction 5 mm anteriorly and
2 mm posteriorly, with 4 mm advancement.
• Mandibular auto-rotation followed by advance­
ment of 10 mm.
• Genioplasty with 6 mm advancement and 4 mm
vertical reduction.
Treatment outcome (Figures 9.2.3–9.2.6)
The degree of gingival display on smiling was greatly
reduced, partly due to the maxillary impaction and
partly due to upper lip lengthening. The lower ante­
rior face height was reduced significantly but the
mandibular plane angle remained steep, because of
the short length of the rami. Chin position and lip
competence were improved and the occlusion and
dental aesthetics were satisfactory.
• Anterior maxillary impaction of 5 mm.
• V-Y incision closure.
• Maxillary advancement of 4 mm at Le Fort 1 level.
2. Occlusion and mandibular position.
Advance mandible to optimal occlusion, reduce
LAFH and improve lip posture.
• Mandibular autorotation and advancement of
10 mm (which will also require posterior maxillary
impaction to achieve positive overbite).
3. Maxillo-mandibular complex rotation.
Reduce steepness of occlusal and mandibular
planes.
• Anti-clockwise rotation.
4. Chin position.
Achieve optimal vertical proportions and profile
balance.
• Advancement and vertical reduction genioplasty.
Objectives of pre-surgical orthodontic
treatment
• Maintain upper incisor inclination to allow for dif­
ferential posterior impaction of the maxilla.
• Level upper and lower arches.
• Maintain lower incisor inclination. Auto-rotation
of the mandible will effectively retrocline the lower
incisors relative to vertical.
• Achieve target overjet of 8 mm. This should allow
class I incisors to be achieved with approximately
4 mm of maxillary advancement and 10 mm of
mandibular advancement plus auto-rotation.
Final surgical plan
On completion of pre-surgical orthodontics (Figure
9.2.2):
Figure 9.2.2  Pre-surgical orthodontics produced only
minor changes in the incisor inclinations. An overjet of
8 mm was achieved, which enabled the planned amount
of mandibular advancement.
Figure 9.2.3  The end of treatment frontal view (a) shows
improved vertical proportions and lip posture. The profile
view (b) shows that there was still a high FMPA, with a
degree of profile convexity, but full correction of these
features would have been difficult to achieve. Some upper
lip lengthening was achieved.

162
Handbook of Orthognathic Treatment
Figure 9.2.5  End of treatment occlusion. A positive
overbite and satisfactory inter-digitation were achieved.
Figure 9.2.6  Smiling frontal view showing a normal
vertical relationship of the upper incisors to the upper lip.
Figure 9.2.4  Superimposition of the pre-surgery (red) and
post-surgery (blue) cephalometric tracings confirms that a
substantial amount of anterior maxillary impaction and
mandibular advancement were achieved. (Produced using
OPAL, British Orthodontic Society).

Case 9.3 
Class III malocclusion
Presentation
Caucasian female, 16 years old, with clear medical
history.
Upper first premolars previously extracted as part of
earlier upper arch alignment.
No psychological contra-indications to treatment.
Patient’s concerns
Functional:
• Unable to bite between front teeth.
Aesthetic:
• Prominent lower jaw.
Figure 9.3.1  Frontal views of the face
at rest (a) and on smiling (b). Note
the mandibular asymmetry and the
cant of the lips as well as the
increased lower anterior face height.
The lateral view (c) shows the
features of severe class lll skeletal jaw
relationship as well as a steep
mandibular plane.
a)
b)
c)
Facial features (Figures 9.3.1 and 9.3.2)
Antero-posterior:
• Severe class III skeletal jaw relationship.
• Para-nasal hollowing.
• Lack of lower lip curvature.
Vertical:
• Short upper lip with lip incompetence.
• Increased upper incisor show at rest and gingival
display on smiling.
• Increased lower anterior face height.
• Steep mandibular plane.
Figure 9.3.2  Pre-treatment occlusion (a). Note the crowding of the retroclined lower incisors, which was helpful in
achieving orthodontic decompensation (b).
a)
b)
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Handbook of Orthognathic Treatment
• Maintain upper incisor inclinations.
• Achieve a reverse overjet of 10 mm. This should
allow approximately 13 mm of total jaw movement
at the level of the incisal edges.
• Achieve transverse arch coordination.
Final surgical plan
On completion of pre-surgical orthodontics (Figures
9.3.2b and 9.3.3):
• The lower incisors were slightly retroclined (83°).
• The target reverse overjet of 10 mm has been
achieved.
• Arch coordination is satisfactory.
The final surgical moves, planned with the aid of
model surgery and photo-cephalometric software,
were as follows:
• Le Fort I maxillary advancement 7 mm, anterior
impaction 2 mm and posterior impaction 2 mm.
• Mandibular autorotation and asymmetric BSSO
mandibular setback 6 mm.
• Genioplasty with 6 mm advancement and 4 mm
vertical reduction.
Treatment outcome (Figures 9.3.4–9.3.7)
The soft tissue objectives were largely achieved. The
maxillary deficiency and the position of the upper
Figure 9.3.3  Superimposed pre-treatment (red) and
pre-surgical (blue) cephalometric tracings show the
degree of proclination of the lower incisors achieved
through pre-surgical orthodontics. There has also been
some extrusion of the upper molars as well as some
further vertical growth. (Produced using OPAL, British
Orthodontic Society).
Transverse:
• Mandibular asymmetry, with chin shifted to right.
• Inter-labial line canted down to the left.
• Narrow alar base.
Intra-oral features (Figure 9.3.2a)
Occlusion:
• Severe class III incisor relationship.
• Reduced overbite.
• Reverse overjet of 4 mm.
• Buccal segments greater than a full unit class III bilat­
erally even with previous loss of upper premolars.
Dentition:
• Upper incisors proclined and mildly crowded.
• Lower incisors severely retroclined and crowded.
• Both upper and lower centrelines shifted to the
right be 2 mm.
Initial combined plan
Desired soft tissue changes and provisional
dento-skeletal movements
1. Upper incisor and maxillary position.
Advancement of the upper lip and para-nasal
regions by 4–5 mm.
Normalisation of upper incisor show.
Lengthening of upper lip.
• Advancement of maxilla by 7 mm, with rotation to
left 2 mm, at Le Fort 1 level.
• Anterior impaction of 2 mm.
• V–Y incision closure.
2. Occlusion and mandibular position.
Set back mandible to achieve optimal occlusion
and correct asymmetry.
Reduce lower anterior face height.
Improve lower lip curvature.
• Procline lower incisors.
• Mandibular autorotation followed by Asymmetric
setback (BSSO) of 6 mm (which will also require
posterior maxillary impaction to achieve positive
overbite).
3. Maxillo-mandibular complex rotation.
Reduce steepness of occlusal and mandibular
planes.
• Anti-clockwise rotation.
4. Chin position.
Acheive optimal vertical proportions and profile
balance.
• Advancement and vertical reduction genioplasty
Key objectives of pre-surgical orthodontic
treatment
• Partially decompensate lower incisors, allowing for
increased post-treatment mandibular plane angle.

Case reports
165
Figure 9.3.4  The end of treatment facial views from the
front (a), and in profile (b), illustrate a dramatic
improvement in facial aesthetics and symmetry.
a)
b)
Figure 9.3.5  Superimposed pre-surgical (red) and
post-surgical (blue) lateral cephalograms show that the
required bi-maxillary movements were largely achieved.
The advancement and reduction genioplasty was essential
in achieving profile balance and improved vertical
proportions. (Produced using OPAL, British Orthodontic
Society).
Figure 9.3.6  End of treatment occlusion. The incisor
relationship and arch coordination achieved were
satisfactory.
Figure 9.3.7  Post-treatment frontal smiling view. The
relationship of the upper incisors to the upper lip is
satisfcatory.
incisors were largely corrected and the chin position
and profile was pleasing. The lower anterior face
height remained slightly increased but was aestheti­
cally acceptable. This could have been improved with
a vertical reduction genioplasty. The steepness of the
mandibular plane was reduced to some extent and the
occlusion and dental aesthetics were satisfactory.

Presentation
Caucasian male, 17 years old with clear medical
history.
Mandibular asymmetry no longer progressive.
No psychological contra-indications to treatment.
Patient’s concerns
Functional:
• Would like bite between front teeth to be better.
Aesthetic:
• Crooked lower jaw.
Facial features (Figure 9.4.1)
Antero-posterior:
• Maxillary deficiency, indicated by malar and para-
nasal hollowing.
• Mandibular prognathism with retrogenia.
• Reduced lower lip curvature.
• Increased gonial angle.
Vertical:
• Increased lower anterior face height.
• Increased mandibular plane angle.
Transverse:
• Transverse mandibular asymmetry with chin
shifted to the right.
Figure 9.4.1  Frontal views of the face
at rest (a) and on smiling (b). The
mandibular asymmetry is mainly in
the transverse plane. The smiling view
showws the upper incisors to be
retroclined clinically and the upper
centreline is shifted slightly to the
right. The profile view (c) reveals
maxillary and malar deficiency. There
is an increased FMPA with a degree of
retrogenia.
a)
b)
c)
Case 9.4 
Mandibular asymmetry with
3D planning
• Mild deviation of the nasal tip to the left.
• No cant of the maxillary occlusal plane.
• Increased naso-labial angle.
Intra-oral features (Figure 9.4.2a)
Dentition:
• Upper incisors mildly retroclined and mildly
crowded.
• Lower incisors retroclined and mildly crowded.
Occlusion:
• Class III incisor relationship with 2 mm reverse
overjet.
• Upper centreline shifted to the right by 2 mm.
• Lower centreline shifted to the right by 6 mm and
coincident with mandibular midline.
Initial combined plan
Desired soft tissue changes and provisional
dento-skeletal movements
1. Upper incisor and maxillary position.
Advancement of upper lip and para-nasal regions
by approximately 4 mm.
Build up of malar regions.
166

Case reports
167
• Asymmetric mandibular setback to achieve class I
incisors and coincident centrelines.
• A genioplasty was judged to be unnecessary.
• Zygomatic onlay grafts.
Treatment outcome (Figures 9.4.5–9.4.8)
The mandibular asymmetry was largely corrected,
although both upper and lower dental centrelines
were still deviated slightly to the right. The soft tissue
profile was acceptable, but there was still a suggestion
of para-nasal hollowing with an increased naso-
labial angle. An advancement genioplasty might
have enhanced the profile balance.
Figure 9.4.2  Pre-treatment occlusion (a). Note the absence of lower arch crowding, which was unfavourable for incisor
decompensation. The lower centerline is shifted significantly to the right as a result of the mandibular asymmetry. (b) A
reverse overjet of 7 mm and satisfactory arch coordination were nevertheless achieved.
a)
b)
Figure 9.4.3  Superimposition of pre-treatment (red) and
pre-sugery (blue) cephalometric tracings. Full lower incisor
decompensation was achieved as well as correction of the
upper incisor inclinations. (Produced using OPAL, British
Orthodontic Society).
Correct upper dental centreline to middle of face.
• Procline upper incisors to normal inclination.
• Le Fort 1 maxillary advancement 6 mm and rotation
to left.
• Zygomatic onlay grafts.
2. Occlusion and mandibular position.
Rotation and asymmetric setback of mandible to
achieve optimal occlusion with coincident dental
midlines.
Improve lower lip curvature:
• Procline lower incisors.
• BSSO setback of 4 mm with rotation 6 mm to left.
3. Maxillo-mandibular complex rotation.
• None required.
4. Chin position.
• Reassess need for genioplasty at final surgical plan­
ning stage
Key objectives of pre-surgical orthodontic
treatment
• Procline upper incisors to normal inclination.
• Procline lower incisors to achieve reverse target
overjet of 8 mm.
• Achieve transverse arch coordination.
Final surgical plan
On completion of pre-surgical orthodontics (Figures
9.4.2b and 9.4.3):
• The upper incisors were slightly proclined.
• The reverse overjet measured 7 mm.
• Arch coordination was satisfactory.
The final surgical plan was formulated with the aid
of Maxilim® three-dimensional software (Figure
9.4.4), in addition to conventional model surgery, as
follows:
• Le Fort I maxillary advancement (6 mm) and rota­
tion to left (2 mm), with no vertical change.

168
Handbook of Orthognathic Treatment
Figure 9.4.4  Representative views of 3-D surgical planning using Maxilim® software.

Case reports
169
Figure 9.4.5  End of treatment facial views. (a) The
mandibular asymmetry was largely corrected. (b) The
naso-labial angle remains slightly increased and an
advancement genioplasty may have been indicated for
ideal profile balance.
a)
b)
Figure 9.4.7  End of treatment occlusion. Coincident
centerlines and a well inter-digitated occlusion were
achieved.
Figure 9.4.8  Post-surgical view on smiling, showing
pleasing facial and dental aesthetics.
Figure 9.4.6  Super-imposed pre-surgical (red) and
post-surgical (blue) cephalometric tracings show the
antero-posterior and vertical surgical movements. The
lower anterior face height was reduced significantly as a
result of the mandibular setback, coupled with a small
amount of autorotation. (Produced using OPAL, British
Orthodontic Society).

Figure 9.5.1  (a) Facial view at rest.
The lower anterior face height is
slightly increased but facial aesthetics
are largely pleasing. The smiling view
(b) shows the upper anterior teeth to
be bowed upwards, reducing the
display of the central incisors. (c) The
profile view reveals a mild degree of
maxillary deficiency, but this was not
of concern to the patient.
a)
b)
c)
Case 9.5 
Anterior open bite
Presentation
Caucasian male, 23 years old with clear medical
history.
Right thumb sucking habit as a child.
No psychological contra-indications to treatment.
Patient’s concerns
Functional:
• Unable to bite between front teeth.
Aesthetic:
• Upper front teeth at different levels.
• No concerns regarding facial appearance.
Facial features (Figure 9.5.1)
Antero-posterior:
• Mild class III skeletal jaw relationship due to maxil­
lary deficiency.
• Mild para-nasal hollowing.
Vertical:
• Reduced display of upper incisors on smiling.
• Lower anterior face height increased.
Transverse:
• No obvious asymmetries.
Intra-oral features (Figure 9.5.2a)
Dentition:
• Upper incisors of average inclination and aligned.
• Lower incisors retroclined and mildly crowded.
• Centrelines correct and coincident.
Occlusion:
• Class III incisor relationship with reverse overjet of
3 mm.
• Anterior open bite, measuring 4 mm maximum and
extending back to the upper second premolars.
• Buccal segments a full unit class III bilaterally.
Initial plan
Desired changes and provisional
dento-skeletal movements
1. Upper incisor and maxillary position.
Advancement of the upper lip and para-nasal
regions by approximately 4 mm.
Correction of upper incisor show at rest and on
smiling.
• Advancement of the anterior maxilla by approxi­
mately 6 mm at Le Fort I level, maintaining inclina­
tion of upper labial segment.
• Anterior maxillary down graft 2 mm.
170

Case reports
171
Figure 9.5.2  (a) Pre-treatment occlusion. The anterior open bite is partly due to the intrusion of the upper incisors and
partly due to posterior maxillary excess. Some compensation is seen in the lower incisors. (b) Sectional mechanics were
used in the preparation for segmental maxillary surgery with the aim of minmizing relapse of the anterior open bite.
Note the space created distal to the canines for the surgical cuts.
a)
b)
Figure 9.5.3  Superimposed pre-treatment (red) and
pre-surgery (blue) cephalometric tracings show that the
sectional leveling mechanics have produced some
extrusion of the upper molars but no intrusion of the
upper incisors. (Produced using OPAL, British Orthodontic
Society).
2. Occlusion and mandibular position.
Closure of anterior open bite and reduction in
LAFH.
• Maintain lower incisor inclination.
• Mandibular auto-rotation to achieve positive
overbite (which will require posterior segmental
maxillary impaction, simultaneously levelling the
maxillary arch).
3. Maxillo-mandibular complex rotation.
• Not applicable.
4. Chin position.
• No adjustment likely to be required.
Key objectives of pre-surgical orthodontic
treatment
• Sectional leveling of upper arch to avoid poten­
tially unstable extrusion of the upper incisors.
• Create space distal to the upper canine roots to
accommodate the surgical cuts.
• Maintain lower incisor inclination.
• Achieve a target reverse overjet of 3–4 mm. This
should produce 5–6 mm of anterior maxillary
advancement.
• Achieve transverse arch coordination.
Final surgical plan
On completion of pre-surgical orthodontics (Figures
9.5.2b and 9.5.3):
• Segmental leveling of the upper arch had been
achieved but with no intrusion of the upper
incisors.
• The reverse overjet measured 4 mm.
• Transverse arch coordination was satisfactory.
The final surgical moves, planned with the aid of
model surgery and photo-cephalometric software,
were as follows:
• Two-part Le Fort I maxillary osteotomy to advance
the anterior maxilla 6 mm, downgraft 2 mm ante­
riorly and segmentally impact 2 mm posteriorly.
• Allow mandibular auto-rotation to close anterior
open bite.

172
Handbook of Orthognathic Treatment
Figure 9.5.5  Superimposed pre- and post-surgical lateral
cephalometric tracings confirm the anterior maxillary
downgraft, the posterior maxillary impaction and the
mandibular auto-rotation to close the anterior open bite.
(Produced using OPAL, British Orthodontic Society).
Figure 9.5.6  End of treatment occlusion. A positive
overbite and overjet were achieved and arch coordination
was satisfactory.
Figure 9.5.7  The vertical relationship of the upper incisors
to the upper lip was normalised and pleasing dento-facial
aesthetics were produced.
Treatment outcome (Figures 9.5.4–9.5.7)
The closure of the anterior open bite was successfully
achieved and the upper incisor show on smiling was
normalised. The soft tissue profile improved through
correction of the maxillary deficiency and pleasing
dental aesthetics were produced. The lower anterior
face height reduced a little and the curvature of the
lower lip improved, although this was not a specific
objective of treatment.
Figure 9.5.4  Post-surgery facial views. From the front (a)
facial proportions are pleasing and the mild para-nasal
hollowing has been corrected. The profile view (b) shows
the upper lip to have moved forwards.
a)
b)

Case 9.6 
Class II, division 1 with hypodontia
Presentation
Caucasian female, 15 years old with clear medical
history.
No psychological contra-indications to treatment.
Patient’s concerns
Functional:
• Finds lack of lower front teeth annoying.
• Upper front teeth dig into lower lip.
Aesthetic:
• Upper front teeth stick out.
• Gaps between front teeth.
• Lower jaw too far back.
Facial features (Figure 9.6.1)
Antero-posterior:
• Class II skeletal jaw relationship.
• Retrognathic mandible.
• Lower lip trap behind upper central incisors.
Vertical:
• Reduced lower anterior face height.
• Deep labio-mental fold.
Transverse:
• No obvious asymmetry.
Intra-oral features (Figure 9.6.2a)
Dentention:
• Developmentally absent 12, 22, 31, 32, 41, 42.
• Upper incisors proclined with large midline
diastema.
Figure 9.6.1  Frontal views of the face
at rest (a) and on smiling (b) show
the reduced lower anterior face
height and lower lip trap. The profile
view (c) shows severe mandibular
retrusion and an accentuated
labio-mental fold.
a)
b)
c)
Figure 9.6.2  (a) Pre-treatment intra-oral view showing proclined upper central incisors and hypodontia. the overjet
could not be measured conventionally but would clearly be increased if the lower incisors were present. (b) The
dentition following pre-surgical orthodontics. Prosthetic upper lateral incisors were attached to the archwire.
a)
b)
173

174
Handbook of Orthognathic Treatment
Key objectives of pre-surgical orthodontic
treatment
• Retract upper central incisors to normal inclination
and close midline disatema.
• Redistribute space for prosthetic 12, 22, 31, 32, 41,
42.
• Achieve arch coordination.
Final surgical plan
On completion of pre-surgical orthodontics (Figures
9.6.2b and 9.6.3):
• The upper incisor inclinations were close to average.
• Spaces were correctly sized for prosthetic teeth.
• Arch coordination was such that achievement of a
class I molar relationship would result in mandibu­
lar advancement of 8 mm.
The final surgical plan, finalised with the aid of
model surgery and photo-cephalometric software,
were as follows:
• Mandibular advancement 8 mm.
• Genioplasty with advancement of 2 mm and verti­
cal augmentation of 4 mm.
Treatment outcome (Figures 9.6.4–9.6.7)
The profile was greatly improved, with the chin
point placed in an aesthetically pleasing position
and the lower lip curvature reduced. The lower lip
rested in front of the upper incisors and the vertical
facial proportions were restored to within the normal
range. The absent teeth were restored using a combi­
nation of bridges, bone grafting and implants.
Occlusion:
• Class II, divison 1 incisor relationship.
• Overjet difficult to define due to absent lower
incisors.
• Buccal segments a full unit class II bilaterally.
Initial combined plan
Desired soft tissue changes and provisional
dento-skeletal movements
1. Upper incisor and maxillary position.
Accept maxillary position.
Retrocline upper central incisors.
• Retraction of central incisors.
2. Occlusion and mandibular position.
Advance mandible to achieve optimal buccal
segment occlusion in the absence of the lower
permanent incisors.
Eliminate lower lip trap.
Increase LAFH and steepness of mandibular plane.
• Mandibular advancement (BSSO) of 8 mm.
3. Maxillo-mandibular complex rotation.
• Not applicable.
4. Chin position.
Achieve optimal vertical proportions and profile
balance.
Improve lower lip curvature.
• Advancement and augmentation genioplasty.
Figure 9.6.3  Superimposition of pre-treatment (red) and
pre-surgery (blue) cephalometric tracings shows some
retraction of the upper central incisors. Significant vertical
growth has continued throughout this phase because of
the patients relatively young age at the start of treatment.
(Produced using OPAL, British Orthodontic Society).
Figure 9.6.4  End of treatment facial views. (a) The
frontal view shows that the lower anterior face height was
normalized. The side view (b) shows that a pleasing
profile was achieved, with a more normal lower lip
curvature.
a)
b)

Case reports
175
Figure 9.6.5  The pre-surgery (red) and post-surgery
(blue) cephalometric superimposition shows the extent to
which pogonion moved forwards and downwards.
(Produced using OPAL, British Orthodontic Society).
Figure 9.6.6  Intra-orally, the edentulous spaces were
restored using implants, following bone grafting, and a
satisfactory class I occlusion was acheived. Some minor
relapse of the upper midline diastema occurred early on
in retention, but the patient was unconcerned.
Figure 9.6.7  End of treatment smiling view, showing
pleasing upper incisor inclination and a normal lower lip
position.

(Trang không có chữ)

Index
acromegaly  50
adaptation to treatment  13
advice on management  6
aesthetic concerns  3
pre-orthodontic surgery  76, 76
airway  138, 138
amber flags  5, 10–11
body image problems  10
disproportionate social effects  11
dissatisfaction with previous
treatment  11
identity issues  10
narcissistic traits  11
preoccupation with minor
defects  10
undue pressure for surgery  10–11
vague concerns with
appearance  10
anterior mandibular
osteotomy  133–6
anterior mandibulotomy  134–5,
135
complications  136
lower anterior segment  133–4, 134
anterior maxillary osteotomy  119–23
complications  121–3
indications  119, 119
Wassmund approach  119–20, 120
Wunderer approach  120–1, 120,
121
anterior open bite  31, 53, 54, 56, 56
case report  170–2, 170–2
antero-posterior jaw relationship  41,
45, 45
asymmetry  28
antero-posterior tooth movement  75
antibiotics  139
anxiety  6, 11, 12–13
Apert’s syndrome  147, 151
appearance
vague concerns with  10
see also aesthetic concerns
Arch bars
bondable  72, 73, 77
conventional  72, 72
see also inter-maxillary fixation
arch width  69–71, 70
articulators  81–3, 83
orthognathic  87–8, 88
blood loss  138
blood tests  137
body dysmorphic disorder  7–8
body form  18
body image  2, 10
Bolton templates  40, 40
brackets  66, 66
breathing  138, 138
canthal drift  152
Carpenter’s syndrome  147
case reports  155–75
anterior open bite  170–2, 170–2
class II malocclusion  157–9, 157–9
class III malocclusion  163–5, 163–5
hypodontia  173–5, 173–5
mandibular asymmetry with 3D
planning  166–9, 166–9
vertical maxillary excess  160–2,
161, 162
CASSOS  94, 100, 105
cast preparation  88–91
antero-posterior movement  90
articulation  89, 89
marking out  89, 90
occlusal repositioning wafer  81, 91
177
Handbook of Orthognathic Treatment: A team approach, First Edition. Ashraf Ayoub, Balvinder Khambay, Philip Benington,
Lyndia Green, Khursheed Moos, and Fraser Walker.
© 2014 John Wiley & Sons, Ltd. Published 2014 by John Wiley & Sons, Ltd.
Page numbers in italics denote figures, those in bold denote tables.
repositioning  90–1, 91
vertical movement  89–90, 90
cephalometrics  39–50
gross inspection  39–40, 39
hard tissue landmarks  41
prediction planning  100
qualitative analysis  40, 40
quantitative analysis  40–9, 41–4,
44–9
reference lines  41
superimposition  49, 49
chin  22–3
position of  58–9
prominence  58–9
circulation  138
class II jaw relationship  53, 67, 69,
157–9, 157–9
class III jaw relationship  53, 65, 76,
77, 163–5, 163–5
clinical assessment  81
communication  12
compression bifocal/multifocal
distraction osteogenesis  143–4,
144
Computer Assisted Surgical Simulation
for Orthognathic Planning see
CASSOS
computerised prediction
planning  96–7, 166–9,
166–9
concerns of patients  17
condylar hyperplasia  50
conebeam CT  36–9, 37, 38
prediction planning  106, 106
craniofacial (hemifacial)
microsomia  153–4, 154
cross-bites  31–2, 32
Crouzon syndrome  147, 149, 151

178
Index
crowding  30, 34, 34, 63–4, 64
curves of Spee  30, 30, 68, 68, 69
decalcification of teeth  18, 18
deep overbite  56
dental appearance  2
dental arches  29–30, 30
coordination  34
dental centrelines  26, 26, 28, 32, 71
dental history  17
dental panoramic tomogram  35–6
dentition see teeth
dento-alveolar dimensions  47
dento-alveolar heights  48, 49
dentofacial assessment  16–50
cephalometrics  39–50
diagnostic records  32–9, 33, 34,
35, 37, 38
facial assessment  18–29, 18,
19–20, 20
general  17–18
intra-oral  29–39
dentofacial dysmorphology  17–18
depomedron  138
depression  6, 8, 11–12
dexamethasone  138
diagnostic records  32–9
collection of  32, 33
role of  32–9
disproportionate social effects  11
dissatisfaction with previous
treatment  11
distraction osteogenesis  139–40, 143,
139–41
compression bifocal/
multifocal  143–4, 144
mandibular  140–3, 141–3
maxillary  143, 143
e-arch  73, 73
ears, shape and position  27
Eastman correction  45, 46, 47
eating disorders  9
expectations  2, 4, 12
unrealistic  12
eyelid shape  27
face bows  84
auricular average value  84
condylar  85
orbital pin  87, 87
orthognathic  87–8, 88
points and planes of
reference  84–5, 84
recording  81, 83–4, 84
registration errors  85–6, 85, 86
selection  81–3, 83
spirit level  87, 87
face height proportions  46–7, 48, 59,
68–9
facial appearance  1–2
facial assessment  18–29, 18, 19–20
bird’s eye view  28, 28
frontal view  24–8, 25–8
lateral view  18, 20–5, 20–5
worm’s eye view  28–9, 28
facial convexity angle  21
facial midline  26
feeding, post-operative  138–139
fistulae  123
fixed appliances  71–2
forehead  21
functional concerns  3
gender dysphoria  10
genioplasty  58–9, 137, 136–7
complications  137
indications  136
procedure  136–7
gingival recession  18, 18
Glasgow Extra-oral Distraction
device  143
Goldenhar’s syndrome  153
growth monitoring  49
“gummy smile”  27, 27, 54
hard tissue/soft tissue ratios  97–9, 98,
99
high level osteotomy  146–54
complications  152
indications  146–7, 147
special investigations  148
timing of surgery  148
Holdaway Harmony Line  23, 23
hypodontia  173–5, 173–5
identity issues  10
incisors
decompensation  63–7, 63–7
inclinations  29–30, 47–9, 48
position of  53–5, 54
reduced vertical display  54
relationship  30–1, 31
show  27, 27, 54
informed consent  137
infra-orbital rims  21
inter-arch mechanics  67, 67
inter-maxillary elastics  74
inter-maxillary fixation  72, 72
intra-arch mechanics  66–7, 66
intra-oral assessment  29–39
dental arches  29–30, 30
soft tissues  32
teeth in occlusion  30–2, 31
inverted L ramus osteotomy  132–134
complications  133
indications  132
procedure  132–133, 133–134
jaw
class II relationship  53, 67, 69,
157–9, 157–9
class III relationship  53, 65, 76, 77,
163–5, 163–5
required movements  52, 52, 65
see also mandible; maxilla
labio-mental angle  22
Le Fort I osteotomy  112–19
bone cut  113, 113, 114
closure  116, 117
final adjustments and
fixation  115–16, 116
indications  112
preparation  112, 112
segmental see Le Fort I segmental
osteotomy
separation and mobilisation  113–
15, 114–15
soft tissue reflection  112–13, 113
Le Fort I segmental
osteotomy  116–19
complications  119
four-piece maxillary  119, 119
mid-palatal split  116–17, 117
procedure  117–18, 117
three-piece maxillary  118–19,
118
two-piece maxillary  118, 118
Le Fort II osteotomy
indications  146–7, 147
surgical procedure  148–9, 148
Le Fort III osteotomy
advantages/disadvantages  152
indications  147, 149, 149
surgical procedure  149–52, 149
learning disability  6
Levasseur-Merril retractor  128, 128
lips
curvature  59
form and symmetry  27–8
lower  22–3, 59
upper  22
long-face syndrome  39
lower anterior segment
osteotomy  133–4, 134
lower lip to sub-mental plane
angle  23
malocclusion  2, 3, 29, 63, 64, 66, 75
class II  157–9, 157–9
class III  163–5, 163–5
types of  48
mandible
antero-posterior relationship  41,
45, 45
asymmetry  59, 166–9, 166–9
morphology  35–6
position  55–7, 55–7
mandibular body osteotomy  130–2
complications  131
indications  130
procedure  130–2

Index
179
mandibular distraction
osteogenesis  140–3, 141–3
mandibular plane angle  23, 24, 45–6,
56–7, 57, 65
master impressions  81
Maxilim  94
maxilla
antero-posterior relationship  45
canting of occlusal plane  54
position of  53–5, 54
surgery  65
surgical expansion  71
vertical excess  160–2, 160–2
maxillary distraction  143, 144
maxillary osteotomy  71
maxillo-mandibular complex
rotation  57–8, 58
MBT™ brackets  66, 66
medical history  17
mid-palatal split  71
mood disturbance  13–14
Nance palatal arch  66
narcissistic traits  11
nasal deviation  28, 122–3
naso-labial angle  22
navigation surgery  108–10, 109, 110
nose  21, 21
occlusal change  33–4
occlusal registration  81
occlusal wafer  72–3
patient/clinician acceptability  73,
73
repositioning  81, 91
occlusion  55–7, 55–7, 69
antero-posterior correction  55–6,
55
cephalometrics  100
checking  74
delivery of  72–3
vertical correction  56–7, 56, 57
see also malocclusion
open bite, anterior see anterior open
bite
orbital complications  152
orbital rims  28
orthodontics  2, 62–79
complications of treatment  18
fixed appliances  71–2
healing phase  74
incisor decompensation  63–7, 63–7
inter-maxillary fixation  72, 72
mechanics  66–7, 66, 67, 69–70, 70
occlusal wafer  72–3
peri-operative  71–3
planning  52
post-surgical  75–6
pre-surgical  11–12, 63–71
progress monitoring  71
retainers  75–6
surgery before  76–8, 76, 77
surgery without  17–18
theatre procedures  73
tooth movement see tooth
movement
osteotomy
anterior mandibular  133–6
anterior maxillary  119–23
high level see high level osteotomy
inverted L ramus  132–4
Le Fort I see Le Fort I osteotomy
Le Fort II see Le Fort II osteotomy
Le Fort III see Le Fort III osteotomy
mandibular body  130–2
sagittal split ramus  123–9
sub-apical  71
vertical subsigmoid  129
overbite  31
deep  56
overjet  30–1, 63, 65
pain  122
minimisation of  138–9
para-nasal region  21
patient planning sheet  81, 82
patients
concerns  17
dissatisfaction with previous
treatment  11
expectations  2, 4, 12
impact on life  3–4
motivation for treatment  4–5
perceptions of problem  3–4
preparation for surgery  12–13
psychological status  5
reactions of others to treatment  13
peri-apical radiographs  36
personality disorders  9
Pfeiffer’s syndrome  147
photography  34
prediction planning  100–1
postoperative care  138
pre-surgical orthodontics  11–12
prediction planning  94–110
accuracy of  97
computerised  96–7
hard tissue/soft tissue ratios  97–9,
98, 99
navigation surgery  108–10, 109,
110
soft tissue profile  95–6, 96
surgery  95, 95
three-dimensional  104–8, 166–9,
166–9
two-dimensional  100–5
preoccupation with minor defects 
10
psychiatric disorders  12
psychological assessment  2–3
motivation for treatment  4–5
outcome  5–6
patient expectations  2, 4, 12
patient perceptions  3–4
psychological issues  1–15
advice on management  6
facial appearance  1–2
red and amber flags  5, 6–11
therapeutic input  11–14
psychological status of patients  5
psychotic disorders  8
radiography
PA skull  39
peri-apical  36
rapid maxillary expansion  70, 70
red flags  5, 7–9
body dysmorphic disorder  7–8
depression  6, 8, 11–12
eating disorders  9
personality disorders  9
psychotic disorders  8
self-harm  9
social phobia  8–9
relapse  122
retainers  75–6
Ricketts zero-meridian line  23, 23
Ricketts “E” Plane  23, 23
root resorption  18
sagittal split ramus osteotomy 
123–8
complications  127–8
condylar segments  126–8, 127
indications  123
procedure  123–5, 123–5
Saithre-Chotzen syndrome  147
SARME (surgically assisted rapid
maxillary expansion)  70–1, 70
schizophrenia  8
scleral show  27, 27
self-harm  9
semi-rigid fixation  74
severity of problem  2
short-face syndrome  39
social evaluation  13
social history  17
social phobia  8–9
soft tissue profile prediction
planning  95–6, 96
somatic delusions  8
special investigations  49–50
stature  18
stereophotogrammetry  34–5, 35
prediction planning  106–8, 106–8
study models  33–4
prediction planning  95
surgery  92–3, 92, 93
sub-apical osteotomy  71
surgery
advances in  92–3, 92
maxillary  65
navigation  108–10, 109, 110

180
Index
prediction planning  95, 95
recent advances  92
see also orthodontics
surgical planning  12–13, 59–60
see also treatment planning
surgical procedures  111–46
anterior mandibular
osteotomy  133–6
anterior maxillary
osteotomy  119–23
blood tests  137
distraction osteogenesis  139–44,
139–40
genioplasty  58–9, 136–7, 136–7
informed consent  137
inverted L ramus osteotomy  131–2
Le Fort I osteotomy  112–19
mandibular body osteotomy  130–1
operative considerations  137–8
postoperative care  138, 138
sagittal split ramus
osteotomy  123–8
vertical subsigmoid
osteotomy  128–30
see also specific procedures
surgical segmental navigation  108–
10, 109, 110
swelling  122
minimisation of  138
technical procedures  80–93
see also specific procedures
teeth  29
crowding and spacing  30, 34, 34,
63–4, 64
extractions  64, 64, 66
iatrogenic damage  18, 18
malocclusion see malocclusion
movement see tooth movement
soft tissue resistance  65
temporary anchorage devices  66–7, 67
therapeutic input
pre-surgical orthodontics  11–12
psychological input
post-surgery  13–14
surgical planning  12–13
three-dimensional prediction
planning  104–8
conebeam CT  106, 106
mandibular asymmetry  166–9,
166–9
planning process  108
software  104–6
stereophotogrammetry  106–8,
106–8
“three-point landing”  68, 69, 75, 75,
79
tongue  32, 33
tooth movement
antero-posterior  75
post-surgical  74–5
resistance to  76
transverse  69–71, 70, 75
vertical  67–9, 68, 69, 75
traction  74, 75
transverse asymmetries  26–7, 26, 27
mandibular  28
transverse proportions  25–6, 26
transverse tooth movements  69–71,
70, 75
Treacher Collins syndrome  153, 153
treatment planning  51–61
chin position  58–9
desired aesthetic changes  51–2
flow diagram  60
maxillo-mandibular complex
rotation  57–8, 58
occlusion and mandibular
position  55–7, 55–7
photo-cephalometric prediction  59
required jaw movements  52, 52
upper incisor and maxillary
position  53–5, 54
see also surgical planning
two-dimensional prediction
planning  100–4
lateral cephalogram  100, 101
lateral profile photograph  100–1
matching  101–2, 102
planning process  102–3, 103
simulation  104, 104
surgical planning sheet  104, 105
undue pressure for surgery  10–11
vertical asymmetries  24–5
vertical maxillary excess  160–2,
160–2
vertical proportions  24, 25
vertical subsigmoid
osteotomy  128–30
complications  130
indications  128
procedure  128–9, 128–9
vertical tooth movement  67–9, 68,
69, 75
vomiting  122
von Binder’s syndrome  147, 147,
149
wax wafers  100, 101