Assessment of Patients for Orthognathic Surgery

L'TanyaJ. Bailey, William R. Proffit, and Raymond White, Jr

Rapid advances in orthognathic surgery now allow the clinician to treat severe dentofacial deformities that were once only manageable by orthodontic camouflage. These cases were often compromised with unacceptable facial esthetics and unstable occlusal results. Over the past 25 years, there have been numerous improvements in technology and the surgical management of dentofacial deformities. These progressions now allow more predictable surgical outcomes, which ensure patient satisfaction. Not all patients are candidates for surgical treatment; therefore, patient assessment and selection remains paramount in the process of diagnosing and treatment planning for this type of irreversible treatment. The inclusion of patients in the decision-making process increases their awareness and acceptance of the final result. The past three decades indicate an increased usage of orthodontic treatment by both children and adults. Patient demographic profiles for severe occlusal and facial characteristics are presented in an effort to understand the epidemiological factors of malocclusion and predict the population's need for this service. (Semin Orthod 1999;5:209-222.) Copy-

right 1999 by W.B. Saunders Company

T nathic surgery have occurred over the past 25 years. Rapid advances in surgical technology
have made it possible to successfully treat patients for whom orthodontic camouflage was once the only m e t h o d of treating a dentofacial deformity, which often resulted in esthetically unacceptable and, quite often, unstable results. Several factors may indicate the n e e d for orthognathic surgery. They often present as impaired mastication and tempromandibular pain and dysfunction, as well as susceptibility to caries and periodontal disease (because of the difficulty maintaining oral hygiene when teeth are severely p r o t r u d e d and irregular). One of the most important factors that is often overlooked is the psychosocial effect from the unestbetic appear-

remendous advances in the area of orthog-

From the Departments of Orthodontics and Oral and Maxillofacial Surgery, University of North Carolina-Chapel Hill School of Dentistry, ChapelHill, NC. Address carrespondence to L'ThnyaJ. Bailey, DDS, MS, Associate Professor; UNC-Chapel Hill School of Dentistry, Department of Orthodontics, ChapelHill, NC 27599-7450. Copyright 1999 by W.B. Saunders Company 1073-8746/99/0504-0002510. 00/0

ance of a severe malocclusion. Proper patient selection remains the primary factor resulting in successful treatment outcome. It is extremely important that the clinician does not overlook the importance of including the patient and parents in the treatmentplanning process. Ackerman and Proffit I suggested the clinician is generally more influenced by objective findings (ie, the problem list), whereas patients are more influenced by subjective findings (ie, their perception of their needs and values). This dichotomy makes effective communication an essential tool when one is faced with the decision between orthodontic camouflage or surgical-orthodontic correction. The m o d e r n concept of patient autonomy versus paternalism in orthodontic treatment planning shifts the role of the doctor from the sole decision maker in the treatment-planning process toward inclusion of the patient as co-decision maker. The patient-parent conference should include the following three components: (1) a description of the problem list by the orthodontist. The patient should have input on the prioritization 209

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of the p r o b l e m list, (2) a review of the risk/ benefit considerations must be presented. The merits of each t r e a t m e n t alternative should be given, including the consideration of no treatm e n t as an option because most orthodontic treatment is elective, and (3) consideration of the patient's expectations and values is of param o u n t importance. I n f o r m e d consent requires not only obtaining the patient's permission to treat after having explained the risks, but also a dialogue between the clinician and patient in deciding on the final t r e a t m e n t plan. It is important that the patient and doctor c o n m m n i c a t e openly a b o u t the decision-making process because the patient's p e r c e p t i o n of the p r o b l e m is not always the same as the doctor's understanding of the issue. 2 A c k e r m a n and Proffit 3 further r e c o m m e n d that the clinician does not ignore the limitations of the soft tissues in guiding the treatmentplanning process. They suggest these soft tissue constraints involve several areas of concern: (1) the pressures exerted on the teeth by the lips, cheeks, and tongue are a p r i m a r y d e t e r m i n a n t of stability, (2) the periodontal a t t a c h m e n t apparatus is a f u n d a m e n t a l consideration in oral health, (3) the t e m p r o m a n d i b u l a r muscular and connective tissue c o m p o n e n t s have a major role in function, and (4) the soft tissue i n t e g u m e n t of the entire face determines esthetics. Cephalometric values guiding the position of the incisors are restricted by racial, ethnic, and p r e t r e a t m e n t positions; thus, orthodontic t r e a t m e n t should reflect the a m o u n t of incisor change that would occur relative to stability because the pretreatm e n t position likely reflects the soft tissue influences. These investigators also suggest that anteroposterior expansion of the incisors by m o r e than 2 m m or transverse expansion by m o r e than 4 or 5 m m will likely be unstable. If macroglossia exists, there is the possibility constriction of the lower arch to close spaces would not be maintained. Previous guidelines have b e e n published outlining the relationship between the periodontium and orthodontic treatment. 4,5 Gingival recession and dehiscence of the alveolar b o n e may occur with orthodontic expansion when the attached gingiva is thin, especially when accompanied by plaque accumulation and inflammation. If there is inadequate attached gingiva,

gingival grafting of the area is r e c o m m e n d e d to avoid recession. Controversy continues regarding the exact p l a c e m e n t of the condyles within the fossae; however, it is generally agreed that treatment that displaces the condyles m o r e than a small distance from their most relaxed retruded position increases the potential for relapse toward a m o r e comfortable location. 6,7 The n u m b e r of potential surgical-orthodontic patients has b e e n elusive. The focus of the remaining discussion provides guidelines to the limits of orthodontic therapy and therefore the indications for orthognathic surgery, as precisely as possible, with estimates on how m a n y patients in the US population would require surgical treatment based on these guidelines.

Indications for Surgical-Orthodontic Treatment

If the patient has a malocclusion with a good skeletal jaw relationship, orthodontic tooth movem e n t alone is usually sufficient to correct a crowded and irregular dentition. A c k e r m a n and Proffit ~ clearly delineated the esthetic guidelines that should be used when evaluating the soft tissue integument. These investigators suggest: 1. Protraction of the incisors would be preferable in a patient with a large nose or chin, providing there would not be excessive deepening of the mentolabial fold. 2. Orthodontics alone can rarely correct severe midface deficiency or m a n d i b u l a r prognathism because these two conditions often are a c c o m p a n i e d by unesthetic lip position and neck form. 3. Moderate amounts of m a n d i b u l a r deficiency are often acceptable to patients, although the orthodontist might prefer m o r e p r o m i n e n c e of the lower face. 4. Maxillary incisors should never be retracted to the point that the inclination of the u p p e r lip becomes negative to a true vertical line. 5. Protrusion of the incisors is excessive and unesthetic if the p r o t r u d i n g teeth cause lip separation greater than 4 m m at rest and lip strain to gain lip seal creates an ill-defined mentolabial sulcus, and orthodontic retraction of the p r o t r u d i n g incisors is indicated.

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6. Overretraction of the maxillary incisors often tilts the oeclusal plane down anteriorly, creating an excessive display of gingiva, which is considered unesthetic. Patients do not m i n d if only m o d e r a t e amounts of gingiva show on smile. 7. W h e n the lower lip is t r a p p e d u n d e r the maxillary incisors (as in cases of excessive overjet) or when the m a n d i b u l a r incisors have b e e n excessively proclined (as in camouflage of skeletal Class II malocclusions), the resulting lip position is unacceptable. 8. Lack of a vermilion b o r d e r (which often results f r o m a concave profile with thinning of the u p p e r lip) is not desirable. Tooth m o v e m e n t that proclines the incisor would create an esthetically fuller lip. 9. Extreme bilabial protrusion is generally perceived as unacceptable, regardless of racial or ethnic group. Most clinicians agree the basic indication for surgical-orthodontic t r e a t m e n t is a skeletal problem of such severity that acceptable correction is not possible with orthodontics alone. Merely correcting the dental malocclusion does not adequately address the problem; the goals of t r e a t m e n t must include good facial esthetics, as well as stability in the ultimate positions of the dentition and jaws. With this in mind, the clinician's responsibility to the potential orthognathic patient is to offer a t r e a t m e n t plan that will accomplish b o t h desirable esthetic and stable results. W h e n a jaw discrepancy accompanies a severe malocclusion, there are three b r o a d possibilities for correction: (1) growth modification, (2) camouflage (orthodontic positioning of the teeth to compensate for the jaw discrepancy), or (3) orthognathic surgery in conjunction with orthodontics to reposition the jaws a n d / o r dentoalveolar segments. Proffit and A c k e r m a n 8 introduced the concept of the envelope of discrepancy to graphically illustrate how m u c h change can be produced by various types of t r e a t m e n t (Fig 1). This diagram helps simplify the relationship of the three basic t r e a t m e n t possibilities for skeletal discrepancies. The inner circle, or envelope, represents the limitations of camouflage treatm e n t involving only orthodontics; the middle envelope illustrates the limits of c o m b i n e d orthodontic t r e a t m e n t and growth modification; and

\
I

- i~\\

\\

/ i/
I B J

Figure 1. The envelopes of discrepancy, showing the

amount of change in the anteroposterior and vertical planes of space that could be expected from orthodontic tooth movement alone (the inner envelope), orthodontic tooth movement combined with growth modification (the middle envelope), and orthognathic surgery (the outer envelope). The possibilities of treatment are not symmetric with regard to the three planes of space. For example, treatment for growth modification is more effective in mandibular deficiency than in mandibular excess. (Reprinted with permission from Proffit WR, Ackerman JL: Diagnosis and treatment planning, in Graber TM, Swain BF [eds]: Current Concepts and Techniques, chap 1, Philadelphia, PA, CV Mosby, 1982.) the outer envelope shows the limits of surgical correction. Growth modification, generally referred to as dentofacial orthopedics, is the most desirable a p p r o a c h to a severe skeletal p r o b l e m when the

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potential for f u r t h e r growth exists. Although the pattern of growth can be favorably modified for some patients, the capacity for major increments in growth is rather limited. T h e variation in response of individual patients, however, suggests growth modification should be a t t e m p t e d in preadolescent patients, a n d parents should be warned that it might not succeed. W h e n a m o d e r a t e skeletal discrepancy exists and there is no potential for further growth (or if m o r e change is required than can be accomplished through growth modification alone), orthodontic camouflage should be considered. T h e teeth are repositioned to establish n o r m a l overjet and overbite in an effort to compensate for the jaw discrepancy. In a m o d e r a t e skeletal Class II malocclusion involving m a n d i b u l a r deficiency, the maxillary incisors can be retracted and the m a n d i b u l a r incisors proclined to establish overjet. Extraction of some teeth will usually be required so that e n o u g h space in the arch can be created to allow significant m o v e m e n t of o t h e r teeth. Such t r e a t m e n t cannot be considered successful if it results in a reasonable dental occlusion at the expense of facial esthetics. In addition, there are limits to how far the periodontium will a c c o m m o d a t e the displacement of teeth f r o m their n o r m a l positions. Consideration of camouflage requires careful examination for the patient's ultimate facial esthetics and occlusal stability. T h e final t r e a t m e n t option for a severe skeletal discrepancy is orthognathic surgery. O n c e growth has ceased, surgery becomes the only means of correcting a severe jaw discrepancy. Although surgery may allow greater changes, there are still limitations to the surgical options, d e p e n d i n g on the type of p r o b l e m and direction of desired jaw m o v e m e n t , and certain problems are m o r e receptive to surgical correction than others. W h e n dental c o m p e n s a t i o n is present, either naturally or previously p r o d u c e d by orthodontic treatment, these dental positions must be reversed before surgical repositioning of the jaws. T h e greater the dental compensation, the smaller the m a g n i t u d e of jaw m o v e m e n t the surgeon has to correct the skeletal discrepancy. T h e t e r m reverse orthodontics is often used in reference to the deliberate m o v e m e n t of teeth in a direction that appears to make the occlusion worse initially when p r e p a r i n g the dentition for orthognathic surgery. W h e n dental compensa-

tions exist, they limit the distance the jaws can be repositioned to achieve a desirable esthetic result. Greater change can be expected when treating a child (who most likely has some r e m a i n i n g potential for growth) with orthodontic tooth m o v e m e n t plus growth modification than for an adult with camouflage orthodontics alone. Consequently, given the same severity of skeletal deformities in b o t h a child and an adult, orthodontics alone in the child may p r o d u c e a desirable result, whereas the adult would not be m a n a g e a b l e without a surgical option. O n e answer to the question of " W h e n is a p r o b l e m too severe for orthodontic treatment only?" is "When the combination of tooth m o v e m e n t and growth modification does not have the potential to bring the patient to n o r m a l occlusion." In a growing child, a malocclusion that c a n n o t be corrected by orthodontics in addition to growth modification is severe e n o u g h that it merits consideration of a surgical plan. In the nongrowing patient, if the malocclusion is too severe to be treated with camouflage orthodontic tooth m o v e m e n t , then a surgical treatment plan should be i m p l e m e n t e d to obtain a reasonable result. T h e envelope of discrepancy is based on occlusal considerations, and esthetic limits apply. Merely obtaining an ideal occlusion at the expense of c o m p r o m i s e d facial esthetics does not constitute a successful t r e a t m e n t outcome. Proffit et al 9 have provided some guidelines for predicting successful o u t c o m e when the choice between surgical versus orthodontic correction exists for an adolescent beyond the adolescent growth spurt (and therefore no longer a p r i m e candidate for growth modification). They c o m p a r e d 40 patients successfully treated with orthognathic surgery for correction of Class II malocclusion with 40 patients successfully treated with orthodontics alone. T h e r e were 21 patients whose orthodontic t r e a t m e n t had b e e n d e t e r m i n e d to be unsuccessful included as a third group in the study. T h e successful treatm e n t in surgical patients resulted from mandibular a d v a n c e m e n t in two thirds of the group; the o t h e r one third h a d vertical repositioning of the maxilla, either alone or in combination with m a n d i b u l a r surgery. Retraction of the maxillary incisors and protraction of the m a n d i b u l a r incisors achieved the successful o u t c o m e in the orthodontic-only group. This g r o u p of patients also e x p e r i e n c e d a significant a m o u n t of vertical

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growth, with 40% having anteroposterior growth greater than 2 m m . T h e important clinical question answered from this study was the difference between the unsuccessfully treated orthodontic g r o u p and the o t h e r two successfully treated groups. Surprisingly, the unsuccessfully treated orthodontic g r o u p h a d similar changes during t r e a t m e n t to the successful group. T h e m a j o r difference was they h a d greater overjet, m o r e severe m a n d i b u l a r deficiency, and greater anterior face height initially. T h e conclusion was a satisfactory orthodontic outcome is unlikely, and therefore surgery is likely to be needed for Class II adolescents beyond the growth spurt when there is overjet greater than 10 m m . Successful orthodontic t r e a t m e n t is less likely when excessive overjet is a c c o m p a n i e d by any of these findings: (1) the p o g o n i o n to nasion-perpendicular distance is greater than 18 m m , (2) m a n d i b u l a r body length is less than 70 m m , or (3) face height is greater than 125 ram.

Treatment Options and O u t c o m e s

T h e following case r e p o r t illustrates some of the t r e a t m e n t options previously discussed.

Case Report
This 9-year, 1-month-old boy (Fig 2A-E) presented in the mixed dentition with a chief complaint of "I have an overbite." T h e patient's medical history indicated he had b e e n hospitalized as a toddler to have tubes placed for repeated ear infections. He had b e e n diagnosed with attention deficit disorder but was not presentiy taking medication. The motivation for t r e a t m e n t was primarily external, f r o m the mother. T h e patient indicated some a p p r e h e n sion, with a lack of desire for wearing o r t h o d o n tic appliances, but would do so if it would give him "straight teeth." No secondary sex characteristics were evident. Previous dental care had b e e n regular, and an oral examination indicated fair oral hygiene, with localized gingivitis and m i n i m u m plaque accumulation. T h e patient's Class II skeletal and dental malocclusion involved m a n d i b u l a r deficiency. T h e patient had an over]et of 7 ram. Space analysis indicated an adequate a m o u n t of space to a c c o m m o d a t e all the p e r m a n e n t teeth. T h e patient was offered a two-phase t r e a t m e n t plan, with phase 1 involving growth modification with

a bionator functional appliance. Comprehensive orthodontics with fixed appliances would follow this phase of treatment, with the timing depend e n t on the e r u p t i o n pattern. The patient was not very compliant, and after 15 m o n t h s (Fig 3A-E), the molars had b e e n corrected to a Class I relationship, but the overjet was r e d u c e d by only 1 m m . T h e r e had b e e n some horizontal growth; however, most of the growth during this period was in a vertical direction. It was decided at this point to discontinue the functional appliance and wait for the eruption of m o r e teeth before initiating phase 2 treatment. Twenty-two m o n t h s passed before a second phase of t r e a t m e n t was r e c o m m e n d e d (Fig 4AE). At this time, the patient was also prescribed a highpull h e a d g e a r and a lower lingual holding arch as m o r e p e r m a n e n t teeth c o n t i n u e d to erupt. Complete fixed appliances were b o n d e d 11 m o n t h s later, and comprehensive t r e a t m e n t c o n t i n u e d for an additional 14 m o n t h s before it was d e t e r m i n e d no additional growth would occur to assist in the correction of the patient's m a n d i b u l a r deficiency. An orthognathic surgical treatment plan involving a bilateral sagittal split osteotomy to advance the mandible, with a lower b o r d e r osteotomy for improved p o g o n i o n projection, was r e c o m m e n d e d . Extraction of the mandibular first bicuspids was required to retract the m a n d i b u l a r incisors and maximize the a m o u n t of surgical advancement. Twelve m o n t h s later, the patient elected to accept this r e c o m m e n d a tion. Figure 5A-E includes the presurgical photographs of this patient. Six m o n t h s after the m a n d i b u l a r surgery, the patient was d e b a n d e d (Fig 6A-E). Although the occlusion was slightly less than ideal, the decision to d e b a n d early was m a d e because of the e x t e n d e d length of treatm e n t time and for medical reasons. Phase 1 t r e a t m e n t time was 15 months, and phase 2 t r e a t m e n t lasted 25 months. T h e total t r e a t m e n t time was e x t e n d e d beyond the average because the dental d e v e l o p m e n t after phase 1 t r e a t m e n t required a transition between the mixed dentition a n d p e r m a n e n t dentition before the p l a c e m e n t o f fixed appliances. T h e cephalometric tracings f r o m (1) initial to end of phase 1 (Fig 7A), (2) end of phase 1 to presurgery (Fig 7B), (3) presurgery to immediate postsurgery (Fig 7C), and (4) postsurgery to final (Fig 7D).

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Figure 2. Patient R.M., aged 9 years 1 month, before treatment. His chief complaint was excess overjet (A, B). Further growth was considered possible. Examination of the profile shows obvious mandibular deficiency. Patient R.M., intraoral views. He has a Class lI, Division 1 malocclusion (C, D, E).

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Figure 3. Facial photographs of R.M. (aged 10 years 3 months) after 15 months of functional appliance (bionator) treatment. Mandibular deficiency was not significantly improved (A, B). Intraoral photographs of R.M. after 15 months of functional appliance treatment showing i m p r o v e m e n t of the molar relationship (C, D, E).

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Figure 4. Facial photographs of R.M. (aged 12 years 1 month) 22 months after cessation of the functional appliance (A, B). At this time, the patient began highpull headgear therapy with a lower lingual holding arch for a period of 11 months before it was determined there was no fllrther growth potential. Tooth eruption did not allow for placement of complete fixed appliances until the age of 14.3 years, at which time he was offered an orthognathic surgical treatment plan, which he declined. Intraoral photographs of R.M. before headgear therapy with a lower lingual arch. He was not very compliant with headgear therapy (C, D, E).

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Figure S. Presurgical photos of R.M., aged 15 years 11 months (A, B). After 12 months of complete fixed orthodontic appliances, he elected to have a bilateral sagittal split osteotomy to advance the mandible, with a lower border osteotomy to improve chin projection. Presurgical intraoral photographs of R.M (C, D, E). Mandibular first bicuspids have been extracted to retract the mandibular incisors and maximize the amount of advancement. This would also help prevent mucogingival problems from developing because the patient also had reduced attached gingiva around the lower anterior teeth.

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Figure 6. Posttreatment facial photographs of R.M. with improved facial balance (A, B). Posttreatment occlusal relationships with ideal ovmjet and overbite (C, D, E). Molar relationship is Class II1 because of extraction of mandibular first bicuspids.

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Figure 7. Superimposition tracings for R.M. showing skeletal changes from initial to after 15 months of functional appliance therapy (solid line, initial; broken line, 15 months) (A). End of phase 1 (functional appliance) to immediately presurgery (solid line, 15 months; broken line, presurgery) (B). Presurgery to immediately postsurgery (solid line, presurgery; broken line, postsurgery) (C). Postsurgery to final (solid line, postsurgery; broken line, final) (D). The radiographs were all taken in natural head position.
The orthognathic surgical option provided improved esthetics and function, and the patient expressed pleasure at the desired outcome. The esthetic improvement was the result of more forward projection of the lower anterior part of the face which provided improved facial balance.

Number of Patients With Potential Need for Orthognathic Surgery

Previous investigations have cited the difficulty estimating the prevalence of severe skeletal malocclusions requiring orthognathic surgery for

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correction of a dentofacial deformity. 1 In the existing literature of the epidemiology of malocclusion, there are very few data that report on facial characteristics or skeletal discrepancies. Summaries of the existing literature have extrapolated the prevalence of dentofacial deformities. 1,11 Most publications describe malocclusion prevalence for adolescents, 12 and only recently has information relative to the adult population b e c o m e available. T h e National Health and Nutrition Estimates Study (N-Hanes III) conducted by the US National Center for Health Statistics describes occlusal traits for a wider age range (age 8 to 50 years).13,14 Because the majority of patients who are candidates for orthognathic surgery are adults with no r e m a i n i n g growth potential, these statistics should be readily available because of the increased usage of o r t h o d o n tic t r e a t m e n t by b o t h children and adults during the past three decades. Proffit et aP 4 s u m m a r i z e d the most recent data available on occlusal characteristics, assuming the most severe characteristics a c c o m p a n y an underlying skeletal discrepancy. Using these data to estimate the potential n u m b e r of patients requiring orthognathic surgery requires some further assumptions a b o u t p r o b l e m severity. Earlier reports suggest the condition for which patients are most likely to present for orthognathic surgical evaluation is m a n d i b u l a r deftciency. 15 T h e presence of severe overjet is highly correlated with a Class II malocclusion, which is suggestive of m a n d i b u l a r deficiency. 9,16 It appears severe Class II malocclusion, with 7 m m or m o r e of overjet, affects approximately 2% of the population and is m o r e prevalent in blacks and Hispanics than whites. N-Hanes III suggests there have b e e n no m a j o r changes in o r t h o d o n tic t r e a t m e n t n e e d during the last 30 years, 14 although the earlier survey was only of children and youths. If it is assumed only the most severe malocclusions (with at least 7 m m of overjet) would be candidates for orthognathic surgery, then approximately 1 million individuals in the US population would be candidates for surgery for a Class II p r o b l e m , with approximately 24,000 cases a d d e d each year (Table 1). l Using reverse overjet as an indicator of Class III malocclusion suggests severe Class III problems are rare in children but occur equally

Table 1. Prevalence of Severe Mandibular Deficiency Requiring Surgery

Parameter
Prevalence of skeletal Class II malocclusion Appropriate age for t r e a t m e n t Severe e n o u g h to warrant surgery Mandibular a d v a n c e m e n t Maxillary setback Both New patients a d d e d to population annually+ + *Based on figures from Proffit et al. 14 t A t 270,000,000 US population. +At 4,000,000 live births per yea1:

PercEntage*
12 65 5 57 2 41 0.6

Numberf
32,400,000 21,060,000 1,053,000 600,210 21,060 431,730 24,000

a m o n g youths and adults. Again, severe Class III p r o b l e m s are m o r e prevalent in Hispanics and blacks than whites. Class III skeletal problems, either m a n d i b u l a r p r o g n a t h i s m or maxillary deficiency, do not r e s p o n d to orthodontic camouflage and growth modification as well as mandibular deficiency. It has b e e n previously suggested that one third of the patients with at least 3 m m of reverse overjet are probably severe e n o u g h to require surgery. 1 Table 2 shows that with this assumption, approximately 580,000 individuals in the United States have a Class III malocclusion severe e n o u g h to require surgical correction, with approximately 12,000 cases a d d e d each year. Trends in Class III surgical t r e a t m e n t indicate fewer isolated m a n d i b u l a r setbacks (the predomin a n t p r o c e d u r e in the 1970s) are being perf o r m e d for correction of this type of malocclusion. A recent study r e p o r t e d an increased n u m b e r of two-jaw and maxillary a d v a n c e m e n t cases for the correction of Class III dentofacial deformities. 17 Less than 10% of the patients with Table 2. Prevalence of Severe Class III Problems Requiring Surgery
Parameter
Prevalence of skeletal Class III malocclusion Appropriate age for t r e a t m e n t Severe e n o u g h to warrant surgery Maxillary a d v a n c e m e n t Mandibular setback Both New patients a d d e d to population annually+ + *Based on figures from Proffit et al. 14 t A t 270,000,000 US population. ++At4,000,000 live births p e r year.

Percentage*
1 65 33 40 9 51 0.3

Number~
2,700,000 1,755,000 579,150 231,660 52,124 295,367 12,000

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a skeletal Class III malocclusion now receive an isolated m a n d i b u l a r setback, whereas maxiUary a d v a n c e m e n t alone is now used in m o r e than 40% of these patients. As late as 1985, 50% of Class III surgery was m a n d i b u l a r setback alone. The reason for the dramatic change is better stability and better esthetics with maxillary surgery. Patients seeking orthognathic surgical consultation for a vertical p r o b l e m present as the third most frequent reason to m a n d i b u l a r deficiency, ~3 with both short-face and long-face problems occurring equally. Previous reports estimated approximately 220,000 with a long-face p r o b l e m severe e n o u g h to warrant surgery, with approximately 6,000 a d d e d to the population annually. 1 Based on c u r r e n t population estimates, this figure has changed very little, with approximately 4,000 patients a d d e d each year (Table 3). Although other skeletal problems (such as short face, asymmetries, and posterior crossbites) requiring surgery exist, if we defer to this earlier report, m these conditions collectively approximate those for the long-face problem. It is a best guess to suggest approximately 219,000 of these " o t h e r s " will also require surgery. T h e o r t h o d o n t i c c o m m u n i t y has l o n g struggled with t r e a t m e n t of c o m b i n e d vertical and a n t e r o p o s t e r i o r problems. Therefore, it might be surmised that m a n y of the Class II or Class III patients would overlap with the longface or other categories, such as asymmetries and crossbites. This previous r e p o r t suggested a 60% overlap between the Class II/Class III and longf a c e / o t h e r groupsm; if this figure is used, the current n u m b e r of persons in the United States who would n e e d orthognathic surgery to correct their severe malocclusion is approximately 1.8 million, or the c o m b i n e d total (Table 4).

Table 4. N u m b e r o f Potential O r t h o g n a t h i c Surgery

Patients Class II Class III Long face Other 1,053,000 579,150 87,750 87,750

219,375 (less 60% overlap) 219,375 (less 60% overlap)

The n u m b e r of individuals in the United States population who would require surgical intervention for satisfactory correction of a dentofacial deformity is impressive, despite the current trend for third-party coverage to deny surgical benefits. The d e m a n d for surgical orthodontic t r e a t m e n t will also continue to increase until the n u m b e r of individuals who can benefit from t r e a t m e n t versus the n u m b e r of those receipting this t r e a t m e n t m o r e closely a p p r o a c h each other.

References
1. Ackerman JL, Proffit WR. Communication in orthodontic treatment planning: Bioethical and informed consent issues. Angle Orthod 1995;65:253-261. 2. Phillips C, Griffin T, Bennett E. Perception of facial attractiveness by patients, peers, and professionals. IntJ Adult Orthod Orthognath Surg 1995;10:127-135. 3. Ackerman JL, Proffit WR. Soft tissue limitations in orthodontics: TreaUnent planning guidelines. Angle Orthod 1997;67:327-336. 4. Vanarsdall RL. Periodontal/orthodontic interrelationships. In: Graber TM, Vanarsdall RL (eds). Orthodontics: Current Principles and Techniques. St Louis, MO: Mosby, 1994;712-749. 5. WennstromJL. Mucogingival considerations in orthodontic treatment. Semin Orthod 1996;2:46-54. 6. Okeson JE Management of Temporomandibular Dism~ ders and Occlusion (ed 3). St Louis, MO: Mosby, 1993; 1-593. 7. Williamson EH. Occlusal concepts in orthodontic diagnosis and treatment. In: Johnston LE (ed): New Vistas in Orthodontics, Philadelphia, PA, Lea & Febiger, 1985; 122-147. 8. Proffit WR, AckermanJL. Diagnosis and treatment planning. In: Graber TM, Swain BF (eds). Current Orthodontic Concepts and Techniques. St Louis, MO: Mosby, 1982; 3-100, chapter 1. 9. Proffit WR, Phillips C, TullochJFC, Medland PH. Surgical versus orthodontic correction of skeletal Class II malocclusion in adolescents: Effects and indications. Int J Adult Orthod Orthognath Surg 1992;7:209-220. 10. Proffit WR, White WR. Who needs surgical-orthodontic treatment? Int J Adult Orthod Orthognath Surg 1990;5: 81-89. 11. McLain JB, Proffit WR. Oral health status in the United States: Prevalence of malocctusion.J Dent Educ 1985;49: 386.

Table 3. Prevalence of Long-Face Problems

Requiring Surgery Parameter
Prevalence of severe anterior open bite Appropriate age for treatment Severe enough to warrant surgery New patients added to population annually + *Based on figures from Proffit et al. 14 tAt 270,000,000 US population. ,+At4,000,000 live births per year.

Percentage* Numbert
0.5 65 25 0.1 1,350,000 877,500 219,375 4,000

222

Bailey, Proffit, and White

12. KellyJ, Harvey C. An assessment of the occlusion of teeth of youths aged 12-17 years. National Center for Health Statistics, Public Health Service, US Department of Health Education, and Welfare Publication No (HRA) 77-1644, Government Printing Office, 1977. 13. BrunelleJA, Bhat M, LiptonJA. Prevalence and distribution of selected occlusal characteristics in the US population 1988-1991.J Dent Res 1996;75:706-713. 14. Proffit WR, Fields HW, Moray LJ. Malocclusion prevalence and orthodontic treatment need in the United

States: Estimates from the N-Hanes III survey. IntJ Adult Orthod Orthognath Surg 1998;13:97-106. 15. Proffit WR, Phillips C, Dann CD IV. Who seeks surgicalorthodontic treatment? I n t J Adult Orthod Orthognath Surg 1990;5:153-160. 16. McNamara JA. Components of Class II malocclusion in children 8-10 years of age. Angle Orthod 1981 ;51:177. 17. Bailey LJ, Proffit WR, White WR. Trends in surgical treatment of Class III skeletal relationships. Int J Adult Orthod Orthognath Surg 1995;10:108-118.