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7
Chin Deformities
Judy Ward, MB, BS,* Silvio Podda, MD,
1
Joe I. Garri, MD, DMD,* S. Anthony Wolfe, MD,*
Seth R. Thaller, MD, DDS
2
Miami, Florida, USA
Facial analysis for chin deformities evaluates the
perioral structures independently and their rela-
tionship to the entire face. Chin deformities in the
absence of malocclusion can be treated by a
genioplasty. Patient evaluation and preoperative
planning and the operative technique for an
osseogenioplasty are outlined with clinical reports
to illustrate.
Key Words: Genioplasty, chin, deformity, retrognathia
T
he chin, occupying its very prominent
position, is one of the elements of the
complex facial structure that contributes to
facial balance and harmony.
1,2
The har-
mony of the facial profile is determined in part by the
size, shape, position, and proportion of the chin with
respect to the other facial elements.
2,3
The facial
profile has been divided into thirds, the lower third
being determined by the size and shape of the chin.
2,3
The patient who presents for facial-contouring
surgery has the goal of correcting imbalances of both
bony and soft tissues of the face to obtain facial
harmony. The position and function of the lips is
determined by the position and form of the under-
lying dentition and chin and the relationship with the
perioral facial mimetic muscles, particularly the
mentalis muscle, which contributes significantly to
labial competence being affected by change in chin
position and altered muscle forces.
4
These patients
should be evaluated in a systematic way, like any
other orthognathic patients.
3,5
Many patients presenting with complaints of a
deficient chin indeed have small mandibles and class
II malocclusion and would benefit from orthodontics
and orthognathic surgery. For the purpose of this
discussion on genioplasty, we have assumed that
patients have a class I occlusion and hence do not
need surgery for correction of their malocclusion.
CLINICAL EVALUATION
T
he facial proportions must be considered and
evaluated as a whole with detailed analysis of
chin position, height of the lower facial third,
symmetry of lower facial third, labiomental sulcus,
dental occlusion, soft tissue characteristics, and nasal
relationship.
5Y7
Traditionally, the face has been evaluated in
terms of vertically equal thirds (Fig 1) and horizontal
equal fifths (Fig2). One shouldkeepinmindthat what
may have been considered ideal proportions can
change over the years and certainly differs with race
and culture. Horizontal lines at the trichion, glabella,
andmenton provide landmarks to divide the face into
upper, middle, and lower thirds (Fig 1; Table 1).
Abnormal proportions require further evalua-
tion of dental occlusion and the facial skeleton to rule
out short or long face syndromes or micrognathia.
The lower third is further subdivided by the stomion
at the point of contact of upper and lower lips.
Stomium to menton should be twice the length the
stomion subnasale distance. Further evaluation of the
frontal view is done by drawing a midsagittal line,
which allows comparison of all paired facial struc-
tures for symmetry.
When evaluating the face in profile, the relation-
ship of the facial thirds also applies and is best
assessedalong the Gonzalez-Ulloa zero meridian. This
is a vertical line drawn perpendicular to the Frankfort
horizontal line, which intersects the nasion (Fig 3). In
the average face, subnasale should fall within this line.
This zero meridian (also called the profile line) can
also be used to assess chin position, because the soft
tissue pogonionVthe most prominent point on the
chinVshould lie approximately in a line through
subnasale making a 10- angle with the zero meridian.
In men, the chin should fall on this line or a couple of
millimeters anterior, whereas in women, it should be
on the line or a couple of millimeters posterior.
16
It is also extremely important to assess the nose,
because balance between the chin and the nose,
especially in the profile view, affects overall facial
887
From the *Miami Childrens Hospital, Miami, Florida; the
1
Department of Plastic and Reconstructive Surgery, St. Josephs
Regional Medical Center and Childrens Hospital, Paterson, New
Jersey; and the
2
Division of Plastic and Reconstructive Surgery,
Jackson Memorial Hospital, Miami, Florida.
Address correspondence and reprint requests to Joe Garri, MD,
DMD, 6280 Sunset Drive, #400, Miami, FL 33143; E-mail: DrGarri@
DrGarri.com
Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 7
harmony. If there is a discrepancy between the
accepted proportions between the chin and the
nose, it is essential to figure out which of the two
structures or if both structures contribute to the
disharmony. Each structure must be evaluated by its
own and how they relate to each other. The ideal
nasal length (RT
i
) is equal to 67% of the middle facial
height (MFH) and equal to the chin vertical measure-
ment Stomion to Mentum (SMe):
RT
i
= 0.67 MFH; RT
i
SMe
The noseYlipYchin plane is determined from a
vertical line drawn through the midpoint of RT
i
touching the upper lip vermilion.
14
Chin projection
should touch this line in men and in women be 3 mm
posterior to it and hence the upper lip sits at or
slightly anterior to the lower lip (Fig 4).
The Ricketts E-line assesses the overall align-
ment of the nose, lip, and chin. It is drawn from the
Fig 1 Facial profile showing the division into upper,
middle, and lower thirds. T = trichion, G = glabella, Sn =
subnasale, Me = menton, FH = Frankfort horizontal, EFH =
upper facial height, MFH=middle facial height, LFH=lower
facial height.
Fig 2 Frontal view with division in equal fifths.
Table 1. Facial Profile With Frankfort Horizontal
Parallel to the Floor
Upper facial height (UFH) Trichion to glabella
Middle facial height (MFH) Glabella to subnasale
Lower facial height (LFH) Subnasale to mentum
MFH should be equal to or slightly (3 mm) less than the LFH.
Fig 3 Gonzalez-Ulloa Zero Meridian. FH = Frankfort
horizontal, N = Nasion, Sn = subnasale, Pg = pogonion.
Perpendicular line to FH which intersects N and Sn
represents the zero meridian or profile line. A line drawn
at 10- to this should intersect with Pg in males or be slightly
anterior to it in females.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 18, NUMBER 4 July 2007
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Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 7
nose tip point pronasali to the most prominent chin
point, the pogonion (Pg
(s)
Vsoft tissue pogonion).
The E-line serves as a reference for the protrusion of
the lips and should fall 4 and 2 mm from the upper
and lower lips, respectively. Disparity can result
from malpositioned lips, nonoptimal tip projection,
or a malpositioned chin
16
(Fig 5). It is important then
to assess each anatomic component separately to
diagnose which component(s) is responsible for the
imbalance.
RADIOGRAPHIC EVALUATION
O
n completion of a detailed clinical evaluation,
confirmatory cephalometric analysis may be
done. Lateral and frontal skull x-rays are taken
and skeletal points on the maxilla and mandible
are evaluated relative to each other and indepen-
dently to the skull base. The important landmarks
on the lateral cephalogram are detailed in Table 2
(Fig 6).
Using cephalometric analysis, many parame-
ters may be compared; the most pertinent ones are
as follows:
SNAis the angle that relates the maxilla to the cranial
base (mean, 82 T 3-);
SNB is the angle that relates the mandible to the
cranial base (mean, 80 T 3-);
ANB is the angle that relates the jaw position relative
to one another. The angle should be zero or positive
to 2 mm.
Fig 4 Vertical line that intersects the midpoint of RT
should also intersect the upper lip and represent the Nose-
Lip-Chin-Plane (NLCP).
Fig 5 Ricketts E-line from the nasal tip; Pronasali = prn
to the pogonion.
Table 2.
Sella (S) Center of the pituitary fossa
Nasion (N) Most anterior point at the nasofrontal junction
Point A Deepest midpoint of the maxillary
alveolar process between the anterior nasal
spine (ANS) and the alveolar ridge
Point B Deepest midpoint on the mandibular alveolar
process between the crest of the
ridge and pogonion
Gonion (Go) Most inferoposterior point at the angle
of the mandible
Gnathion (Gn) Cephalometric intersection of facial
and mandibular planes
Pogonion (Pg) Most anterior point along the contour
of the symphysis
Orbitale (Or) Lowest point on the inferior bony border
of the left orbital cavity
Menton (Me) Lowest point on the contour of
the mandibular symphysis
Porion (Po) Most superior extent of the
external auditory meatus
Mandibular plane Line joining gonion with menton
Frankfort horizontal plane Line joining the porion and orbitale
Aesthetic line Line joining tip of nose with the chin
CHIN DEFORMITIES / Ward et al
889
Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 7
A patient with a class I occlusion will have normal
angles and attention can be turned to determining
the ideal chin point.
Holdaways Angle
Nasion-B point line intercepts forms an angle of 7 to 9
with a tangent to the upper lip and chin. If the ANB
angle is enlarged or reduced, the difference is
correspondingly added to or subtracted from the H
angle.
18
CLASSIFICATION OF CHIN DEFORMITIES
A
n extensive classification system of chin defor-
mities was described by Guyuron,
15
which
includes:
Class I: macrogeniaV(a) horizontal, (b) vertical, (c)
combination of both;
Class II: microgeniaV(a) horizontal, (b) vertical, (c)
combination of both;
Class III: combinedV(a) horizontal macrogenia with
vertical microgenia, (b) horizontal microgenia with
vertical macrogenia;
Class IV: asymmetric ChinV(a) short anterior facial
height, (b) normal anterior facial height, (c) long
anterior facial height;
Class V: witchs chinVsoft tissue ptosis;
Class VI: pseudomacrogeniaVnormal bony volume
with excessive soft tissue; and
Class VII: pseudomicrogeniaVnormal bony volume
withretrogenia secondary to excessive maxillary growth
and associated mandibular clockwise autorotation.
DETERMINATION OF SURGICAL PROCEDURE
A
fter facial analysis is complete, a surgical plan is
formulated based on aesthetics (guided by facial
analysis and cephalometric measurements), which
may involve changing the chin position in the ver-
tical, horizontal, or lateral planes.
1,11,13
The desired
Fig 7 Osteotomy line for a genioplasty.
Fig 8 Sliding genioplasty. Genioglossus and geniohyoid
remaining attached to the inferior border.
Fig 6 Cephalometric tracing.
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quantitative movement of the soft tissue chin point
should be decided on preoperatively and based on
this, the necessary bony movement needed to
produce a reciprocal soft tissue change is calculated.
Depending on the movement made on the bony
menton, the corresponding soft tissue change will
vary. With advancement genioplasty, the ratio of soft
tissue advance at the level of the gnathion has been
predictably calculated to be 0.9:1. Additional benefits
include increase in the submental length and cervico-
mental angle, improved relationship of the lower lip
to the mandibular incisor with less eversion, and
overall advancement of the genialYtongueYhyoid
position, which can have a functional effect in
individuals with nocturnal snoring.
17
The soft tissues
of the chin follow vertical lengthening bony move-
ment with a 1:1 ratio. Reduction osteotomies, how-
ever, have a less predictable effect on the soft tissues
because of the redundancy of the soft tissue that is
created. Horizontal reduction results in a soft tissue
change, which follows the ratio of 0.6:1, whereas for
vertical reduction, the ratio is 0.25:1.
17
SURGICAL TECHNIQUE
T
he techniques that can be used to change the
position and/or the size of the chin are essen-
tially of two types
1,9
: bone contouring techniqueV
genioplasty and use of alloplastic chin implants. The
first option, chin osteotomy or osseous genioplasty, is
discussed here. A genioplasty may be performed as a
single procedure or in conjunction with orthognathic
or other facial cosmetic procedures as part of an over-
all treatment plan to optimize facial aesthetics and
harmony.
1,8,11,13
A genioplasty is performed preferably under
general anesthesia, although sedation and local
anesthesia can be used. The patient is positioned
Fig 9 Jumping genioplasty.
Fig 10 Interpositional bone grafting.
Fig 11 Wedge genioplasty.
Fig 12 Stepladder genioplasty.
CHIN DEFORMITIES / Ward et al
891
Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 7
supine; a donut or headrest should not be used to
allow for adequate head extension. The surgeon
stands at the head of the table where contour and
symmetry of the chin is best appreciated.
Local anesthesia with a vasoconstrictor is infil-
trated below the mucogingival sulcus extending
posteriorly to the second premolar. The incision is
then performed with a needle tip Bovie or a surgical
knife on the free mucosa of the vestibule, leaving a
cuff of tissue for closure. Optimal exposure is
paramount, so the incision extends from cuspid to
cuspid. The incision is extended perpendicularly
thought the mentalis muscle and periosteum, which
is then striped with an elevator to expose the anterior
border of the mandible.
Particular care is taken in exposing the inferior
border until the mental foramen is clearly identified
and the mental nerve protected.
10
Normally the
inferior alveolar nerve exits the mandible through
the mental foramen, which is located just below the
second premolar equidistant from the superior and
inferior border of the mandible. After positive
identification of the neurovascular bundle, it is
imperative to perform a dissection below it, because
the genioplasty osteotomy extends well posteriorly
on the mandible from this point.
The midline of the mandible is then marked by
comparison to the dental midline and other facial
structures, most commonly with the use of an
oscillating saw to carve a permanent vertical mark
in the cortical bone. The oscillating saw is then used
perpendicular to this line to make an osteotomy of
the anterior mandible full-thickness to the lingual
cortex. Then the reciprocating saw is used to
complete the osteotomy laterally. The level of the
osteotomy must be at least 5 mm below the canine
root
11
and when extended laterally 6 mm below the
inferior to the mental foramen.
20
Fig 13 Patient presented with a deficient, asymmetrical chin for which a centering, advancement genioplasty was
undertaken. (A) - Frontal, preoperative; (B) - Frontal, postoperative; (C) - Lateral preoperative; (D) - Lateral, postoperative.
Fig 14 Retrognathia with evidence of mentalis strain preoperative. An advancement genioplasty was undertaken with a
much improved facial profile and mentalis function. (A) - Frontal, preoperative; (B) - Frontal, postoperative; (C) - Lateral,
preoperative; (D) - Lateral, postoperative.
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When cutting in the area of the inferior border of
the mandible, the surgeons nondominant hand is
used to palpate the tip of the blade, thus ensuring
that both cortical walls have been fully cut. When all
the osteotomies have been completed, the periosteal
elevator is then placed at the osteotomy site in
the midline and, with a torquing motion, the two
segments of the bone are separated. Once the
separation is done, the distal segment should
maintain its lingual attachments that consist of the
two muscles genioglossus and geniohyoid (Fig 7).
These muscles need to be stretched at this point if
advancement is planned. It is recommended that
the pogonion not be advanced beyond a perpen-
dicular dropped from the lower lip because this
results in a markedly exaggerated appearance of
the chin.
The distal segment is then placed in the desired
position and the inferior border checked for any
sharp edges or steps that are smoothed with a rasp.
Rigid fixation is achieved with a bone plate or
screws. Plates can either be prefabricated to different
lengths of chin advancement or regular straight
plates, which are bent to fit in the operating room.
For screw fixation, 2-mm bicortical screws are
usually used, of which two are needed to attain
adequate fixation.
When vertical shortening is anticipated, two
osteotomies are performed following markings at
the level of the B point of the mandible and a second
inferiorly on a parallel plane. The distance between
the parallel osteotomies should be calculated
preoperatively and should be equal to the amount
of desired reduction. The inferior osteotomy has to be
performed first such that the superior one is
performed on a stable segment. After the osteotomies
have been completed, the intervening bone fragment
is removed and the two segments placed in the
proper position and the fixation applied. For increase
in the vertical dimension, a singular osteotomy is
necessary and an intervening bone graft is placed in
between the two bony segments.
Once the fixation is successfully completed, the
surgical site is copiously irrigated and the soft tissues
are then closed. This can be done in two layers, first
the muscle layer followed by the mucosa or just a
single layer with resorbable sutures. An external
dressing is not necessary in these cases, but many
surgeons advocate the use of foam tape around the
chin to maintain soft tissue stability and reduce the
postoperative edema.
The genioplasty procedure is further differen-
tiated and classified depending on the variation of
techniques, the reciprocal movements of the man-
dible segments, and the final result that needs to be
achieved.
1,11Y13
The classification follows:
1. In the sliding genioplasty, the osteotomy segment
slides anteriorly and the lower third vertical
dimension is not modified (Fig 8).
2. In the jumping genioplasty, the caudal segment is
moved anteriorly and placed in front of the
mandible, almost like an implant. The lower soft
tissue attachments of the segment should be
preserved to avoid bone resorption. This nomen-
clature was actually used for the first time by
Gilles and indicates the attempt to improve the
sagittal projection of the chin and decrease the
height of the lower facial third
24
(Fig 9).
Fig 15 27-year-old male who desired a stronger chin underwent a 5 mm advancement genioplasty concomitant with
submental liposuction. (A) - Frontal, preoperative; (B) - Frontal, postoperative; (C) - Lateral, preoperative; (D) - Lateral,
postoperative.
CHIN DEFORMITIES / Ward et al
893
Copyright @ 200 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. 7
3. In the graft genioplasty or interpositional genio-
plasty, the advancement is achieved with the
interposition of bone graft between the mandible
segments to advance the chin as well as increase
the lower facial height (Fig 10).
4. In the wedge genioplasty, the anteroposterior
dimension and projection of the chin is increased
and the height of the lower facial third is
decreased (Fig 11). Two horizontal osteotomies
parallel to each other and to the occlusal plane are
performed and, after the caudal cut is made, the
segment between the osteotomies is resected. In
this case, you reduce the lower facial third height
considerably. It is important to let the patient
know that a certain degree of soft tissue ptosis
may occur.
5. In the case of oblique genioplasty, the osteotomy
is performed obliquely on the sagittal plane,
allowing the distal fragment to slide anteriorly
and superiorly if the posterior aspect of the cut is
more caudal. In case the posterior aspect of the cut
is more cephalad, the distal fragments slide
anteriorly and inferiorly.
6. The stepladder/two-tiered genioplasty technique
is used instead in cases of important sagittal
advancement without significant modification of
the lower facial third height. Two osteotomies are
performed and the lower segment is advanced
sagittally over an already advanced proximal
segment (Fig 12).
7. Finally, there are a special group of procedures,
in which the vertical and horizontal asymmetry
are corrected and these are called asymmetric
genioplasty. Normally, a lateral wedge of the
bone is resected on the longer side and used in
the contralateral side. The midline is also shifted
to the center of the facial axis during this
procedure.
Figures 13, 14, and 15 show patients who have
undergone genioplasty surgery with stable post-
operative results.
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