The surgicaborthodontic correction of

mandibular defiiency. Part II I.-

Dr. Epker

Bruce N. Epker, D.D.S., Ph.D.,* and Leward C. Fish, D.D.S., M.S.**

Fort Worth, Texas

As discussed in Part I of this study, persons with mandibular deficiency and Class II malocclusions exhibit a wide
spectrum of esthetic, cephalometric, and occlusal characteristics. In many such patients optimal overall results are
best obtained via a combined orthodontic-surgical approach. In such patients a critical evaluation is essential to
decide (1) the optimal operation and (2) the appropriate orthodontic-surgical sequencing. Our method of making
these two basic decisions was presented in Part I. In this article the indications for mandibular advancement with or
without genioplasty, total subapical mandibular advancement, superior repositioning of the maxilla, and inferior
repositioning of the maxilla are discussed in detail. These alternatives are illustrated with representative cases, and
the results are discussed. The intention of these two presentations is to illustrate an orthodontic-surgical approach
to the correction of mandibular deficiency and Class II malocclusion that is predicated on a systematic evaluation of
the individual patient rather than a standard approach.

Key words: Orthognathic surgery, Class II occlusion, mandibular deficiency, genioplasty, anterior maxillary
ostectomy, mandibular advancement, superior repositioning of maxilla, inferior repositioning of maxilla

In Part I of this paper we discussed the basic

preparatory orthodontic treatment and listed those basic
surgical procedures that may be appropriate in treatment
of the patient who has a mandibular deficiency. Illustra-
tive cases treated by genioplasty and anterior maxillary
ostectomy were presented. Part II will complete the
spectrum of surgical techniques by presenting cases to
illustrate each of the remaining surgical options listed in
Part I, beginning with mandibular advancement.
Mandibular advancement of total mandible
sag&al osteotomy
In the majority of persons MD can be corrected
most simply and successfully via a mandibular ad-
vancement in concert with orthodontic treatment. Pre-
surgical orthodontic treatment is most often required to
eliminate dental compensations to the existing skeletal
deformity by retracting lower incisors, thus allowing
more complete skeletal correction. The curve of Spee
in the upper and lower arches is also often excessive,
and this precludes advancement of the mandible into a
Class I occlusion with reasonable overbite and overjet.
In addition, the upper arch is frequently too narrow to
permit advancement without producing a posterior
crossbite. In some cases, however, the arches are level
and the surgery can be done early. On occasion, an
anterior mandibular subapical osteotomy can be per-
formed simultaneously with the advancement to level
an excessive curve of Spee. If, however, the existing
“deep bite” is due to a reverse curve of Spee in the
maxilla, then consideration can be given to correction of
this reverse curve via an anterior maxillary procedure.
CASE 5
via Esthetic evaluation
The full-face evaluation of this 18-year-old male patient
revealedno significant abnormal esthetic findings (Fig. 1, A ).
In profile, the nasolabial angle was normal, the labiomental
fold prominent, and the chin recessivewith the resultant poor
chin-lip-nose balance (Pig. 1, B).
Csphalometric evaluation
Both facial axis and facial depth indicated a recessive
chin. The maxilla was within normal limits anteroposteriorly
(Fig. 1, C). The mandibular plane angle was slightly low.
The entire lower dental arch seemed to be placed posteriorly,
and both upper and lower incisors were much too upright.
The functional occlusal plane would indicate that the deep
bite was due to overeruption of the lower incisors. Both lips
were recessive relative to the E line.

*Director, Oral and Maxillofacial Surgery and Center for Correction of Dento- Occlusal analysis
facial Deformities, John Peter Smith Hospital.
**Orthodontist, Center for Correction of Dentofacial Deformities, John Peter Alignment. All teeth were present, and no asymmetry
Smith Hospital. existed. There was moderate crowding in the lower arch,

491
 Fig. 1. Case 5. A, Pretreatment full-face photograph. 8, Pretreatment profile. C, Pretreatment
cephalometric tracing.

Fig. 1, D and E. Pretreatment and posttreatment occlusion.

while the upper arch showed the typical Class II, Division 2 normal limits. Therefore, the definitive treatment plan de-
configuration (Fig. 1, D). cided upon was as follows:
Inter-arch relations. A Class II molar and canine relation 1. Presurgicul orthodonric,s. Rapid maxillary expansion
existed with a deep bite (Fig. 1, E). (4 mm.) followed by alignment and leveling of both
arches
Treatment plan 2. Surgery. Mandibular advancement via sagittal os-
When the patient protruded the mandible into an edge-to- teotomies.
edge incisal relation, the esthetics were improved and judged 3. Postsurgical orthodontics. Finishing and retention.
good; yet the teeth could not be placed into a Class I occlusion
because of the excessive curves of Spee in both arches and Treatment results
because of the tooth alignment. Feasibility model surgery The esthetic, cephalometric, and occiusal results are
prior to orthodontic treatment confirmed the inability to place shown in Fig. 1, D to H.
the patient into a Class I canine and molar occlusal relation
with reasonable overjet and overbite relations. A cephalo- Comment. In some cases of mandibular deficiency
metric prediction tracing revealed that presurgical nonextrac- syndrome, the patient is able to protrude the lower jaw
tion orthodontic treatment and mandibular advancement sur- into a reasonable Class I occlusion, simulating surgical
gery placed most cephalometric values within essentially advancement of the mandible. In such instances, a

Fig. 1 (Cont’d). F, Posttreatment full-face
cephalometric tracing.
clinical, photographic, and cephalometric evaluation
of the patient in this position will allow an accurate
determination of the desirability of the results that
would be achieved with only mandibular advancement.
In most cases, however, this is not possible, because
excessive vertical opening occurs posteriorly, produc-
ing an unrealistic result. Thus, prediction tracings
must be done in order to assist one in making determi-
nations such as the need for simultaneous augmentation
genioplasty .
This case is typical of the Class II, Division 2,
mandibular deficiency with deep bite and illustrates the
combined surgical-orthodontic treatment most com-
monly rendered. It is important that, from an orthodon-
tic standpoint, several general guidelines be followed.
First, extractions should be predicated solely upon
crowding and the relation of the teeth to basal bone.
Opening of the bite anteriorly can be done easily, with
good stability, by the surgical procedures; thus, a tem-
porary presurgical orthodontic deepening of the bite is
of little consequence and may be beneficial in allowing
a more noticeable increase in lower face height when
the mandible is advanced.‘, ’ Second, the more the bite
is opened surgically, the more the lower face height
will increase and the less pogonion will be advanced.
Indeed, in the extreme deep bite case, the teeth may be
advanced to correct the Class II malocclusion while
pogonion does not come forward at all. This must be
appreciated and the situation corrected by adding an
augmentation genioplasty to the surgical plan, by ex-
tracting teeth in the lower arch, or by leveling the upper
Surgical-orthodontic correction of mandibular dejiciency 493
photograph. G, Posttreatment profile. H, Composite
and lower arches via intrusion of incisor teeth ortho-
dontically or surgically. It must be emphasized in the
deep bite case that if maximal pogonion advancement
and minimal vertical increase are desired the arches
must be leveled by intrusion of anterior teeth orthodon-
tically or surgically, thus minimizing the opening rota-
tion of the distal segment when the mandible is ad-
vanced. Third, the intrusion or extrusion of specific
teeth in the leveling process is unnecessary, except for
the vertical position of the upper incisors relative to the
upper lip and as noted above. Leveling of the lower
curve of Spee via extrusion of posterior teeth and/or
intrusion of anterior teeth is quite acceptable and, in our
experience, is stable when done in conjunction with a
mandibular advancement.
Recently, we have shown that the result of man-
dibular advancement surgery is stable if the sur-
geon achieved several specific technical objectives.** 3
Otherwise, relapse occurs.
Finally, seldom is a suprahyoid myotomy of benefit
in these patients, especially if the suprahyoid muscles
are not lengthened more than 30 percent of their origi-
nal length, as they can readily adapt to this change
physiologically.4 This is due primarily to the fact that,
with mandibular advancement in MD with deep bite,
the mandible generally rotates in an opening direction,
with lower incisors advancing more than the chin, thus
minimally lengthening the suprahyoid muscles. The
opposite is true in MD patients with steep mandibular
plane angles and insufficient overbite, where suprahy-
oid myotomies may be indicated.
494 Epker and Fish

Fig. 2. Case 6. A, Pretreatment full-face photograph. B, Pretreatment profile. C, Pretreatment

cephalometric tracing.

Fig. 2, D and E, Pretreatment and posttreatment occlusion

Mandibular advancement with prior
surgical-orthodontic maxillary expansion
Some persons with MD cannot undergo the indi-
cated surgical advancement of the mandible because a
transverse deformity (crossbite) would be produced
when the mandible was advanced. This situation is
complicated in the adult in whom palatal expansion by
orthodontic means is unstable .5
CASE 6
Esthetic evaluation
A 27-year-old woman was evaluated for correction of a
dentofacial deformity. In the frontal view, facial symmetry,
balance, and morphology were good. In the lower third of the
face, however, there was a deep labiomental fold and ever-
sion of the lower lip (Fig. 2, A). In profile, the nasal projec-
tion was strong, with a slight dorsal hump. The nasolabial
angle was normal, between 90 and 110 degrees. The lower lip
posture was poor and the chin was quite retrusive (Fig. 2, B 1.
Cephalometric evaluation
Both facial axis and facial depth indicate the presence of a
recessive chin (Fig. 2, C). The mandibular plane angle was
within normal limits. The maxilla was normally positioned
relative to the cranial base, even though it was 6 mm. anterior
to the facial plane. The functional occlusal plane was in nor-
mal relation to Xi point, and the lip embrasure and the lower
incisors were observed to be supererupted. The lower in-
cisors were recessive in relation to the A-PO line, and the
Volume 84 Surgical-orthodontic correction of mandibular dejiciency 495
Number 6

Fig. 2 (Cont’d). F, Posttreatment full-face photograph. G, Posttreatment profile. Ii, Composite

cephalometric tracing.

lower lip was excessivelyeverted becauseof the upper incisor
teeth.
Occlusal analysis
Alignment. All teeth were present, with moderate crowd-
ing in the lower arch. The upper arch was V shaped, and the
lower arch was U shaped (Fig. 2, D).
Interarch relations. A severe Class II molar and canine
occlusion and a deep bite were present (Fig. 2, E).
Treatment plan
The treatment plan consisted of the following:
1. Preliminary dental care. Peridontal therapy.
2. Phase 1 surgery. Selected maxillary osteotomies
for combined surgical-orthodontic expansion of the
maxilla.6, ’
3. Orthodontics: Leveling and alignment of maxillary
teeth and lower arch from the canine distally.
4. Phase 2 surgery. Advancement of the mandible with
sagittal osteotomies and removal of the four lower
incisors for peridontal reasons.
5. Postsurgical orthodontics. Finishing and retention.
6. Dejinitive restorative dentistry. Anterior mandibular
six-unit fixed bridge.
Treatment results
The esthetic, skeletal, and occlusalchangesproduced can
be seenin Fig. 2, D toH. The patient has been followed for 6
years, with a stable result.
Comments. Two aspects of this patient’s treatment
will be commented on:
SURGICAL-ORTHODONTIC SEQUENCING. As preVi-
ously stated, our premise is to perform surgery as early
as possible in the overall surgical-orthodontic treatment
sequence. Yet, in most persons with mandibular deti-
ciency, considerable presurgical orthodontic proce-
dures must be done in order to place the upper and
lower arches into reasonable occlusion at the time of
surgery. Thus, in many cases of mandibular deficiency,
most of the orthodontic treatment is completed prior to
surgery.
EXPANSION OF THE MAXILLA. Ill PerSOnS Over 18
years of age, rapid maxillary expansion results in a high
percentage of relapse.5 Therefore, one must consider a
combined surgical-orthodontic expansion in such in-
stances.6* ’ Our general approach, when the maxilla
will have to be widened to accommodate the advanced
mandibular dentition, is as follows. If the patient is an
adult and the amount of expansion is greater than 5
mm.7 a combined surgical-orthodontic approach is
used. If it is less than 5 mm., orthodontic rapid maxil-
lary expansion should be attempted. However, if the
midpalatal suture does not open as evidenced by the
early creation of a diastema between the central in-
cisors, one should stop and use the combined surgical-
orthodontic approach.
Mandibular advancement with augmentation
genioplasty
In some patients with MD in whom a mandibular
advancement is indicated in concert with preparatory
orthodontics, there is a co-existing microgenia which
requires an augmentation genioplasty if an optimum
496 Epker und Fish
Fig. 3. Case 7. A, Pretreatment
lometric tracing.
esthetic result is to be achieved. A typical example IS
the following case of a patient who was referred for
consultation regarding her dentofacial deformity.
CASE 7
Esthetic evaluation
Good facial symmetry existed. There was some lower
third facial imbalance, and the patient exhibited a dolichoce-
phalic face (Fig. 3, A ). In profile, a prominent nose, a normal
nasolabial angle, and a retrusive chin were present. There was
virtually no neck-chin angle (Fig. 3, B ).
Cephalometric evaluation
Facial axis and facial depth were low, indicating a reces-
sive chin (Fig. 3, C). The maxilla was 7 mm. anterior to the
facial plane but was in essentially normal relation to the cra-
nial base. The functional occlusal plane was in normal rela-
tion to Xi point and the lip embrasure. The lower lip appeared
prominent, largely because of the extreme recession of the
chin.
Occlusal analysis
Alignment. Both upper and lower arches were normal in
shape, with moderate crowding and good symmetry. The
lower second premolars had not yet erupted (Fig. 3, D).
Interarch relations. A Class II, Division 1 malocclusion
was present in both molar and canine areas. There was a
tendency toward posterior crossbite (Fig. 3, E).
Treatment plan
The treatment plan decided upon was as follows:
1. Presurgical orthodontics. Extraction of upper second
full-face photograph. 6, Pretreatment profile. C, Pretreatment cepha-
premolars and lower first premolars. Space closure
with Class III elastics to produce a severe Class 11.
2. Surgery. Sagittal advancement of mandible; augmen-
tation genioplasty.
3. Postsurgical orthodontics. Finishing and retention.
Treatment results
The esthetic, skeletal, soft-tissue and, occlusal results are
shown in Fig. 3, D to H.
Comment. Prediction tracings in such cases, as well
as having the patient protrude the mandible into a Class
I occlusion, typically demonstrate that the chin remains
retrusive and poor chin-lip-nose balance results. More-
over, the neck-chin angle remains poor. In most such
cases, the relatively prominent nose makes it even more
important to consider augmentation genioplasty since
this de-accentuates the nose. Previously, with the
dolichocephalic face, alloplastic augmentation of the
chin generally was preferred since better lateral aug-
mentation can be done, thus improving the front-face
morphology.7 More recently, however, in an effort to
eliminate the use of alloplasts, Epker used a horizontal
osteotomy with widening to achieve the same objec-
tives. (See Case 1.)
Of further interest is the extraction choice in this
case. By choosing to extract the lower first premolars,
one can retract the lower incisors maximally, thus ef-
fectively increasing the amount of advancement and
maximizing the pogonion. Extraction of the upper sec-
ond premolars will allow essentially no retraction of the
Volume 84 Surgical-orthodontic correction of mandibular dejiciency 497
Number 6

Fig. 3 (Cont’d). D and E, Pretreatment and posttreatment occlusion. F, Posttreatment full-face photo-
graph.

Fig. 3 (Cont’d). G, Posttreatment profile. H, Composite cephalometric tracing.

498 Epker und Fish

Fig. 4. Case 8. A, Pretreatment full-face photograph. 6, Pretreatment profile. C, Pretreatment cepha-

lometric tracing.

Fig. 4. (Cont’d). D, Posttreatment full-face photograph. E, Posttreatment profile. F, Composite

cephalometric tracing.

upper incisors and will produce a severe Class II mal-
occlusion, again maximizing the amount the mandible
can be advanced. Using Class III elastics in addition to
the above will help guarantee success in achieving the
desired esthetic result.
Mandibular advancement with reduction
genioplasty
A few patients have severe Class II occlusion and yet
the chin projection is esthetically acceptable. In such a
case, if the mandible is to be advanced, the chin becomes
too prominent and must be reduced. This problem will
be illustrated with the following case report.
CASE 8
Esthetic evaluation
The patient had good facial symmetry, balance, and mor-
phology The only notable problem was eversion of the lower
lip and a deep labiomental fold (Fig. 4, A ). In profile, again
the face was normal with rhe exception of the lower lio and
Vohme 84 Surgical-orthodontic correction of mandibular deficiency 499
Number 6

Fig. 5 (Cont’d). G, Posttreatment profile. H, Composite cephalometric tracing. I and J, Posttreatment

occlusion.

Fig. 5 (Cont’d). D and E, Pretreatment occlusion.) F, Posttreatment full-face photograph.

 Fig. 5. Case 9. A, Pretreatment full-face photograph. B, Pretreatment profile. C, Pretreatment cepha-
iometric tracing.

labiomental fold. Significantly, there wa5 good balance fntrrcrrch relntiom. There was a full Class II. Division 1
between the nose, the upper lip, and the chin projection malocclusion with deep bite.
(Fig. 4, B).
Treatment plan
Cephalometric evaluation
The treatment plan called for the following:
The facial depth showed a normal chin projection, while
I Prrsurgical orthodontics. The orthodontic treatment
the facial axis would indicate a tendency toward a short facial
plan was to correct the problem via nonextraction
height (Fig. 4, C). The mandibular plane angle was extremely
orthodontics. Growth and/or orthodontic mechanics
low, again indicative of a short lower face height. The func-
produced a vertical change, but no correction of the
tional occlusal plane was angled upward toward Frankfort
Class 11 problem, so the patient was advised that sur-
anteriorly and was in normal relation to the lip embrasure but
gical intervention would be indicated to correct this
very low relative to Xi point posteriorly. The mandibular
problem.
dentition was recessive, and this was the essential cause of the
2. Surgery. Mandibular advancement with a reduction
Class II occlusion. The maxilla and upper dentition were
genioplasty.
normally related to the cranial base. A deep labiomental fold
3. Postsurgical orthodontics. Finishing and retention.
was generated by the recessive nature of the mandibular den-
tition.
Treatment results
Occlusal analysis
The esthetic, skeletal, and soft-tissue results are shown in
Alignment. The upper and lower arches had been well Fig. 4, D, E, and F.
aligned and leveled by nonextraction orthodontic treatment.
Arch form and symmetry were good. Commmr. It is known that the vast majority
Volume 84
Number 6
(perhaps 95 percent) of persons with mandibular
deficiency and a low mandibular plane angle have a
primary component of anterior mandibular growth
which is advantageous to orthodontic correction during
active growth.8 Accordingly, in cases such as the one
illustrated, it is often suggested that the patient did not
cooperate and wear the elastics and/or headgear and,
therefore, the Class II occlusion was not corrected.
It has been our finding that in a number of such cases
(as in the one just presented) when the growth of the
specific patient is analyzed the patient did not conform
to the norm but, instead, grew downward and back-
ward like the patient with a high mandibular plane
angle.’ In these cases the vertical growth pattern
andior the orthodontic mechanics, rather than the pa-
tient’s lack of compliance, may be at fault. When this
occurs, the problem can be resolved by means of surgi-
cal correction.
In cases like this, when a good pogonion exists
prior to surgery, simply advancing the mandible will
produce a chin that is too protrusive. This is readily
determined by having a patient protrude the mandible
into a Class I occlusion and then evaluating the es-
thetics created and/or doing a prediction tracing. In
such instances, one has the option of either advancing
the mandible and simultaneously reducing the chin, as
was done in this case, or performing a total subapical
mandibular advancement, as will be discussed in the
following case. When advancement and reduction
genioplasty are done, the genioplasty must be carefully
planned in order to achieve predictable esthetic results.
In planning, one can use the prediction tracing NB : Pog
relation to determine the amount of pogonion that must
be reduced. However, simply excising this amount of
bony chin will produce predictably poor results.i. y In
reduction genioplasties, the symphysis must not be de-
gloved. Instead, a cut is made and/or a wedge of bone
is removed while as much soft tissue as possible is left
attached to the distal portion and the entire bony-
soft-tissue chin is retruded and wired. When this is
done, essentially a 1: 1 reduction of soft-tissue chin to
hard-tissue chin occurs.
Total subapical mandibular advancement
CASE 9
A 17-year-old girl was evaluated with respect to a dento-
facial deformity.
Esthetic evaluation
The front-face evaluation revealed good symmetry, with
a foreshortened lower third of the face and an everted lower
lip (Fig, 5, A ). In profile the prominent labiomental fold was
the only significant finding, with the chin projection being
judged essentially normal (Fig. 5, B ).
Surgical-orthodontic correction of mandibular dejiciency 501
Cephalometric evaluation
Facial depth was normal. The facial axis was excessive,
which would indicate that the lower face height was de-
creased. The mandibular plane angle was low, again pointing
toward decreased lower face height. Point A was behind the
facial plane because of the proclination of the upper incisors
and the prominence of pogonion. The upper molar was nor-
mally related to the cranial base. The occlusal plane was
tipped upward toward Frankfort anteriorly, being essentially
normal relative to the lip embrasure but low posteriorly rela-
tive to Xi point (Fig. 5, C).
Occlusal analysis
Alignment. The lower right first molar was missing.
Symmetry was good, and slight crowding was present (Fig.
5, D).
Interarch relations. There was a Class 11 deep bite
malocclusion. Transverse relations were normal (Fig. 5, E).
Treatment plan
The esthetic features suggested that esthetics would be
optimized by bringing the mandibular “dentoalveolar” seg-
ment forward and not increasing the chin projection or retract-
ing the upper lip.
Since the models could be positioned into a good Class I
molar and canine occlusion, it was recommended that the
problem be resolved with only surgical intervention.
In profile, the chin point was considered not to be retru-
sive. Therefore, a total mandibular subapical advancement
was decided upon. However, this case could have been han-
dled exactly as the previous case, since these two operations
will produce almost identical results.
Treatment results
Fig. 5, F and G shows the changes in appearance, and the
composite cephalometric tracing and final occlusion are
shown in Fig. 5, H, I, and J. The patient has been followed
for 4 years and has maintained a stable result.
Comment. Three points must be discussed with re-
gard to which of the two preceding operations (man-
dibular advancement with reduction genioplasty or total
subapical mandibular advancement) might best be done
in these cases. These points are (1) technical ease, (2)
vertical changes, and (3) segmentalizing the mandible.
TECHNICAL EASE. It is technically easier to perform
a sagittal mandibular advancement and reduction ge-
nioplasty than a total subapical mandibular advance-
ment. Moreover, the anatomy in most cases in which a
total subapical advancement would be desirable (good
chin projection with low mandibular plane angle and
with the Class II occlusion being due to posteriorly
placed dentition and alveolus) is such that the inferior
alveolar neurovascular bundle is close to the inferior
border of the mandible. This not only makes the total
subapical mandibular advancement technically dif-
502 Epker and Fish
Fig. 6. A, Decortication of bone overlying
teotomy cuts. D, Angled cut behind last molar tooth.
ficult, but, moreover, it is associated with a higher
incidence of postoperative inferior alveolar nerve
dysesthesia. In order to avoid injury to the nerve in
such cases, we have employed a modified approach, in
which the entire inferior alveolar neurovascular bundle
is exposed prior to performance of the actual os-
teotomies (Fig. 6). This has essentially eliminated
the problems with injury to the nerve that occurred
previously.
VERTICAL CHANGES. IIl most low-angle MD CaSeS,
when mandibular advancement is done, the lower third
of the face is lengthened because of the deep bite.
Nevertheless, a distinct advantage of the total subapical
advancement of the mandible is the fact that, with this
operation, the lower third of the face can be lengthened
significantly by the addition of bone between the seg-
ments if desired (Part I, Fig. 1, H).
SEGMENTALIZING THE MANDIBLE. A feature of the
surgery that has not yet been discussed is the occasional
benefits of surgical leveling of the mandibular occlusal
nerve. B, Dissection of nerve from bone. C, Making os-
plane (that is, excessive curve of Spee). When model
surgery reveals this to be feasible, the total subapical
advancement of the mandible is to be considered.’
Superior repositioning of the maxilla
with genioplasty
We have previously discussed this form of treat-
ment, including details of the surgical techniques and
surgical-orthodontic sequencing, in patients with and
without open bite.7, “3 j2 The following case will be
presented briefly to reiterate that in the patient with a
Class II open bite we most always correct the vertical
(open bite) and transverse (cross bite) deformities in the
maxilla, since it has proved to be stable.
CASE 10
Esthetic evaluation
A 19-year-old woman was referred for consultation re-
garding a severe dentofacial deformity consistent with a Class
II open bite deformity (Fig. 7, A ). Frontal evaluation revealed
 Surgical-orthodontic correction of mandibular deficiency 503

Fig. 7. Case 10. A, Pretreatment full-face photograph. 8, Pretreatment profile. C, Pretreatment cepha-
lometric tracing.

Fig. 7 (Cont’d). D and E, Pretreatment and posttreatment occlusion. F, Posttreatment full-face photo-
graph.
504 Epker und Fish

Fig. 7 (Cont’d). G, Posttreatment profile. H, Composite cephalometric tracing.

a long face, lip incompetence, excessive exposure of the 2. Surgery. Superior repositioning of the maxilla in three
upper teeth, and a small, pointed chin. In profile a large nose segments; augmentation genioplasty.
and a recessive chin were most apparent (Fig. 7. B ). 3. Postsurgical orthodontic~s. Finishing and retention.

Cephalometric evaluation Treatment results

The facial depth was extremely small, as was the facial
axis, indicating an exceptionally recessive chin with a long
lower face (Fig. 7, C). The mandibular plane angle was ex-
tremely high, confirming a long lower face. The maxilla was
normal in anteroposterior position, but the teeth were verti-
cally overerupted relative to the palatal plane and the upper
lip. The occlusal plane was high posteriorly relative to Xi
point but low anteriorly relative to the lip embrasure. The lips
appeared protrusive relative to the E line, but this was decep-
tive because of the recessive nature of the chin.
Occlusal analysis
Alignment. All teeth were present with a V-shaped upper
arch, and a U-shaped lower arch. There was severe crowding
in both the upper and lower arches (Fig. 7, D).
INTERARCH RELATIONS. A ClaSS 11 IlldOCChSiOn, Open
bite, and bilateral posterior crossbite existed (Fig. 7. E ).
Treatment plan
The following treatment plan was decided upon:
1. Presurgical orthodontics. Extraction of the lower first
premolars, full banding of the lower arch and align-
ment with maximal retraction of the anterior teeth,
extraction of the upper first premolars, and segmental
alignment and leveling of the upper teeth.
Fig. 7,D, E, F, G, andH illustrates the esthetic, skeletal,
soft-tissue, and occlusal results.
Comment. The decision to operate in the maxilla in
most cases with Class II open bite deformity is predi-
cated upon the fact that we believe the most successful
and stable results can be achieved via correction of the
vertical (open bite) and transverse (crossbite) deformi-
ties that exist in these cases via maxillary surgery.‘“. ‘I
However, an additional decision must be made in such
cases. Will the autorotation of the mandible that ac-
companies superior maxillary repositioning correct the
Class II malocclusion? Will it be necessary (as in this
case) to move the maxilla posteriorly? Or will simulta-
neous mandibular advancement be necessary? Here is
where prediction tracings plus careful correlation with
clinical esthetic findings become essential. l2
Patients with Class II malocclusion accompanied by
a high mandibular plane angle have been considered
among the most difficult to treat because of problems
with esthetics, function, and stability. These problems
can most often be related to (1) improper diagnosis, (2)
improper treatment planning, (3) unstable orthodontic
results, (4) improper selection of the surgical tech-
Volume 84 Surgicul-orthodontic correction of mandibulur deficiency 505
Number 6

Fig. 8. Case 11. A, Pretreatment full-face photograph. 8, Pretreatment profile.

Fig. 8 (Cont’d). C, Pretreatment cephalometric tracing. 0 and E, Presurgical occlusion

506 Epker utd Fish

Fig. 8 (Cont’d). F, Posttreatment full-face photograph. G, Posttreatment profile. H, Composite

cephalometric tracing.

Fig. 8 (Cont’d). I and J, Posttreatment occlusion.

nique, and (5) inadequate postoperative care. With su- other end of the vertical spectrum, a vertically deficient
perior repositioning of the maxilla in these cases, we maxilla along with a mandibular deficiency.
have had excellent stability of results.13’ I4
CASE 11

Inferior repositioning of the maxilla with Esthetic evaluation

mandibular anterior subapical ostectomy
and mandibular advancement
Infrequently, we see a Class II patient who, by the
very nature of his or her problem, cannot be adequately
treated by single-jaw surgery. This condition is most
frequently found in the patient who, in addition to hav-
ing a deficient mandible, has a vertically excessive
maxilla. We have addressed this problem in a previous
article. l2
The following case, involving a Class II, Division 2
malocclusion, is presented because it represents the
An 1gyear-old male patient was seen in consultation re-
garding a severe dentofacial deformity consistent with a Class
II, Division 2, deep bite malocclusion. Front-face esthetics
revealed a foreshortened appearance to the lower third of the
face with a deep labiomental fold and prominent lips (Fig. 8.
A). In profile, the compressed appearance of the lips and short
face were again apparent (Fig. 8,B). The chin appeared small
relative to the nose and the labial fullness.
Cephalometric evaluation
The facial depth would indicate a chin with normal an-
teroposterior position. The high facial axis and the extremely
Volume 84
Number 6
low mandibular plane angle are indicative that the lower third
of the face is short. The maxilla was cephalometrically pro-
trusive. The occlusion was a full Class II, with the lower
dentition retruded to the A-PO line. The interincisal relation-
ship was much too vertical. Both upper and lower incisors
were supererupted relative to the functional occlusal plane,
which was tipped up anteriorly and poorly related to both Xi
point and the lip embrasure (Fig. 8, C).
Occlusal analysis
Alignment. Both upper lateral incisors were missing, and
the upper right deciduous canine was retained. All teeth were
abnormally small, and the anterior teeth were excessively
worn. Both arches were reasonably U shaped, with spacing
and a midline deviation to the left in the upper arch. There
was an extreme curve of Spee in the lower arch and a reverse
curve in the upper arch (Fig. 8, D ).
Interarch relations. The occlusion was a full-step Class
II, with extreme overbite and mild overjet. The upper arch
was wider at the first premolar area than the lower, producing
a buccal crossbite (Fig. 8, E).
Treatment plan
It was decided that treatment should consist of the fol-
lowing:
1. Presurgical orrhodontics. Extraction of the remaining
deciduous canine; consolidation of the upper anterior
teeth and proclination to correct the midline; leveling
and alignment of the upper posterior segment, the
lower posterior segment, and the lower anterior
segment.
2. Surgep. Anterior subapical ostectomy to level lower
arch; mandibular sagittal advancement; maxillary OS-
tectomies to advance and inferiorly reposition the
posterior segments.
3. Posrsurgical orthodontics. Finishing and retention.
Treatment results
Fig. 8, F to J illustrates the esthetic, skeletal, soft-tissue,
and occlusal results.
Comment. The one aspect of this case that warrants
specific comment is the necessity to reposition the
posterior segments of the maxilla inferiorly to level the
upper curve of Spee. The fact that the upper incisors are
vertically related normally to the upper lip makes it
esthetically unacceptable to reduce the curve by su-
perior repositioning of the anterior segment. That
would produce a disastrous result, with the patient
being unable to show any teeth at rest and to show only
lower incisors upon smiling. Furthermore, the lower
face height would not be improved and the “squashed”
appearance would only be accentuated by the edentu-
lous appearance.
Also, when the maxilla is inferiorly repositioned, it
must be skeletally stabilized in order to avoid the severe
(mean, 50 percent) relapse. I5
Surgical-orthodontic correction qf mandibular dejiciency 507
CONCLUSIONS
This article has discussed in detail the specifics of
diagnosis and treatment of the patient with mandibular
deficiency. In our experience, all types of MD can be
stably treated and esthetically improved if proper atten-
tion is paid to the features discussed in this article, thus
enabling proper surgical technique and orthodontic
treatment to be rendered.
The following persons participated in the treatment of
Cases3,4,and8:L.Wolford,D.D.S.,G.Wessberg,D.D.S.,
P. Paulus, D.D.S., M.S., and J. Mills, D.D.S., M.S.
REFERENCES
1. Epker, B. N., Wolford, L. M., and Fish, L. C.: Mandibular
deficiency syndrome: Surgical consideration for mandibular ad-
vancement, Oral Surg. 45: 349-363, 1978.
2. Schendel, S. A., and Epker, B. N.: Results after mandibular
advancement surgery: An analysis of 87 cases,J. Oral Surg. 38:
265-282, 1980.
3. Epker, B. N., and Wessberg, G. A.: Mechanisms of early
skeletal relapse following surgical advancement of the mandible,
Br. J. Oral Surg. 20:175-182, 1982.
4. Wessberg, G. A., and Epker, B. N.: The effect of suprahyoid
myotomies in results with mandibular advancement, J. Oral.
Surg., 1981.
5. Wertz, R. A.: Skeletal and dental changes accompanying rapid
midpalatal suture opening, AM. J. ORTHOD. 58: 41-66, 1970.
6. Epker, B. N., Paulus, P. J., and Fish, L. D.: Surgical-
orthodontic correction of maxillary deficiency, Oral Surg. 46:
171-205, 1978.
7. Epker. B. N., and Wolford, L. M.: Dentofacial deformities:
Surgical-orthodontic correction, St. Louis, 1980, The C. V.
Mosby Company.
8. Wolford, L. M., Schendel, S. A., Walker, G., and Epker,
B. N.: Mandibular deficiency syndrome: Clinical delineation
and therapeutic significance, Oral Surg. 45: 329-348, 1978.
9. Hohl, T. H., and Epker, B. N.: Macrogenia: A study of treat-
ment results with surgical recommendations, Oral Surg. 41:
545-567, 1976.
10. Epker, B. N., and Fish, L. C.: Surgical-orthodontic correction
of open-bite deformity, AM. J. ORTHOD. 71: 278-299, 1977.
11 Fish, L. C., Wolford, and L. M., Epker, B. N.: Surgical-
orthodontic correction of vertical maxillary excess, AM. J.
ORTHOD. 73: 241-257, 1978.
12 Epker, B. N., and Fish, L. C.: Superior repositioning of the
maxilla: What to do with the mandible, AM. J. ORTHOD. 78:
164-191, 1980.
13 Schendel, S. A., Eisenfeld, J., Bell, W. H., and Epker, B. N.:
Superior repositioning of the maxilla: Stability and soft tissue
relations, AM. J. ORTHOD. 70: 633-674, 1976.
14 Epker, B. N.: Superior repositioning of the maxilla: Long term
results, J. Maxilla fac.Surg. 9: 199-254, 1981.
1.5. Wessberg, G. A., and Epker, B. N.: Surgical inferior reposition-
ing of the maxilla: Treatment considerations and comprehensive
management, Oral Surg. 52: 349-356, 1981.
Reprint requests to:
Dr. Bruce N. Epker
Center for Correction of Dentofacial Deformities
John Peter Smith Hospital
1500 South Main St.
Fort Worth, Texas 76104