501

CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 501517

Basic Guidelines
for the Surgical Correction
of Mandibular Anteroposterior
Deficiency and Excess
a,b,
Johan P. Reyneke, BChD, MChD, FCMFOS (SA), PhD *

- Treatment planning - Mandibular anteroposterior excess

- Mandibular anteroposterior deficiency Class III malocclusion
Class II, division 1 malocclusion - Summary
Class II, division 2 malocclusion - References

Since Trauner and Obwegeser [1] first intro- Treatment planning

duced the sagittal split ramus osteotomy for the
surgical correction of anteroposterior dentofacial
deformities of the mandible, refinement in treat-
ment planning [2], modifications of surgical de-
sign [35], exciting developments in technology
[6,7], and a better understanding of bone and
soft tissue biology [8] have improved the treatment
offered to patients. Apart from scientific knowl-
edge, the development of an artistic flair to diag-
nose and achieve optimal esthetic results has
become an essential part of the orthognathic sur-
geons armamentarium.
Although this article deals with guidelines for the
correction of mandibular anteroposterior dentofa-
cial deformities only, the clinician should keep in
mind that each patient has a unique set of dentofa-
cial problems requiring a specific treatment re-
sponse, and a patient may often have more than
one deformity.
Patients who have malocclusions present with
a wide range of functional and esthetic needs and
can generally be grouped into three categories.
The first group comprises most patients who have
a normal jaw relationship, and their malocclusions
can be corrected by routine orthodontic means
alone. The second group of patients present with
mild to moderate skeletal and esthetic discrepancies
that can, however, still be treated by dental com-
pensation (camouflage) and growth modification.
The third group of patients has moderate to severe
skeletal and esthetic discrepancies and requires or-
thodontics combined with surgery. Delineation
among the groups, in particular between groups
two and three, is challenging and important. Any at-
tempt to treat a group three patient with group two
treatment principles will result in complications
such as compromised esthetics and poor stability.

a
Department of Maxillofacial and Oral Surgery, University of the Witwatersrand, Private Bag 3, WITS 2050,
Johannesburg, South Africa
b
Department of Oral and Maxillofacial Surgery, University of Oklahoma, 1201 N. Stonewall, Oklahoma City,
OK 73117, USA
* Centre for Orthognathic Surgery and Implantology, Sunninghill Hospital, P.O. Box 5386, Rivonia, 2128
South Africa.
E-mail address: drjprey@global.co.za

0094-1298/07/$ see front matter 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2007.05.004
plasticsurgery.theclinics.com
502 Reyneke
Borderline cases exist among the groups, and treat-
ment of these patients are influenced by factors
such as
Patients preference. Although some patients
have predominantly esthetic concerns, others
with similar dentofacial deformity are con-
cerned by their malocclusion. Some patients
may decline the recommended extractions,
or even modest enamel reduction, let alone
orthognathic surgery!
Orthodontists preference. The orthodontists di-
agnosis, experience, attitude toward orthog-
nathic surgery, and inclination to refer
patients for surgery greatly influences the pa-
tients own decision to seek surgical treatment.
The orthodontists attitude is often influenced
by previous good or bad experiences with or-
thognathic surgery or the availability of a suit-
ably experienced surgeon in the area.
Financial coverage. Regrettably, many health in-
surers do not fund the correction of this basic
human functional disability of the facial and
oral region, and some patients may not be
able to afford the recommended treatment
plan.
Despite the aforementioned variables, the key
aims of successful treatment are the establishment
of balanced facial esthetics and functional harmony
between the teeth, the musculature, and the tempo-
romandibular joints. It remains the clinicians re-
sponsibility to provide the patient with all realistic
treatment possibilities.
When commencing treatment planning, the first
question to be addressed is, What is the facial pat-
tern and occlusion that can be achieved by ortho-
dontic treatment alone? In many cases, an
acceptable result may be achieved by orthodontic
means alone and it should then be the treatment
of choice. If, however, the orthodontics only op-
tion requires unrealistic amounts of tooth move-
ment (beyond the alveolar bony base) that would
result in poor soft tissue support, surgery should
be recommended to the patient. Treatment should
be declined if the patient does not agree to surgery.
This article deals with the group of patients who re-
quire both orthodontics and surgery for the correc-
tion of anteroposterior mandibular dentofacial
deformity.
Mandibular anteroposterior deficiency
Patients who have mandibular skeletal deficiency
and Class II malocclusion form the largest single
group of patients requiring orthognathic surgery.
Class II, division 1 malocclusion
Clinical characteristics
Profile view
A convex profile (increased facial contour angle)
(Fig. 1)
Often, a retruded chin with a normal shape. Aug-
mentation of the chin by means of an implant
or sliding genioplasty is often required in com-
bination with mandibular advancement. Gen-
ioplasty is, however, only indicated when the
chin itself is retrusive with an obtuse labio-
mental fold, the lip-chin-throat angle is ob-
tuse, and the chin-to-neck length is deficient.
Genioplasty is not an alternative for mandibu-
lar surgery and poor esthetic results are often
achieved when the chin is augmented in cases
requiring mandibular advancement (Fig. 2).
A deficient mandible, giving the illusion of
a large nose. It is for this reason that rhino-
plasty should be deferred until after mandibu-
lar advancement.
An obtuse lower lip-chin-throat angle
A short chin-to-throat length
An everted lower lip that often wedges in behind
the upper incisors
An acute labiomental fold
Frontal and three-quarter view
A curled lower lip with increased exposure of
vermillion (see Fig. 1B, C)
A weak-appearing chin, often with a double chin
appearance
A deep labiomental fold
Dental characteristics
An increased overjet (see Fig. 1D)
Often, an increased overbite and accentuated
curve of Spee
Often, crowding of the lower incisors caused by
the deficient mandible
A tendency to maxillary dental protrusion with
interdental spacing
A Class II molar and canine relationship
Cephalometric analysis
An increased ANB angle (6 ) (see Fig. 1E)
A mandible that is relatively short, in relation to
the maxillary length (93:100 mm)
Protrusive lower incisors (114 to the mandibu-
lar plane)
A decreased interincisor angle (96 )
An increased occlusal plane angle (20 )
An increased facial contour angle ( 27 )
The immediate presurgical cephalometric tracing
is illustrated in Fig. 1F and the surgical prediction
tracing is illustrated in Fig. 1G. The posttreatment
result is demonstrated in Fig. 1HK.
 Mandibular Anteroposterior Deficiency and Excess 503

Fig. 1. (A) Typical facial profile associated with Class II division 1 occlusion and skeletal mandibular
anteroposterior deficiency. (B and C) Frontal and three-quarter view of a patient with Class II division 1 occlusion
and deficient mandible. (D) The presurgical orthodontic treatment is completed in this case. The teeth are
aligned, the dental arches coordinated, and the required overjet established. (E) Cephalometric analysis of
the patient. The required extractions of upper second bicuspids and lower first bicuspids are indicated. (F)
The incisor decompensation, improved incisor angulation, and planned overjet are evident. (G) The mandible
is advanced by 6 mm, the chin is advanced by 4.5 mm, and the expected soft tissue changes were predicted.
(HK) The improved soft tissue, skeletal, and dental harmony is well demonstrated.

Treatment planning advancement should be established. In cases with

Treatment planning follows, once all the orthog-
nathic diagnostic data have been obtained and as-
sessed. A problem list is formulated and soft
tissue, skeletal, and dental objectives are set for
the case. First, the ideal soft tissue facial outcome
(objective) should be predicted. The question
must then be asked, Where should the orthodon-
tist place the teeth to enable the surgeon to achieve
the soft tissue goals? In other words, the required
incisor overjet that will allow adequate mandibular
microgenia, the chin may also have to be advanced
to establish ideal chin projection and shape. Aug-
mentation of the chin in cases where the chin shape
is acceptable is contraindicated. Genioplasty is not
a substitute for mandibular surgery (see Fig. 2).
When developing a cephalometric prediction for
the correction of mandibular anteroposterior defi-
ciency, the ideal anteroposterior chin position is
first established by using specific cephalometric pa-
rameters. A good rule is to place the chin
504 Reyneke

Fig. 1 (continued)

(pogonion) at, or 1 mm posterior to, a true vertical
line dropped from the glabella.
This sequence is illustrated in Fig. 3. In this case,
the facial contour angle is used to indicate the ideal
anteroposterior position of pogonion, and a facial
contour angle (14 ) is constructed on the original
tracing (see Fig. 3A). In the case illustrated, the
chin contour is acceptable and genioplasty is not
considered. However, in cases requiring genioplasty
to improve the chin contour, the genioplasty is

Fig. 2. The true vertical line is drawn through the glabella, and the chin (pogonion) should ideally touch, or be 1
mm behind, the line. (A) The chin is 5 mm behind the line; however, the chin shape is good. (B) The mandible is
advanced by 5 mm (pogonion on the line) and an acceptable esthetic result is achieved. (C) The chin is advanced
by 5 mm, resulting in a knobby chin shape.
 Mandibular Anteroposterior Deficiency and Excess 505

Fig. 3. The facial contour angle is used to indicate the ideal anteroposterior position of pogonion and a facial
contour angle (14 ) is constructed on the original tracing (A). The mandible is now advanced by moving the pre-
diction tracing to the right until the soft tissue pogonion touches the constructed lower facial plane. Note that
the incisors are now in crossbite (B). The incisors can now be placed (decompensated) in their normal relation
(the correct overbite and overjet and in the central trough of bone). The need for tooth extractions, dental
arch expansion, leveling of occlusal curves, and so forth is established (C). The prediction tracing is moved to
the right, into its original position. An increased overjet is now evident and represents the amount of man-
dibular advancement required to achieve the predicted soft tissue result (D). The prediction tracing can
now be moved to the right again until the teeth occlude in a Class I relation and the final soft tissue is profile
predicted (E).

predicted at this stage and soft tissue contour is
drawn on the original tracing. The mandible is
now advanced by moving the prediction tracing
to the left until the soft tissue pogonion touch the
constructed lower facial plane. The incisors are
now in crossbite (see Fig. 3B) and can now be
placed (decompensated) in their normal relation
(with the correct overbite and overjet and in the
central trough of bone). The lower incisors are re-
tracted and the angle of the upper incisor improved.
Once the ideal position of the incisor teeth is pre-
dicted, the positioning of the posterior teeth needs
to be planned and reconciled with the incisor posi-
tion. The need for tooth extractions, dental arch ex-
pansion, leveling of occlusal curves, and so forth, is
established (see Fig. 3C). The prediction tracing is
moved to the right, into its original position. An
increased overjet is now evident and represents
the amount of mandibular advancement required
to achieve the predicted soft tissue result (see
Fig. 3D). The prediction tracing can now be moved
to the left again until the teeth occlude in a Class I
relation and the final soft tissue profile predicted
(see Fig. 3).
Nonsurgical treatment
In the preadolescent patient with growth potential
and severe mandibular deficiency, orthodontic
growth modification treatment should certainly be
attempted and will usually involve
The elimination of any dental interference by
opening the bite
Encouraging relative forward growth of the man-
dible by impeding maxillary growth using
506 Reyneke
Class III mechanics with elastics, headgear, or
the use of intraosseous implants
Allowing posterior but not anterior tooth erup-
tion, which will cause downward rotation of
the mandible opening the bite
After completion of the adolescent growth spurt,
growth potential declines rapidly. The growth po-
tential of boys and girls differs substantially and it
may become a therapeutic and diagnostic dilemma.
The best treatment approach to the adolescent pa-
tient at this stage is to discuss the possibility of sur-
gical correction with the patient and then attempt
nonextraction treatment with growth modification.
The response to this treatment after 6 to 12 months
will be a good indicator of the approach to follow
(ie, orthodontic camouflage or orthodontics com-
bined with surgery).
Orthodontic camouflage treatment usually con-
sists of the following:
Correction of the excessive overjet by retraction
of the maxillary incisors (with or without ex-
tractions) and proclination of the lower
incisors
Correction of the excessive overbite by intrusion
of the upper and lower incisors and down-
ward rotation of the mandible by opening
the bite
Any compromised treatment has certain disad-
vantages. Camouflage orthodontic treatment for
patients requiring mandibular advancement sur-
gery often results in poor esthetics. These patients,
to a varying degree, develop convex profiles, poor
upper lip support, obtuse nasolabial angles (wors-
ening with age), short chin-to-neck lengths (with
a tendency to double chin), and thin upper lip
vermilions.
The orthodontic treatment goals for dental cam-
ouflage and for orthodontics combined with sur-
gery differ substantially. It is therefore imperative
that the decision is made at the start of definitive
orthodontic treatment as to whether the treatment
approach will be solely orthodontic or orthodon-
tics combined with surgery.
Combined orthodontics and surgery
The presurgical orthodontic goals for Class II divi-
sion 1 malocclusion patients are as follows:
1. Place the incisors in their planned anteroposte-
rior and vertical positions. The ideal presurgical
position of the incisors is planned by perform-
ing a surgical visual treatment objective. The
amount of mandibular advancement is dictated
by the overjet created by the presurgical
orthodontics, and failure to eliminate dental
compensations before surgery will limit the
surgical advancement and eventually the esthetic
outcome.
2. Eliminate crowding. Crowding is often present
in the lower arch, and alignment of the lower
dental arch may require extractions. Crowding
is most often present in the anterior region of
the arch and requires extraction of the first bicus-
pids. In cases where crowding is present in the
midarch, the second bicuspids should be ex-
tracted. Crowding is not often present in the up-
per arch and it is often possible to create space
(albeit limited) by expansion of the maxillary
arch, an adjustment often needed to accommo-
date the mandibular arch following advance-
ment. If extractions are indicated in the upper
arch, the second bicuspids are often the teeth
of choice. This extraction allows the orthodon-
tist to eliminate the crowding, place the upper
incisors in their planned position, and use the
remaining space by advancement of the molar
teeth.
3. Establish arch compatibility. Postoperative sta-
bility is enhanced by good arch compatibility
and proper tooth intercuspation. The orthodon-
tist should ensure that all dental interferences
are eliminated before surgery. The maxillary
intercanine distance should be sufficient to ac-
commodate the mandibular arch following
mandibular advancement, whereas the lower
second molars should be banded and leveled
with the rest of the arch. Similar arch forms
should be established, with their transverse di-
mensions coordinated to prevent postoperative
posterior crossbites.
4. Level the dental arches. Not all occlusal curves
should be leveled before mandibular advance-
ment. Patients who have Class II malocclusions,
short faces, and prominent chins may not toler-
ate mandibular advancement from an esthetic
point of view. In these cases, it is preferable
not to level the curve of Spee presurgically. Ad-
vancement of the mandible results in a rotational
movement, advancing the lower incisors with
only slight advancement of the chin. The height
of the chin and lower face increases, which is
also esthetically advantageous for these patients
(Fig. 4).
Surgical advancement of the mandible
The surgical procedure of choice for the advance-
ment of the mandible is the bilateral sagittal split
ramus osteotomy (Fig. 5). Following advancement
of the mandible, the chin may still appear deficient,
and augmentation of the chin by means of an im-
plant or sliding genioplasty may be indicated.
When the chin is advanced, it is, however, impor-
tant to keep in mind that chin shape is more

important than the position of the chin (position of
pogonion). Attempts to improve chin prominence
by means of a genioplasty procedure in cases re-
quiring mandibular advancement will result in
a poor chin shape (knobby chin) (see Fig. 2).
Modern surgical design for the bilateral sagittal
split ramus osteotomy is illustrated in Fig. 5. It is
important to include the lower border in the distal
segment when performing the vertical osteotomy
Mandibular Anteroposterior Deficiency and Excess 507
Fig. 4. (A) The tracing of a pa-
tient with a Class II deep bite
and an accentuated curve of
Spee. The height of the lower
lip and chin is deficient in rela-
tion to the upper lip length
(22 mm to 36 mm). In this
case, the occlusal curve should
not be leveled before surgery.
(B) A surgical prediction trac-
ing of the patient in A. The
mandible was advanced and
rotated, resulting in incisor
and second molar contact and
bilateral open bites. The open
bites can quite easily be closed
postoperatively by means of
orthodontics.
on the body of the mandible (the osteotomy must
include the lingual cortex). The author also believes
that it is advantageous to strip the medial pterygoid
muscle and stylomandibular ligament attachments
from the medial side of the mandibular angle, al-
lowing for more accurate condylar positioning
and control of the proximal segment. Once the
osteotomy is completed, the proximal segment is
advanced, and the authors preference is to use
Fig. 5. (A) Modern surgical design for
the bilateral sagittal split ramus os-
teotomy. It is important to include
the lower border in the distal segment
(when performing the vertical osteot-
omy on the body of the mandible,
the osteotomy must include the lin-
gual cortex) (arrow a). (B) The author
also believes that it is advantageous
to strip the medial pterygoid muscle
and stylomandibular ligament attach-
ments from the medial side of the
mandibular angle (arrows b and c) to
allow for more accurate condylar posi-
tioning and control of the proximal
segment. The proximal segment is
advanced and fixated by means of
three bicortical positioning screws.
The arrow indicates the inclusion of
the lingual cortex in the osteotomy.
(C) Many mandibular-deficient cases
require both mandibular and chin ad-
vancement. In these cases, the sagittal
split osteotomy is combined with
a genioplasty (as in the case in Fig. 1).
Note that by changing the angulation
of the chin osteotomy, the height of
the chin can be altered. (D) The mandi-
ble and chin are advanced and rigid
fixation placed.
508 Reyneke

Fig. 6. (AF) Typical facial characteristics of a patient with a Class II division 2 occlusion and anteroposterior man-
dibular deficiency. The square, shortened lower facial third is evident. The upper right canine (13) is impacted,
the upper incisors are upright, and the lateral incisors are flared in this Class II division 2 deep bite case. (G) All
the typical characteristics are well illustrated in the analysis of this patients cephalometric radiograph. (H) The
incisor decompensation allows the surgeon to advance the mandible. The esthetic soft tissue requirement is an
important factor that will dictate the amount of decompensation and subsequent advancement of the mandi-
ble. (I) It is evident from the surgical prediction (4 mm advancement) that the chin will be in an acceptable po-
sition with a good shape. Genioplasty is therefore not indicated. (JL) The improved facial balance is evident in
the frontal profile and three quarter views. (MO) A stable and functional occlusion has been achieved.

three bicortical positioning screws for fixation. Class II, division 2 malocclusion
Many mandibular-deficient cases require both Clinical characteristics
mandibular and chin advancement, and in these Profile view
cases, the sagittal split osteotomy is combined A square-appearing mandible and short lower
with a genioplasty. By changing the angulation of facial height (Fig. 6A)
the chin osteotomy, the height of the chin can be al- A prominent-appearing chin
tered. When the chin is advanced along a steep Often, a deep labiomental fold
plane, the chin height shortens, whereas the height A mandibular plane angle that tends to be
is maintained with a more horizontal osteotomy. low

Fig. 6 (continued)
Frontal and three-quarter view
A deep labiomental fold (Figs. 6B, C)
A face that appears short and masseter muscles
that are often well developed
An everted lower lip
Dental characteristics
Retroclined upper central incisors (Figs. 6DF)
Labially inclined and flared upper lateral
incisors
A deep overbite
An excessive curve of Spee
An anterior locking effect of the incisors that
may lead to clicking of the temporomandibu-
lar joints
The gingival tissue behind the maxillary incisors
that is often inflamed because of trauma from
the lower incisors, especially in older patients
Cephalometric analysis
Upright upper incisors (88 to SN plane)
(Fig. 6G)
Increased ANB angle (5 )
Slight increase in the facial contour angle ( 16 )
Low mandibular plane angle (28 )
Low occlusal plane angle (10 )
Treatment planning
The previously discussed principles regarding treat-
ment planning also apply to Class II division 2
cases; however, the amount of maxillary incisor
Mandibular Anteroposterior Deficiency and Excess 509
teeth decompensation and the amount of presurgi-
cal leveling of the curve of Spee in the lower dental
arch need special attention. The incisor decompen-
sation and the increase in the dental overjet are dem-
onstrated in Fig. 6H, whereas the expected soft and
hard tissue changes are illustrated in Fig. 6I.
Treatment
Presurgical orthodontics The same presurgical or-
thodontic treatment principles as for Class II divi-
sion 1 cases apply:
It is very seldom necessary to extract teeth in the
upper dental arch and the need to extract bi-
cuspids in the maxilla should be carefully
assessed.
The maxillary incisors should be tipped labially
to create lip support, a good arch form, and
sufficient overjet.
Most patients in this group require little or no
presurgical leveling of the curve of Spee,
which allows for rotational surgical move-
ment of the mandible, limiting the advance-
ment of the chin. The bilateral open bites
that result can be corrected by orthodontics
after surgery.
Surgical treatment Several surgical treatment op-
tions exist for these cases:
In cases where chin prominence is not excessive,
advancement of the mandible by means of
510 Reyneke
a sagittal split osteotomy is the procedure of
choice (see Fig. 5).
A total subapical osteotomy advances the den-
toalveolar part of the mandible. The chin po-
sition (pogonion) is maintained, the lower lip
is advanced, and the acute labiomental fold is
improved. The inferior alveolar nerve requires
dissection from the mandible, and should be
released from the mental foramen before the
segment can be advanced, which is a major
disadvantage with high neurosensory morbid-
ity; it is for this reason that the procedure is
not often performed (Fig. 7).
The mandible may be advanced by means of a
bilateral sagittal split osteotomy combined
with a reduction genioplasty. This option
gives the surgeon more control of the chin po-
sition and shape (Fig. 8).
Mandibular anteroposterior excess
Class III malocclusion
A skeletal Class III malocclusion may be the result
of maxillary anteroposterior deficiency, mandibular
Fig. 7. (A) It is evident from
the surgical design for the
total subapical osteotomy
that the inferior alveolar
nerve needs to be dis-
sected from the mandibu-
lar canal. This maneuver
unfortunately adds to the
neurosensory morbidity of
the procedure. (B) The
dentoalveolar part of the
mandible is advanced,
whereas the chin main-
tains its original position.
anteroposterior excess, or a combination of the two
deformities. Approximately 20% to 30% of all skel-
etal Class III cases are caused by isolated mandibu-
lar prognathism [9,10]. It is therefore important for
the clinician to differentiate between the two defor-
mities, not only concerning the diagnosis but also
from a skeletal growth point of view. Excessive man-
dibular growth may continue until the early
twenties, whereas maxillary growth (especially in
deficient maxillas) may be completed by the age
of 14 or 15. The timing of surgery in the adolescent
patient who has a Class III malocclusion is there-
fore important. In true mandibular anteroposterior
excess cases, the clinician may be wise to postpone
surgery as late as possible to ensure that facial
growth is complete. A comparison of serial cephalo-
metric radiograph tracings (taken 6 months apart)
is one method of quantifying growth increments,
and radioisotope bone scan studies give the clini-
cian an idea of the growth activity of the condyles.
Delaying surgery may be wise; however, it is not al-
ways practical, nor is it possible to determine with
accuracy whether mandibular growth has stopped
[11]. Moreover, the effect that the deformity may
Fig. 8. (A) The osteotomy
design for mandibular ad-
vancement by means of
a bilateral sagittal split os-
teotomy and reduction
genioplasty. Note that by
changing the angulation
of the genioplasty osteoto-
my, the vertical dimension
if the chin may be altered.
(B) The mandibular seg-
ments are fixed with bi-
cortical positioning
screws, and plate fixation
is used to fix the chin
segment.
 Mandibular Anteroposterior Deficiency and Excess 511

Fig. 9. (A) The strong, prominent mandible of this patient who has mandibular anteroposterior excess is evident
in frontal view. (B) Typical profile of a patient who has mandibular anteroposterior excess. (C) A cephalometric
tracing with the intended osteotomy lines for the sagittal osteotomy. (D) Class III occlusion following the ortho-
dontic preparation for surgery. (EH) Improved esthetic and functional results are demonstrated in postopera-
tive outcome.
512 Reyneke

Fig. 10. As the first step, the ideal anteroposterior position of the chin (pogonion) is positioned, based on the
facial contour angle of 14 . A vertical line is drawn representing the vertical osteotomy on the body of the
mandible (A). The prediction tracing is now traced and all the hard and soft tissue structures that will not be
surgically moved and the constructed facial contour angle are traced. The prediction tracing is moved to the
left until pogonion falls on the constructed lower facial plane. An increased overjet is now present (B). The in-
cisor teeth can now be orthodontically repositioned into the ideal overjet and overbite and placed in the cen-
tral trough of bone (C). The prediction tracing is next moved back to its original position. A large incisor
crossbite is now evident. This tracing serves as the orthodontic treatment objective and represents the presur-
gical orthodontic goal (D). The prediction tracing is moved to the left until the incisors are in an ideal relation-
ship. The amount of mandibular setback can be assessed by measuring the distance between the vertical
osteotomy lines (E).

have on the socio-psychologic well-being of the pa-
tient often forces the clinician to consider surgery at
an earlier stage [12]. Some patients who have severe
mandibular excess may elect to have surgery earlier,
accepting the fact that a second procedure may be
necessary at a later stage [13].
The effect of early surgical intervention on skele-
tal growth is not clear [14,15]. The general assump-
tion is that surgery to the jaws before cessation of
growth will retard further growth. This assumption
has been based primarily on the observations fol-
lowing cleft palate repair. However, little reason ex-
ists to believe that orthognathic surgery performed
before maturation would alter the intrinsic growth
pattern.
Clinical characteristics
Profile view
Increased chinthroat length (Fig. 9)
Flat lower lip with a thin vermilion
Prominent-appearing lower third of the face, as
a result of a protrusive chin
An obtuse labiomental fold
An acute lip-chin-throat angle
A well-defined lower border of the mandible
 Mandibular Anteroposterior Deficiency and Excess 513

Fig. 11. (A) The osteotomy

design for mandibular set-
back procedure. The me-
dial pterygoid muscle and
stylomandibular attach-
ments on the medial side
of the mandibular angle
should be dissected off the
bone. (B) The overlapping
buccal bone (representing
the amount of mandibular
setback) should be re-
moved. Three bicortical po-
sitioning screws are placed
on each side as rigid
fixation.

A concave profile (a decreased facial contour
angle)
Frontal view
Often, an asymmetric chin (see Fig. 9B)
A chin that appears flat, with reduced labiomen-
tal fold
A mandible that appears strong and long
A thin upper lip with reduced vermilion
exposure
Dental characteristics
Mandibular incisors that are often compensated
and lingually inclined (see Fig. 9D)
A Class III occlusion with anterior and posterior
crossbites
A lower dental midline that is often asymmetric
Attached gingival tissue that is thin in the lower
incisor area
Treatment planning
By using the cephalometric treatment objective, the
amount of dental decompensation and the size of
the anterior crossbite required to allow for adequate
mandibular setback can be established (Fig. 10).
Refinement of chin esthetics is often necessary.
This sequence is illustrated in Fig. 10. The surgi-
cal cephalometric prediction for the correction of
anteroposterior mandibular deformities is similar
to the prediction for mandibular deficiencies. The
chin contour is first assessed and if genioplasty is in-
dicated to improve the chin shape, it should be pre-
dicted on the original tracing, irrespective of the
anteroposterior chin (pogonion) position at this
stage. As the first step, the ideal anteroposterior po-
sition of the chin (pogonion) is selected by using
the cephalometric parameter of choice. In this
case, the facial contour angle is used and an angle
of 14 is selected and constructed on the original
tracing. A vertical line is drawn representing the ver-
tical osteotomy on the body of the mandible (see
Fig. 10A). The prediction tracing is now traced
and all the hard and soft tissue structures that will
not be surgically moved, and the constructed facial
contour angle, are traced. The prediction tracing is
moved to the right until pogonion falls on the

Fig. 12. (A) Small transverse

skeletal and dental discrep-
ancies can be corrected in
the mandible by perform-
ing an interdental osteoto-
my in the symphysis area
in combination with the bi-
lateral sagittal osteotomy.
(B) In this case, the poste-
rior dental arch is narrowed
by inward rotation of the
posterior mandibular seg-
ments. Plate fixation is
used in the symphysis area.
514 Reyneke

Fig. 13. (A) Bilateral coro-

noidectomies are first per-
formed. The ramus
osteotomy is then per-
formed from the coronoid
notch downward to the an-
gle of the mandible poste-
rior to the alveolar
foramen. The soft tissue at-
tachments on the medial
sides of the proximal seg-
ments should be stripped
off the bone to allow for
good bone contact. (B) The
distal part of the mandible
is set back and the overlap-
ping bone is demonstrated.

constructed lower facial plane. An increased overjet Treatment

is now present (see Fig. 10B). The incisor teeth can
now be orthodontically repositioned into the
ideal overjet and overbite and placed in the central
trough of bone (see Fig. 10C). The prediction trac-
ing is next moved back to its original position. A
large incisor crossbite is now evident. This tracing
serves as the orthodontic treatment objective and
represents the presurgical orthodontic goal (see
Fig. 10D). The prediction tracing is moved to the
left until the incisors are in an ideal relationship.
The amount of mandibular setback can be assessed
by measuring the distance between the vertical os-
teotomy lines (see Fig. 10E).
Presurgical orthodontics
1. Position the incisor teeth in the central trough of
bone and the planned anterior crossbite to allow
ideal mandibular setback, optimum esthetics,
and long-term stability.
2. Eliminate or reduce dental compensations. The
alveolar bone of the mandibular symphysis in
these cases is usually very thin with a small
area of attached gingival tissue. Orthodontic de-
compensation of the lower incisors is therefore
often limited.
3. Coordinate the transverse dimension of the pos-
terior dental arches. In cases with a skeletal

Fig. 14. A vertical line is constructed through the glabella. The chin (pogonion) should be 1 mm behind or on the
line. (A) Pogonion is 4 mm ahead of the line; however, the contour of the chin is good. The mandible is set back
until pogonion lies on the line and an acceptable profile is achieved (B). Reducing the mental area by genio-
plasty obliterates the labiomental fold, with a poor esthetic result (C).
 Mandibular Anteroposterior Deficiency and Excess 515

Fig. 15. A patient who has mandibular anteroposterior excess (A and B) and a Class III occlusion (D). Note that
the chin is deficient and mandibular setback combined with advancement of the chin is planned on the ceph-
alometric tracing (C). The posttreatment esthetic result (E and F), prediction tracing (G) and occlusion (H). Note
the improved chin contour achieved by the chin advancement.
516 Reyneke
transverse discrepancy, the transverse dimension
of the mandible may be surgically altered
(Fig. 11).
4. Place the lower dental midline in the middle of
the chin so that surgical correction of the dental
midline also corrects skeletal asymmetry. In pa-
tients who have severe asymmetry of the chin,
the facial asymmetry can be corrected by
genioplasty.
Surgical treatment The two surgical alternatives
for mandibular setback are the bilateral sagittal split
ramus osteotomy and the vertical ramus osteotomy.
When correcting mandibular anteroposterior ex-
cess by means of a bilateral sagittal split procedure,
the surgeon should pay attention to various aspects
of the surgical technique (Fig. 12):
The medial pterygoid muscle and stylomandibu-
lar ligament attachments should be carefully
dissected and freed from the medial aspect
of the mandibular angle. These soft tissue at-
tachments interferes with the distal segment
because it is set back and also hampers control
of the ramus and condylar positioning (see
Fig. 12).
One of the disadvantages of this procedure is the
relatively high incidence of neurosensory
morbidity [16].
Condylar positioning during this procedure may
be demanding, especially when mandibular
asymmetry is corrected concurrently. Small in-
tersegmental defects may develop, and care
should be taken not to close the defects
when placing rigid fixation. Closure of the de-
fects by compression of the segments leads to
condylar displacement (peripheral condylar
sag) and incorrect occlusion [17].
Transverse discrepancies (dental crossbites) can
be corrected by performing an interdental os-
teotomy in the symphysis area in combina-
tion with the sagittal split osteotomy (see
Fig. 12).
The rigid fixation of choice for this procedure is
either bicortical positional screws or interseg-
mental plate fixation.
Mandibular setback by means of bilateral vertical
ramus osteotomies is an alternative surgical proce-
dure for the sagittal split osteotomy and, as with
the latter procedure, certain aspects need consider-
ation (Fig. 13):
The neurosensory morbidity following this pro-
cedure is much lower than for the sagittal split
osteotomy.
A disadvantage of this procedure is that inter-
maxillary fixation is required for at least 14
days following surgery.
This procedure allows larger setback procedures
than the sagittal split osteotomy.
No internal rigid fixation is required following
surgery.
A genioplasty may be combined with mandibu-
lar setback procedures. Although the mandible
may be excessive in these cases, the chin shape
may be acceptable. An attempt to correct pogonion
anteroposterior position by reducing the chin by
means of a genioplasty procedure obliterates the la-
biomental fold, resulting in poor esthetics
(Fig. 14). One should not assume that patients
who have mandibular anteroposterior excess al-
ways also have large chins (macrogenia) requiring
reduction. As a result of the forward and downward
growth of the mandible, the anterior mandible is
often vertically excessive and the chin may need ver-
tical reduction. However, in certain groups, man-
dibular anteroposterior excess is often found in
combination with a deficient chin (microgenia)
(Fig. 15).
Summary
During the past decades, knowledge and under-
standing of all aspects of orthognathic surgery has
increased greatly. Diagnostic skills and treatment
planning have become more sophisticated and,
through experience, surgical techniques have at-
tained a level enabling the treatment of the most
complex jaw deformities with confidence. In this
article, guidelines for the treatment of mandibular
anteroposterior dentofacial deformities were dis-
cussed. It should, however, always be kept in
mind that the face and mouth are complex, three-
dimensional structures and multifunctional in
character. An artistic flair and the ability to think
originally have become essential for the orthog-
nathic surgeon, because no two dentofacial defor-
mities are the same.
References
[1] Obwegeser H, Trauner R. Zur operationstechnik
bei der prognatie und anderen unterkieferanom-
lien. Deutsche Zahn-Mund-und Kieferheil-
skunde 1955;23:14.
[2] Arnett GW, Mclaughlin RP. Facial and dental
planning for orthodontists and oral surgeons.
Philadelphia: Mosby; 2004.
[3] Dal Pont G. Retromolar osteotomy for correction
of prognathism. Surgery 1961;19:427.
[4] Hunsuck E. A modified intraoral sagittal splitting
technique for correction of mandibular progna-
thism. J Oral Surg 1968;26:24950.
[5] Epker BN. Modification in the sagittal osteoto-
my of the mandible. J Oral Surg 1977;35:
1579.
 Mandibular Anteroposterior Deficiency and Excess
[6] Feretti C, Reyneke JP. Mandibular sagittal split
osteotomies fixed with biodegradable or tita-
nium screws: a prospective study of postopera-
tive stability. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2002;93:5347.
[7] Turvey TA, Bell RB, Tejera TJ, et al. The use of self-
reinforced biodegradable bone plates and screws
in orthognathic surgery. J Oral Maxillofac Surg
2002;60:5965.
[8] Reyneke JP. Distraction osteogenesisthe future!
Br J Oral Maxfac Surg 2001;39:1801.
[9] Proffit WR, White RP. Etiological factors in the
development of dentofacial deformity. In: Surgi-
cal orthodontic treatment. Sec I. St Louis (MO):
CV Mosby; 1991. p. 2470.
[10] Proffit WR, Phillips C, Dann C, et al. Stability af-
ter surgical orthodontic correction of class III
malocclusion. I. Mandibular setback. Int J Adult
Orthodon Orthognath Surg 1991;6:718.
[11] Enlow DH. Facial growth [Chapter 6]. edition 3.
Philadelphia: Saunders; 1990. p. 193221.
[12] Phillips C, Bennet ME. Psychological ramifica-
tions of orthognathic surgery [Chapter 25]. In:
517
Fonseca RJ, Betts NJ, Turvey TA, editors. Orthog-
nathic surgery, vol. 2. Philadelphia: Saunders;
2000. p. 50635.
[13] Reyneke JP. In essential in orthognathic surgery
[Chapter 4]. Chicago: Quintessence; 2003. p.
171175.
[14] Turvey TA, Simmons K. Orthognathic surgery be-
fore completion of growth [Chapter 26]. In:
Fonseca RJ, Betts NJ, Turvey TA, editors. Orthog-
nathic surgery, vol 2. Philadelphia: Saunders;
2000. p. 53549.
[15] Snow M, Turvey TA, Waller D, et al. Surgical
mandibular advancement in adolescents: post
surgical growth related to stability. Int J Orthod
Orthog Surg 1991;64:14351.
[16] Nishioka GJ, Maso M, Van Sickels JE. Neurosen-
sory disturbances with rigid fixation of the bilat-
eral sagittal split osteotomy. J Oral Maxillofac
Surg 1987;45:205.
[17] Reyneke JP, Feretti C. Intraoperative diagnosis of
condylar sag after bilateral sagittal split ramus
osteotomy. Br J Oral Maxfac Surg 2002;40:
28592.