Combined Surgical and Orthodontic Treatment

Malocclusion Severity as an Indication for Surgery

One indication for surgery obviously is a malocclusion too severe for orthodontics alone. It is possible now to be at least semiquantitative about the limits of orthodontic treatment in the context of producing normal occlusion. As the diagrams of the “envelope of discrepancy” (Figure 19-4) indicate, the limits vary both by the tooth movement that would be needed (teeth can be moved further in some directions than others) and by the patient’s age (the limits for tooth movement change little if any with age, but growth modification is possible only while active growth is occurring). Because growth modification in children enables greater changes than are possible by tooth movement alone in adults, some conditions that could have been treated with orthodontics alone in children (e.g., a centimeter of overjet) become surgical problems in adults. On the other hand, some conditions that initially might look less severe (e.g., 5 mm of reverse overjet) can be seen even at an early age to require surgery if they are ever to be corrected.

Keep in mind that the envelope of discrepancy outlines the limits of hard tissue change toward ideal occlusion, if other limits due to the major goals of treatment do not apply. In fact, soft tissue limitations not reflected in the envelope of discrepancy often are a major factor in the decision for orthodontic or surgical–orthodontic treatment. Measuring millimeter distances to the ideal condylar position for normal function is problematic, and measuring distances from ideal esthetics is impossible. The diagnostic and treatment planning approach discussed in Chapters 6 and 7 reflects a greater emphasis on soft tissue considerations in modern treatment and is essential when camouflage versus surgery is considered.

Orthognathic Surgery versus Temporary Skeletal Anchorage

The advent of temporary skeletal anchorage in the form of miniplates or bone screws has led many orthodontists to wonder if this could decrease the number of patients who would need surgery. Applications of skeletal anchorage in treatment of adults have been discussed in detail in Chapter 18. Tooth movement for patients with a jaw discrepancy, of course, is camouflage—successful only if the jaw discrepancy is no longer apparent enough to be a problem. It is true that protruding maxillary incisors in a patient with mandibular deficiency can be retracted further with skeletal anchorage. This is as likely to produce a camouflage failure as to correct the problem. The limits of orthodontic treatment are much more a matter of facial appearance than anchorage.

There are two circumstances, however, in which skeletal anchorage may be an alternative to orthognathic surgery. Moving the maxilla up with a LeFort I osteotomy is highly stable and predictable and has made it possible to correct anterior open bite/long-face problems that previously could not be treated. Maxillary posterior teeth can be intruded using miniplates at the base of the zygomatic arch or long bone screws reaching into the same area (see Figures 18-50 to 18-52). It is clear now that 3 to 4 mm intrusion can be obtained, with an expected short-term relapse of about 1 mm, and that for the average patient, 2 mm closure of the open bite occurs for every 1 mm posterior intrusion. At this point, however, neither the long-term stability of this treatment nor the limits of intrusion have been established. The indications and contraindications for posterior intrusion will become much clearer in the next few years.

The other interesting possibility for skeletal anchorage is protraction of the maxilla in preadolescent children (see Chapter 13). It is apparent now that Class III elastics to skeletal anchors in the posterior maxilla and anterior mandible are more effective than reverse-pull headgear to the teeth in moving the maxilla forward. As with face mask treatment, however, the moment of truth comes during adolescence, when mandibular growth can lead to a return of the Class III problem. Can the maxilla be moved far enough forward at ages 10 to 12 to prevent the need for later surgical advancement? For some children, this seems likely, but no data exist for long-term outcomes, and the more the problem is mandibular prognathism than maxillary deficiency, the greater the chance of growth that eventually will require surgery.

Esthetic and Psychosocial Considerations

The negative effect on psychic and social well being from dentofacial disfigurement is well documented,^4,5 and it is clear that this is why most patients seek orthodontic treatment. Those who look different are treated differently, and this becomes a social handicap. Treatment to overcome social discrimination is not “just cosmetic.” It is neither vain nor irrational to desire an improvement in facial appearance that can improve one’s total life adjustment. This motivation, not surprisingly, is even stronger in patients with the more severe deviations from the norm that might require orthognathic surgery. If an improvement in appearance is a major goal of treatment, it makes sense that in addition to the jaws and teeth, changes in the nose, and perhaps other changes in facial soft tissue contours that could be produced by facial plastic surgery, should also be considered in the treatment planning. The integration of orthognathic and facial plastic surgery is a current and entirely rational trend.

The great majority of patients who undergo orthognathic procedures report long-term satisfaction with the outcome (80% to 90%, depending on the type of surgery). A similar number say that, knowing the outcome and what the experience was like, they would recommend such treatment to others and would undergo it again.⁶ On long-term recall, patients often comment that the changes produced by their surgery gave them the confidence they needed in order to succeed in their business or profession.

This does not mean, of course, that there are no negative psychologic effects from surgical treatment. First, a few patients have great difficulty in adapting to significant changes in their facial appearance. This is more likely to be a problem in older individuals. If you are 19, your facial appearance has been changing steadily for all your life, and another change is not a great surprise. If you are 49 and now suddenly see a different face in the mirror, the effect may be unsettling. Psychologic support and counseling therefore are particularly important for older patients, and major esthetic changes in older adults may not be desirable. As we have discussed in Chapter 18, adults seeking treatment fall into two groups: a younger group who seek to improve their lot in life and an older group whose goal is primarily to maintain what they have. The older group may need orthognathic surgery to achieve their goal, but for them, often treatment should be planned to limit facial change, not maximize it.

Second, whatever the age of the patient, a period of psychological adjustment following facial surgery must be expected (Figure 19-5). In part, this is related to the use of steroids at surgery to minimize postsurgical swelling and edema. Steroid withdrawal, even after short-term use, causes mood swings and a drop in most indicators of psychologic well being. The adjustment period lasts longer than can be explained by the steroid effects, however. The surgeon learns to put up with complaining patients for the first week or two postsurgery. By the time orthodontic treatment resumes at 3 to 6 weeks postsurgery, the patients are usually—but not always—on the positive side of the psychologic scales. Sometimes the orthodontist also has to wait for a patient to make peace with his or her surgical experience.

In the short-term, an important influence on the patient’s reaction to surgical treatment is how well the actual experience matched what he or she was expecting. Interestingly, orthognathic surgery does not rate high on discomfort/morbidity scales. Mandibular ramus surgery requires about the same pain medication as extraction of impacted wisdom teeth; maxillary surgery is tolerated better than that. From a psychologic perspective, it is not so much the amount of pain or discomfort you experienced that determines your reaction, it is how this compares with what you thought would happen. This highlights the importance of carefully preparing patients for their surgical experience.

Computer Simulation of Alternative Treatment Outcomes

It always has been a moral and ethical imperative to allow the patient to make important decisions about what treatment he or she will accept, and now it is a legal obligation as well. Involving the patient as decisions are made about the choice of alternative treatments is an essential element of informed consent (see Chapter 7).

Computer image predictions are particularly valuable in helping patients decide between camouflage and surgery and in planning surgical treatment. The patient can view the impact on the soft tissue profile of orthodontic camouflage versus surgery when these are realistic treatment alternatives (Figure 19-6) and also view the effect of varying amounts of surgical change—more or less mandibular advancement, for example, or the effect of genioplasty or rhinoplasty in addition to change in jaw position. Predictions of changes in the frontal view still are artwork rather than scientifically based, but current computer prediction programs do a good job of predicting profile changes,⁷ and steady improvements continue to occur. It is one thing to describe in words what the different outcomes of camouflage and surgery would be and something else to help the patient visualize it by seeing image predictions.

At one point, there was great concern that showing predictions to patients might lead to unrealistic expectations and disappointment with the actual result, but patient responses show that this risk is minimal or nonexistent. In a randomized trial, those who saw the prediction images before surgery were more, not less, likely to be satisfied with their result.⁸ Only the patient can decide whether the difference between surgical correction of jaw relationships and orthodontic camouflage would be worth it in terms of the additional risk and cost of surgery. Computer simulations help them do that.

Extraction of Teeth and the Camouflage/Surgery Decision

The decision for camouflage or surgery must be made before treatment begins because the orthodontic treatment to prepare for surgery often is just the opposite of orthodontic treatment for camouflage. It is a serious error to attempt camouflage on the theory that if it fails, the patient can then be referred for surgical correction. At that point, another phase of “reverse orthodontics” to eliminate the effects of the original treatment will be required before surgery can provide both normal jaw relationships and normal occlusion (Figure 19-7).

The critical importance of deciding on camouflage or surgery at the beginning of treatment is illustrated by the difference in extractions needed with the two approaches. In camouflage, extraction spaces are used to produce dental compensations for the jaw discrepancy and the extractions are planned accordingly. For example, with orthodontic treatment alone, a patient with mandibular deficiency and a Class II malocclusion might have upper first premolars removed to allow the retraction of the maxillary anterior teeth. Extraction in the lower arch would be avoided, and the lower incisors probably would be tipped facially to help reduce the overjet (Figure 19-8).

The extraction pattern for this same patient would be quite different if mandibular advancement were planned (see Figure 19-6). Instead of creating dental compensation for the jaw deformity, the orthodontic treatment now would be planned to remove it. In the upper arch, the position of the incisors relative to the maxilla often is normal or retrusive; if so, upper premolar extraction would be undesirable. Often in mandibular deficiency the lower incisors are protrusive relative to the chin. Then there are two possibilities: extraction in the lower arch to retract them and temporarily increase the overjet so the chin will be brought further forward when the mandible is advanced or a lower border osteotomy to move the chin forward.

A similar but reversed situation would be seen in a patient with a skeletal Class III problem. If camouflage were planned, typical extractions might be lower first premolars alone, lower first and upper second premolars, or one lower incisor. Surgical preparation of a Class III patient often requires moving the lower incisors forward and retracting the upper incisors (which may require extraction of upper first premolars) to correct their axial inclinations and increase the reverse overjet (see Figure 19-7). As a general rule, Class III problems are less amenable to camouflage than Class II because retracting the lower incisors may make the chin appear even more prominent, just the opposite of effective camouflage. If space were needed in the lower arch, second rather than first premolar extraction would be a logical choice so that the lower incisors were not retracted.

It obviously is important for the patient who could be treated either way to understand all these considerations in the decision between camouflage and surgery. Although the patient can and must make the decision, it remains true that some conditions can be treated better with orthodontics alone than others, simply because the impact on facial esthetics is likely to be better. Some characteristics that can make the difference between satisfactory camouflage treatment and camouflage failure are summarized in Box 19-1.

Mandibular Surgery

The sagittal split osteotomy (see Figure 19-2) now is used for almost all mandibular surgery because of several advantages over mandibular body procedures and alternative techniques for ramus surgery:

In contemporary treatment, a lower border osteotomy of the mandible to reposition the chin relative to the mandibular body (Figure 19-11) is a major adjunct to ramus procedures, especially when the mandible is advanced. It is used in about 30% of the patients who receive a ramus osteotomy and in about the same number of patients with maxillary surgery. The lower border procedure allows the chin to be moved transversely, forward or back, and up or down.

Other mandibular procedures are used primarily for major advancements or surgery involving the condyles. An extraoral approach often is required, and a bone graft is likely to be needed. Rarely, a midline osteotomy of the mandible with removal of an incisor is used to narrow it anteriorly.⁹

Maxillary Surgery

The LeFort I osteotomy with downfracture of the maxilla (see Figure 19-3) dominates contemporary maxillary surgery just as the sagittal split dominates mandibular surgery. It allows the maxilla to be moved up and/or forward with excellent stability. Moving the entire maxilla back is quite difficult because of the structures behind it, but this is not necessary when the upper teeth are protrusive. A segmental osteotomy, closing the space where a premolar was extracted, allows the anterior teeth to be retracted and posterior teeth to be moved superiorly so that anterior open bite is closed as the mandible rotates upward and forward (Figure 19-12). Segmental osteotomies also allow the posterior maxilla to be widened or (less frequently) narrowed.

Expansion is done with parasagittal osteotomies in the lateral floor of the nose or medial floor of the sinus that are connected by a transverse cut anteriorly. In a two-piece osteotomy, a midline extension runs forward between the roots of the central incisors; this may or may not be included in a three-piece osteotomy (Figure 19-13). If constriction is desired, bone is removed at the parasagittal osteotomy sites. In expansion, either bone harvested in the downfracture or bank bone is used to fill the void created by lateral movement of the posterior segments.

Orthopedic palatal expansion of the type used in adolescents is not feasible in adults because of the increasing resistance from interdigitated midpalatal and lateral maxillary sutures. Surgically assisted rapid palatal expansion (SARPE), using bone cuts to reduce the resistance followed by expansion of the jackscrew to separate the halves of the maxilla, is another possible treatment approach for adult patients with a narrow maxilla (Figure 19-14). The original idea of surgically assisted expansion was that cuts in the lateral buttress of the maxilla would decrease resistance to the point that the midpalatal suture could be forced open (i.e., microfractured) in older patients. Although this usually works in patients in their late teens or early twenties, the chance of inadvertent fractures in other areas is a concern, especially for patients in their thirties or older. For SARPE now, surgeons usually make all the cuts needed for a LeFort I osteotomy, omitting only the final step of downfracture. This allows widening of the maxilla against only soft tissue resistance, manipulating the osteotomy sites with what amounts to distraction osteogenesis. If only expansion is desired, this provides a somewhat less invasive approach than segmental osteotomy.

The implication of SARPE is that the problem affects only the transverse plane of space, and this is when it is most useful. One of its purported advantages over segmental osteotomy has been better stability, and some surgeons have advocated a preliminary phase of SARPE before LeFort I osteotomy to move the maxilla anteroposteriorly or vertically. Current data, however, show that relapse of the dental expansion that accompanies SARPE occurs (Figure 19-15) and that its long-term stability is similar to that with segmental osteotomy.¹⁰ It is difficult therefore to justify the additional cost and morbidity of surgically assisted expansion as a first stage of surgical treatment in a patient who would require another operation later to reposition the maxilla in the anteroposterior or vertical planes of space. The primary indication for preliminary SARPE is such severe maxillary constriction that segmental expansion of the maxilla in the LeFort I procedure might compromise the blood supply to the segments.

Dentoalveolar Surgery

Segments of the dentoalveolar process can be repositioned surgically in all three planes of space (Figure 19-16), but in this surgery as in other types, there are important limitations. The principal one is the distance of movement that is possible: in most instances, only a few millimeters. A significant but less important limitation is the size of the segment: a three-tooth or larger segment is preferred, a two-tooth segment is acceptable but less predictable, and a one-tooth segment is a problem waiting to occur.

The reason for both limitations is the same. After an osteotomy beneath the bone segment and teeth, the blood supply is the surprisingly good collateral circulation via the facial and lingual mucosa. This has to be preserved to maintain the vitality of the teeth and the integrity of the bone. The further a segment is moved and the smaller it is, the greater the chance of interrupting not only the usual blood supply but also the collateral supply.

An osteotomy below the root apices cuts the nerves to the pulp of the teeth in that segment, and of course there is no collateral innervation. The short-term result is something that dentists rarely observe: a vital but denervated pulp that does not respond to electrical stimulation. At that point, pulp vitality can be demonstrated by the maintenance of either normal pulp temperature (temperature probe) or blood flow (Doppler flow meter), and reinnervation of the pulp often occurs after a few months. Even though the major vessels to the tooth pulp are cut, less than 2% of the involved teeth require endodontic treatment. Even if the apex of a tooth is inadvertently cut off, pulp vitality is likely to be maintained by blood flow through auxiliary foramina.

Distraction Osteogenesis

Distraction osteogenesis is based on manipulation of a healing bone, stretching an osteotomized area before calcification has occurred in order to generate the formation of additional bone and investing soft tissue (see Chapter 8).¹¹ For correction of facial deformities, this has two significant advantages and one equally significant disadvantage.

The advantages of distraction are that (1) larger distances of movement are possible than with conventional orthognathic surgery and (2) deficient jaws can be increased in size at an earlier age. The great disadvantage is that precise movements are not possible. With distraction, the mandible or maxilla can be moved forward, but there is no way to position the jaw or teeth in exactly a preplanned place, as can be done routinely with orthognathic procedures. This means that patients with craniofacial syndromes, who are likely to need intervention at early ages and large distances of movement and for whom precision in establishing the posttreatment jaw relationship is not so critical, are the prime candidates for distraction of the jaws.

Moderately severe hemifacial microsomia, in which a rudimentary ramus is present on the affected side, is a major indication for distraction (Figure 19-17). Distraction is not needed in the milder forms of this syndrome in which mandibular asymmetry exists but the mandible is reasonably complete (for these patients, growth modification is possible), and it cannot be used as the initial stage of treatment in patients so severely affected that the entire distal portion of the mandible is absent. For them, a bone graft is necessary, and distraction at a later time can be one way to lengthen the graft. The timing of treatment for the moderately severe hemifacial patients remains controversial, but social acceptability becomes a factor in the decision. To improve the child’s facial appearance, intervention to advance the mandible on the affected side often is considered at ages 6 to 8, and at that time both of its advantages make distraction a frequent choice. Early treatment, however, is unlikely to be followed by normal growth of the distracted area, and later orthognathic surgery or a second round of distraction probably will be required.

Patients with facial syndromes that include severe maxillary deficiency (e.g., Crouzon, Apert; see Figure 5-12) also are candidates for early distraction. In these patients, appropriate bone cuts in the posterior and superior areas of the maxilla can allow advancement of the entire midface, similar to what can be achieved with LeFort III surgery but without the need for extensive bone grafts. For patients with problems of this type, the precision with which the teeth can be placed in proper occlusion simply becomes a secondary consideration. The fact that later orthodontic and surgical treatment will be required reinforces this attitude toward the initial treatment.

For less severe maxillary or mandibular deficiency, however, distraction offers no advantage over a sagittal split or LeFort I osteotomy. The orthognathic procedures allow the teeth and jaws to be precisely positioned, and an excellent clinical result can be anticipated in the great majority of the patients. For these patients, distraction is a more difficult way to accomplish a surgical result that requires more extensive postsurgical orthodontics.

One of the things that cannot be done with orthognathic surgery is widening the mandibular symphysis because there is not enough soft tissue to cover a bone graft in that area. Distraction makes this quite possible (Figure 19-18) and provides additional space in the incisor area. Does that make it an acceptable method for nonextraction treatment of lower incisor crowding? When crowded incisors are aligned with orthodontic expansion, this is accomplished at the expense of incisor protrusion and doubtful stability, especially if mandibular canines are expanded without also retracting them. The important clinical questions therefore are whether symphysis distraction provides a more stable and less protrusive result than nonextraction orthodontics and whether either approach to expanding the mandibular dental arch gives a better result than premolar extraction to provide space for alignment.

With distraction at the symphysis, not only osteogenesis (formation of new bone) but also histogenesis (formation of new soft tissue) occurs. The formation of new periosteum over the distracted area is what makes widening the symphysis possible. To relieve lip and cheek pressure against expanded mandibular canines, however, soft tissue changes would have to extend to the muscles of facial expression at the corners of the mouth. To date, there is no evidence that expansion with distraction is more stable than conventional distraction, and given the distance from the osteotomy site to the soft tissues at the corner of the mouth, it seems unlikely that this would be the case.

Adjunctive Facial Procedures

A variety of adjunctive facial procedures can be used as adjuncts to orthognathic surgery to improve the soft tissue contours beyond what is available from repositioning the jaws.¹² Conceptually, this can be viewed as a form of camouflage, done surgically rather than orthodontically.

These procedures can be put into five groups: chin augmentation or reduction, rhinoplasty, facial soft tissue contouring with implants, lip procedures, and submental procedures. Considering them briefly, in turn:

Postsurgical Stability and Clinical Success

Timing of Surgery

As a general rule, early jaw surgery has little inhibitory effect on further growth. For this reason, orthognathic surgery should be delayed until growth is essentially completed in patients who have problems of excessive growth, especially mandibular prognathism. For patients with growth deficiencies, surgery can be considered earlier but rarely before the adolescent growth spurt.

Correction of Combined Vertical and Anteroposterior Problems

Other Considerations

Orthodontic Appliance Considerations

In contemporary surgical–orthodontic treatment, a fixed orthodontic appliance has three uses: to (1) accomplish the tooth movement needed in preparation for surgery, (2) stabilize the teeth and basal bone at the time of surgery and during healing, and (3) allow the necessary postsurgical tooth movement while retaining the surgical change. In terms of appliance selection, the second use is the determining factor: the appliance must permit the use of full-dimension rectangular archwires for strength and stability during the stabilization phase of treatment. Any of the variations of the edgewise appliance (including self-ligating brackets), in either 18- or 22-slot, are acceptable for stabilization, but the self-ligating bracket should allow a full-dimension steel wire to be ligated in place for the surgical stabilization. Integral hooks on brackets, however, are not a good choice for attaching the wires needed to hold the jaws in the planned position as surgical fixation is applied because tying directly to a bracket increases the chance of dislodging it at a particularly awkward time.

A modern lingual appliance can be used for presurgical orthodontics, as can clear aligners, but in both cases brackets on the facial surface of the teeth must be placed for stabilization and finishing. The standard Begg appliance does not provide the control needed for stabilization, and its Tip-Edge variant (see Figure 16-10) is less than optimal for stabilization.

For surgical–orthodontic treatment, ceramic brackets pose a dilemma. Their appearance makes them appealing to esthetically conscious adults who choose surgery, but the brittleness of the ceramic material makes them susceptible to fracture, especially when the jaws are being tied together in the operating room so rigid fixation can be placed. Patients who are told that ceramic brackets might compromise their surgical result usually accept metal brackets instead. If ceramic brackets are used, they should be restricted to the maxillary anterior teeth. The surgeon must treat them gently and be prepared to deal with problems in the operating room.

Presurgical Orthodontics

Patient Management at Surgery

Postsurgery Care

With the current emphasis on controlling health care costs, hospital stays for modern orthognathic surgery have been reduced considerably. Sagittal split osteotomies of the mandibular ramus often are performed now at outpatient surgery centers, without overnight hospitalization, and lower border osteotomy of the mandible almost never requires an overnight stay. Maxillary osteotomies typically require overnight hospitalization, and two-jaw surgery almost always requires a 1 to 2 day hospital stay. A well-qualified and experienced nursing team is important in providing the postsurgical care. With early discharge after jaw surgery, telephone access to the nursing team is important. Patients require surprisingly little pain medication, particularly following maxillary surgery. Rigid fixation and an early return to jaw movements eliminates the discomfort associated with having the jaws wired together for several weeks.

Patients are advised to maintain a soft diet (e.g., milkshakes, potatoes, scrambled eggs, yogurt) for the first week after surgery. Over the next 2 weeks they can progress to foods that require some chewing (soft pasta, meat cut into pieces), using the degree of discomfort as a guide to their rate of progression. By 6 to 8 weeks after surgery, they should be back on a normal diet. Note that this coincides with the time when the orthodontist can allow the patient to eat without the use of elastics (see below).

This progression can be assisted considerably by physical therapy beginning as soon as the postsurgical intracapsular joint edema is resolved—typically about 1 week after the surgery. For the first week, patients are advised to open and close gently within comfortable limits. Over the next 2 weeks, three 10- to 15-minute sessions of opening and closing exercises as well as lateral movements are indicated, with the patient closing into the splint. From the third to the eighth week, the range of motion is increased. The goal is to achieve optimum function by 8 weeks.

Postsurgical Orthodontics

Once a satisfactory range of motion is achieved and the surgeon is satisfied with the initial healing, the finishing stage of orthodontics can be started. With rigid fixation, this now is at 2 to 4 weeks postsurgery.

It is critically important that when the splint is removed, the stabilizing archwires are also removed and replaced by working wires to bring the teeth to their final position. This means that usually the orthodontist, not the surgeon, should remove the splint. Light vertical elastics are needed initially with these working archwires (Figure 19-29), not so much for tooth movement—the archwires should do that—but to override proprioceptive impulses from the teeth that otherwise would cause the patient to seek a new position of maximum intercuspation. Until the stabilizing archwires are removed, the teeth are held tightly in the presurgical position. Removing the splint without allowing the teeth to settle into better interdigitation can result in the patient adopting an undesirable convenience bite, which in turn complicates orthodontic finishing and could stress recent surgery sites.

The choice of archwires during the postsurgical orthodontics is determined by the type and amount of movement needed. The typical settling of teeth into full occlusion can be achieved rapidly using light round wires (typically 16 mil steel) and posterior box elastics with an anterior vector that supports the sagittal correction. A flexible rectangular wire in the upper arch to maintain torque control of the maxillary incisors (in 18-slot, 17 × 25 beta-Ti [TMA]; in 22-slot, 21 × 25 M-NiTi [Nitinol or equivalent]) often is a good choice, with a round wire in the lower arch.

Elastics should not be discontinued until a solid occlusion is established. Typically, patients wear the light elastics full time, including while they are eating, for the first 4 weeks; full time except for eating for another 4 weeks; and just at night for a third 4-week period. Elastics can be discontinued during any further detailing of the occlusion. Patients are increasingly intolerant of continued treatment after about 6 months, so it is important to finish the postsurgical orthodontics within that time if possible.

A typical sequence of treatment is shown in Figure 19-30 and in the previous case reports in this chapter.

Retention after surgical orthodontics is no different than for other adult patients (see Chapter 17), with one important exception: if the maxilla was expanded transversely, it is critically important not only to maintain the expansion during the finishing orthodontics, but also to have full-time retainer wear in the maxilla for at least 6 months. If a transpalatal lingual arch was placed following surgery, it should not be removed during the first postsurgical year.

1. Trauner, R, Obwegeser, H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Oral Surg Oral Med Oral Pathol. 1957;10:671–692.

2. Bell, WH. LeFort I osteotomy for correction of maxillary deformities. J Oral Surg. 1975;33:412–426.

3. Epker, BN, Wolford, LM. Middle third facial osteotomies: Their use in the correction of acquired and developmental dentofacial and craniofacial deformities. J Oral Surg. 1975;33:491–514.

4. Eagly, AH, Ashmore, RD, Makhijani, MG, et al. What is beautiful is good, but …: a meta-analytic review of research on the physical attractiveness stereotype. Psych Bull. 1991;110:109–128.

5. Oland, J, Jensen, J, Elklit, A, et al. Motives for surgical-orthodontic treatment and effect of treatment on psychosocial well-being and satisfaction: a prospective study of 118 patients. J Oral Maxillofac Surg. 2011;69:104–113.

6. Phillips, C, Proffit, WR. Psychosocial aspects of dentofacial deformity and its treatment (Chapter 3). In: Proffit WR, White RP, Sarver DM, eds. Contemporary Treatment of Dentofacial Deformity. St. Louis: Mosby, 2003.

7. Smith, JD, Thomas, PM, Proffit, WR. A comparison of current prediction image programs. Am J Orthod Dentofac Orthop. 2004;125:527–536.

8. Phillips, C, Bailey, LJ, Kiyak, HA, et al. Effects of a computerized treatment simulation on patient expectations for orthognathic surgery. Int J Adult Orthod Orthogn Surg. 2001;16:87–98.

9. Joondeph, DR, Bloomquist, D. Mandibular midline osteotomy for constriction. Am J Orthod Dentofac Orthop. 2004;126:268–270.

10. Chamberland, S, Proffit, WR. Short- and long-term stability of SARPE revisited. Am J Orthod Dentofac Orthop. 2011;139:815–822.

11. Crago, CA, Proffit, WR, Ruiz, RL. Maxillofacial distraction osteogenesis (Chapter 12. In: Proffit WR, White RP, Sarver DM, eds. Contemporary Treatment of Dentofacial Deformity. St. Louis: Mosby; 2003:357–393.

12. Sarver, DM, Rousso, DR, White, RP, Jr. Adjunctive esthetic surgery (Chapter 13. In: Proffit WR, White RP, Sarver DM, eds. Contemporary Treatment of Dentofacial Deformity. St. Louis: Mosby; 2003:394–415.

13. Sarver, DM, Rousso, DR. Plastic surgery combined with orthodontic and orthognathic procedures. Am J Orthod Dentofac Orthop. 2004;126:305–307.

14. Snow, MD, Turvey, TA, Walker, D, et al. Surgical mandibular advancement in adolescents: postsurgical growth related to stability. Int J Adult Orthod Orthognath Surg. 1991;6:143–151.

15. Roberts, HG, Semb, G, Hathorn, I, et al. Facial growth in patients with unilateral clefts of the lip and palate: a two-center study. Cleft Palate-Craniofacial J. 1996;31:372–375.

16. Kiyak, HA, West, RA, Hohl, T, et al. The psychological impact of orthognathic surgery: a 9-month followup. Am J Orthod. 1982;81:404–412.