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

+*:
Fort Worth, Texas

During superior repositioning of the maxilla (SRM), the mandible antorotatc.~ ,fivwrrrtl
and upward at pogonion, with the condyle as the center of rotation. Thus, in each
instance when planning surgical superior repositioning of the maxilla one must decide.
on the basis of esthetics and cephalometric prediction criteria, the mugnitude of
autorotation and the contribution of this rotation toward the desired occlusal and
esthetic result. In many instance.s the maxilla can be moved somewhat posteriorly or
anteriorly, and thus simultaneous mandibular surgery is not required to achielme the
desired result. In some cases, however, simultaneous mandibular ad~~ancement ot
set-back is required to achieve the desired occlusal and esthetic result. This article
discusses the specijics of making the decision regarding what to do with the mandible
when superiorly repositioning the maxilla.

Key words: Superior repositioning of the maxilla, maxillary surgery, vertical

maxillary excess

I n previous publications we have discussed those indications which dictate

surgical superior repositioning of the maxilla. 1-6 These articles on superior repositioning
have discussed surgical techniques, the sequencing of surgery and orthodontics, and the
stability of results following superior repositioning of the maxilla. No discussion of what
to do with the mandible when superiorly repositioning the maxilla was presented. It is the
purpose of this article to discuss in detail (1) the various simultaneously indicated surgical
procedures in the mandible when the maxilla is being repositioned superiorly, (2) how to
determine which of these procedures is appropriate for a given patient, and (3) to illustrate
these various possibilities with case presentations.

Simultaneously indicated procedures in the mandible when the maxilla is

superiorly repositioned
When the maxilla is superiorly repositioned surgically, upward and forward autorota-
tion of the mandible occurs, with the condyle acting as the center of rotatione6 This article
will discuss the autorotation effect and five simultaneous mandibular surgical procedures
which can be used when the maxilla is moved superiorly. The six possible effects on the
mandible are (1) autorotation only, (2) anterior subapical mandibular surgery, (3) aug-

*Director, Oral and Maxillofacial Surgery and Center for Conection of Dentofacial Deformities,
John Peter Smith Hospital.
**Orthodontist, Center for Correction of Dentofacial Deformities, John Peter Smith Hospital.

164 0002~9416/80/080164+28$02.80/0 0 1980 The C. V. Mosby Co.

Volume 78
Number 2
Surgical superior repositioning of maxilla 165

mentation genioplasty, (4) mandibular advancement, (5) reduction genioplasty, and (6)
mandibular set-back.
To decide which of these procedures is most appropriate for a given patient, one must
(1) decide on the basis of esthetics exactly how much to move the anterior maxilla
superiorly”, 5 and (2) do a cephalometric prediction tracing to (a) determine the exact
amount of autorotation of the mandible that will occur with the planned amount of
superior maxillary repositioning,* (b) determine the amount of anterior or posterior
movement of the maxilla which will be required after the mandibular autorotation to
establish the desired occlusion, and (c) determine if the patient’s profile facial esthetics
will be sufficiently improved with only the superior repositioning of the maxilla and
mandibular autorotation, or if a simultaneous procedure in the mandible is indicated to
achieve the desired esthetic and occlusal results.
Each of the listed options of what to do in the mandible will be discussed sequentially.
The decision to have only autorotation in the mandible. There are two types of patient
in whom no simultaneous mandibular surgery is indicated in the mandible. The first is the
patient with a Class I occlusion whose maxilla can be simultaneously moved superiorly
and anteriorly (anteriorly the amount dictated by the autorotation while maintaining a
Class I occlusion) with improvement in facial esthetics. Such a patient will have an obtuse
to normal nasolabial angle, some paranasal recessiveness, and a slightly deficient chin.
The second is the patient with a Class II malocclusion whose maxilla will be moved
superiorly and somewhat posteriorly in conjunction with the autorotation of the mandible,
to correct the malocclusion without compromising profile facial esthetics. Such a patient
typically presents with a normal to acute nasolabial angle, normal to full paranasal areas,
and a mildly deficient chin.
The decision for mandibular subapical surgery. Anterior mandibular subapical sur-
gery is indicated (1) when there is an extreme curve of Spee which can be surgically
leveled, (2) when the lower dental midline is asymmetrical and can be surgically cor-
rected, and (3) when the lower anterior segment needs to be retracted a great distance.
While these situations can usually be handled orthodontically, we elect to treat them
surgically when doing so will signijkantly shorten the over-all treatment time. However,
when time-consuming orthodontic treatment must be done in other areas, this generally
negates the benefit of shortening treatment time by performing anterior subapical man-
dibular surgery and we correct the lower arch orthodontically.
The decision for augmentation geniopfasty. Patients who will benefit from simulta-
neous augmentation genioplasty are basically the same as those who require no mandibu-
lar procedure, except that they have a more deficient chin. In these persons, despite the
increase in chin prominence produced by the mandibular autorotation, the chin is still
recessive and therefore in poor balance with the lips and nose. This contour deficiency of
the chin can be the result of either the lack of a sufficient bony pogonion or the lack of
normal soft-tissue thickness in the pogonion area. A second type of patient who will
benefit from augmentation genioplasty is the patient with proclination of the lower incisors
and extreme crowding, where “ideal” orthodontic uprighting of the lower incisor is
impossible with removal of only two premolars. We prefer to augment the chin in such

*Due to differing geometric relationships, the actual amount of mandibular autorotation will vary with each case
and must be determined via a prediction tracing!
 0G
Fig. 1A to C. A, Front face before treatment. B, Profile before treatment. C, Cephalometric tracing
before treatment.

cases rather than remove four or more teeth in one arch in an effort to “harmonize” the
mandibular dentition to a deficient mandible. Importantly, when one elects to extract
numerous teeth in the lower arch to avoid genioplasty, the overjet generally becomes SO
extreme as to necessitate a mandibular advancement, rhus producing rhe need for more
surgery-not less!
 Fig. 1D and E. Models before and after treatment.

The decision for mandibular advancement. Patients requiring simultaneous mandibu-

lar advancement when undergoing superior surgical repositioning of the maxilla usually
fall into two categories. The first is the patient with a Class II malocclusion and an
excessively obtuse nasolabial angle. Here autorotation alone will not correct the maloc-
clusion and the necessary posterior movement of the maxilla to correct the Class II
malocclusion is contradicted, as it will make the patient look worse by further increasing
the nasolabial angle, retruding the lips, and further accentuating the nasal prominence.
Obviously, in such instances, this is a matter of degree. If the mandibular autorotation
corrects all but 2 mm. of the malocclusion and the nasolabial angle is only slightly obtuse,
it is sensible to move the maxilla back this small amount and avoid simultaneous mandibu-
lar advancement. On the other hand, if the nasolabial angle is severely obtuse and/or a
great posterior movement of the maxilla (5 mm.) is required, an unsatisfactory profile
Fig. 1F to Ii. F, Front face after treatment. G, Profile after treatment. H, Cephalometric tracings before
and after treatment.

esthetic result is certain and simultaneous mandibular advancement must be considered.

The second is the patient with an extreme Class II malocclusion whose mandible is
obviously deficient in size and in whom posterior movement of the maxilla would be of
such magnitude as to noticeably worsen the facial appearance.
In both of these types, the mandibular retrognathia is frequently accompanied by
microgenia. Thus, an augmentation genioplasty must be considered in addition to the
planned mandibular advancement.
 78
Surgical superior repositioning of maxilla
2

Fig. 2. Cephalometric prediction tracings of surgical results and surgical plus postsurgical orthodontic
results.

The decision for reduction genioplasty. Reduction genioplasty can be accomplished in

either the vertical and/or the anteroposterior direction. ’ Patients who benefit from vertical
reduction are generally those in whom a significant proportion of the long appearance to
the lower third of the face is the result of an excessive distance between the lower incisor
tooth and the inferior border of the chin. Patients requiring an anteroposterior reduction
are those with an initially normal to strong pogonion and in whom the mandibular autoro-
tation secondary to superior maxillary repositioning produces a chin that is too protrusive.
Such patients will generally have a Class I malocclusion with a normal to strong chin prior
to surgery. In such cases the decision must be whether to perform a reduction genioplasty
or a mandibular set-back.
The decision for mandibular set-back. Patients requiring mandibular set-back are of
two general types: (1) the Class I patient with an acute nasolabial angle who therefore
cannot tolerate any forward movement of the maxilla, and (2) the Class III patient whose
occlusion will become even more Class III with maxillary superior repositioning. The
latter situation classically exists in persons with Class III open-bite deformity.8 In the
former, the already acute nasolabial angle precludes any further forward movement of the
maxilla and upper incisors, as would be necessary secondary to the mandibular autorota-
tion. There are two subtypes of this patient. The first is the patient with some crowding to
the dentition wherein, following surgery, the protrusive nature of the incisors and acute-
ness of the nasolabial angle can be corrected by extraction orthodontics. Here, unless the
chin becomes too prominent, we would opt for the orthodontic treatment to correct the
acute nasolabial angle. The second patient is the one with a good occlusion and little or no
crowding. Here, if orthodontic treatment is unwarranted or unnecessary, it is essential to
set back the mandible at the same time that the maxilla is moved superiorly and posteriorly
to keep from producing an objectionably acute nasolabial angle.
 L. R.

Fig. 3A to C. A, Front face before treatment. 9, Profile before treatment. C, Cephalometric tracing
before treatment.

Selection of the proper surgical procedure

What to do with the mandible is primarily dependent upon what can be done with the
maxilla (that is, what the patient’s facial esthetics will most benefit from) as far as
simultaneous anterior or posterior movement of the maxilla along with superior reposi-
tioning is concerned. This requires correlation of existing facial esthetics with prediction
tracing changes.
Volume 78
Number 2

Fig. 3D and E. Models before and after treatment.

The first decision is how far to move the maxilla superiorly, as is determined clini-
cally.4, s The second decision is what simultaneous anteroposterior changes in the maxilla
are desirable to optimize facial esthetics. These indicated esthetic changes are then corre-
lated to the prediction tracings. 9 The first prediction tracing done is one which will move
the maxilla the desired amount superiorly and correct the existing malocclusion with only
autorotation of the mandible. This tracing will tell the clinician how much anteroposterior
movement of the maxilla will occur with no mandibular surgery and where the chin will be
with the least possible surgery. These changes are then correlated with those which were
clinically determined to be most desirable. If the movement of the maxilla is 6 mm.
posteriorly and the related facial esthetics (alar base width, paranasal areas, and nasolabial
angle) are worsened significantly by this movement, simultaneous mandibular advance-
ment surgery must be considered to avoid this posterior repositioning of the maxilla. A
 Am. J. Orthod.
AURUS~ 1980

I-1G-78 -
4-13-78 - - - - _

0
Ic

Fig. 3F to Il. F, Front face after treatment. G, Profile after treatment. H, Cephalometric tracings before
and after treatment.
Volume 18
Surgical superior repositioning of mmilla 173
Number 2

1. R

Original Mandibular Advancement Maxilla Superior

Fig. 4. The occlusion which could be obtained before any orthodontic treatment is seen in the model
surgery.

second prediction tracing is done accordingly. However, it must be noted that when
minimal movement (1 to 4 mm.) of the maxilla anteriorly or posteriorly will eliminate the
need for mandibular surgery, such movement is not usually considered clinically sig-
nificant. In such cases simultaneous mandibular surgery is generally not indicated.
These principles of treatment planning via correlation of facial esthetics with
cephalometric prediction tracings will be illustrated with selected case reports of the
various possible options of what to do with the mandible when the maxilla is superiorly
repositioned.

Case reports
Case 1. The decision to have only autorotation in the mandible
An 1%year-old white female patient was referred upon her requestfor correction of lip incompe-
tence and excessive exposure of the maxillary anterior teeth.
Esthetic evaluation. Frontally, facial symmetry was good. The upper and middle thirds of the
face were in normal balance, with the nose appearing long because of the narrow alar bases. The
lower third appeared long. There was an excessive interlabial gap (1 mm.) and excessive exposure
of upper anterior teeth (10 mm.) (Fig. 1A).
In the profile the upper and middle thirds of the face appearednormal. The nasolabialangle was
normal (90 to 110 degrees). Again, the excessive interlabial gap was noted and the chin was
moderately recessive with eversion of the lower lip (Fig. 1B).
Cephalometric evaluation. Both facial axis and facial depth were dolichocephalic with a high
mandibular plane angle and moderate convexity, or the height of the lower two thirds face (ANS-
GN) was excessive. Both upper and lower incisors were protrusive, and the lower lip was ahead of
the E line (Fig. 1C).
Occlusul andysis. Occlusion was a Class I with 8 mm. of crowding in the lower arch. There
174 Epkrr wd Fish

Fig. 5. Prediction on the right of proposed segmental maxillary surgery and anterior mandibular subapi-
cal surgery.

were no teeth missing. The overbite was within normal limits, while the overjet was excessive. Both
upper and lower arches were symmetrical with good arch form (Fig. ID).
Twarmnt pluming decision: Wlttrt 10 c/o \l?rh rhe mctndihle:~ The primary desired change in
facial esthetics could be achieved by moving the maxilla 8 mm. superiorly so that a normal upper
tooth-to-lip relation would exist. This would also produce some widening of the alar bases, which
would be desirable. In profile the paranasal and nasolabial angles were considered normal, and so it
was desired not to alter these significantly, especially the nasolabial angle. The chin was recessive
and would be esthetically enhanced by becoming more protrusive.
A prediction tracing was made with only superior maxillary repositioning and maintenance of
the Class I occlusion. This resulted in a 4 mm. anterior movement of the anterior maxilla and central
incisors. Since four premolars were to be removed for orthodontic reasons, this amount of surgical
forward movement of the anterior teeth could be eliminated with postsurgical orthodontics. With the
autorotation of the mandible that would occur with the superior repositioning of the maxilla, it was
determined that the chin would move forward 5 mm. and produce a satisfactory chin-lip-nose
balance. Therefore, the following treatment plan was adopted (Fig. 2):
Presurgical orthodontics:
Full band
Surgery:
Superior repositioning of maxilla with extraction of four first premolars and four third
molar impactions
Postsurgical orthodontics:
Standard treatment for a maximum-anchorage Class I, four-bicuspid extraction case
The treatment results are illustrated in the photographs and tracings in Fig. 1D to H. *

Case 2. The decision for mandibular subapical surgery

A 20-year-old female patient with a chief complaint that her lips did not come together and that
too much of her upper front teeth showed was seen in consultation.
Estheric e\uluarion. Frontally, good facial symmetry existed and the upper and middle thirds of
the face appeared in normal balance. The nose exhibited narrow alar bases. The lower third of the
face appeared long with an excessive interlabial gap (8 mm.) and excessive exposure of upper front
teeth (8 nm.) (Fig. 3A).
*Orthodontic treatment by Dr. Richard C. Meyer, Little Rock, Ark
 M. 5.
8-l6-75

0c
Fig. 6A to C. A, Front face before treatment. B, Profile before treatment. C, Cephalometric tracing
before treatment.
176 Epker and Fish

Fig. 6D and E. Models before and after treatment.

In the profile the upper and middle thirds of the face were normal. The nasolabial angle was
normal, and the nose exhibited a turned-up tip. The excessive interlabial gap was again evident. The
lower lip was somewhat everted, and the chin projection was recessive (Fig. 3B).
Cephalometric e\%a/uation. The facial axis was distinctly dolichocephalic, while the facial depth
was only moderately so. The mandibular plane angle was steep and convexity was high. The upper
incisors were protrusive, with overjet being extreme while the overbite was less than normal. The
lower lip was everted and forward of the E line (Fig. 3C).
Occlusal analysis. The lower right first molar was missing, and an appliance had been placed to
maintain the space. The upper arch was symmetrical, with the teeth well aligned. The upper central
incisors were previously crowned to correct a midline diastema. The lower arch was asymmetrical,
with the teeth being shifted to the patient’s right. There was moderate crowding in the lower anterior
region. The occlusion was a full Class II on the right and Class I on the left. Overjet was excessive
(8 mm.) and overbite was minimal (Fig. 30 and E).
Treatment planning decision: What to do with the mandible? The primary desirable change in
facial esthetics to be achieved was to move the anterior maxilla 6 mm. superiorly to produce a
Volume 78
Number 2
Surgical superior repositioning of maxilla 177

11. s.
s-2:1-75 (27.1) -
8..20-76 (28.1) --- -

\\I
\I
‘1 II

Fig. 6F to Ii. F, Front face after treatment. G, Profile after treatment. H, Cephalometric tracings before
and after treatment.
Fig. 7. Cephalometric prediction tracings of surgical-orthodontic changes with and without augmenta-
tion genioplasty.

normal upper tooth-to-lip relation. This would produce widening of the alar bases. which would be
desirable. In profile the nasolabial angle was slightly acute, and the upper incisors were protrusive.
It would be desirable to reduce the protrusion of the incisors and thus reduce the acuteness of the
nasolabial angle. To affect this change, it would be necessary to reposition the maxilla posteriorly
simultaneously with its planned superior repositioning. This can be achieved in two ways: (1) move
the entire maxilla posteriorly or (2) extract premolar teeth and move the anterior maxilla back. The
decision of which to do is predicated upon occlusal results as determined by model surgery.
The lower arch was asymmetrical, with the midline being to the right and the curve of Spee
excessive. A Class I canine relationship, corrected midline, and leveled curve of Spee could be
achieved by removal of a premolar on the left and performing a mandibular subapical ostectomy
with removal of some bone below the apices of the teeth to simultaneously level the lower arch.
Since lower subapical surgical retraction was planned, it was decided to do feasibility model surgery
by also retracting the maxillary anterior teeth with premolar extractions.
Models were cut to simulate the above changes, and an occlusion which would be easily finished
orthodontically was obtained (Fig. 4). A prediction tracing was done, reflecting the 6 mm. superior
repositioning, the retraction of the upper incisors, and the retraction, rotation, and depression of the
lower subapical segment. From this prediction it was noted that if the above procedures were
executed the patient would have a proper incisor-to-lip relationship, a normal nasolabial angle, and
good chin projection (Fig. 5). By including the lower subapical procedure, treatment time would be
considerably shortened. Therefore, the following treatment plan was adopted:
Presurgical orthodontics:
Full band
Surgery:
Superior repositioning of the maxilla in three pieces with removal of both upper first
premolars; lower subapical surgery with removal of the lower left first premolar, rotating
the lower segment to the left, depressing and retracting it
 Surgid superior repositioning of maxilla 179

K. P.

Fig. 8A to C. A, Front face before treatment. B, Profile before treatment. C, Cephalometric tracing
before treatment.

Postsurgical orthodontics:
Finish space closure on lower left
Align and level
Finish
Retain
The treatment results are illustrated in the photographs and tracings in Fig. 30 to H.
 Am. J. Orthud.
180 Epker und Fish
A ups, 1980

Fig. 8D and E. Pretreatment occlusion.

Case 3. The decision for augmentation genioplasty

A 27-year-old woman was evaluated. She had previously worn retainers and had had one lower
incisor tooth removed because of crowding. Her primary concern was facial esthetics.
Esrheric evaluation. Frontally, there was facial asymmetry due to a deviated nose. The patient
had normal upper and middle third facial balance. The nose was narrow, as were the alar bases.
Excessive exposure of the maxillary teeth. lip incompetence, and a long lower third of the face were
evident (Fig. 6A).
A dorsal nasal hump was present in the profile. The nasolabial angle was slightly acute, and
lip incompetence was confirmed. A severely recessive chin and ever-ted lower lip were evident
(Fig. 6B).
Cephulometric evaluation. Both facial axis and facial depth were extremely dolichocephalic,
with a high mandibular plane angle and moderate convexity. The lower face height was excessive.
Both upper and lower incisors were extremely protrusive, with the lower incisor being 10 mm.
ahead of the A-PO line (Fig. 6C).
Occlusal clnalysis. Occlusal analysis reveals moderate crowding in the upper arch, with good
arch symmetry and form. The lower arch similarly had good arch form, moderate crowding, and a
missing lower left central incisor. Both arches revealed a minimal curve of Spee. A Class I molar
occlusion was present on the right, while the left was one half-step Class 11. Considerable attrition
was noted on all teeth from the canines posteriorly (Fig. 60 and E).
Treatment planning decision: What to do with rhe mandib/e? The desired change in front facial
esthetics was to be accomplished by straightening the asymmetrical nose, improving the upper
tooth-to-lip relationship, producing lip competence, and widening the alar bases. These changes
dictated that the maxillary incisors be moved superiorly approximately 6 mm. In profile, the
nasolabial angle was already acute and therefore anterior movement of the maxilla and upper incisor
would not be preferable. The chin was extremely recessive and, although it would become less so by
the mandibular autorotation, it was questionable that autorotation alone would produce an adequate
chin. With these facts in mind, a prediction tracing was done, including the extraction of four first
premolars and maximal retraction of the incisor teeth. In this tracing it was evident that the chin,
while improved, was still recessive (Fig. 7). To improve the chin-lip-nose balance, it was therefore
decided to perform an augmentation genioplasty of sufficient magnitude to bring pogonion forward
to a position which would normalize both the A-PO-lower incisor relationship and the NB-Pog
relationship. A new prediction tracing was made with the addition of a 10 mm. augmentation
genioplasty, and the resultant profile was deemed acceptable.
 Surgicul superior reposirioning of maxilla 181

Fig. 8F to H. F, Front face after treatment. G, Profile after treatment. H, Cephalometric tracings before
and after treatment.

Model surgery was then performed, and a Class 1 occlusion was attained from which the case
could be easily finished orthodontically. Thus, the following treatment plan was adopted:
Presurgical orthodontics:
Full band
Surgery:
Superior repositioning of the maxilla in one piece
182 Epker md Fish

Fig. 81 and J. Posttreatment occlusion

Fig. 9. Cephalometric prediction tracings with only SRM and with SRM plus mandibular advancement.

Augmentation genioplasty of 10 mm
Extraction of four first premolars
Postsurgical orthodontics:
Retract canines
Retract incisors
Finish
Retain
The treatment results are illustrated in the photographs and tracings in Fig. 60 to H

Case 4. The decision for mandibular advancement

A 17-year-old girl was referred by her orthodontist for surgical correction of a Class II maloc-
clusion and open-bite. The patient expressed concern about her excessive upper tooth exposure.
 E. M.

Fig. 10A to C. A, Front face before treatment. B, Profile before treatment. C, Cephalometric tracing
before treatment.

Esthetic eduarion. Frontally, the patient had good facial symmetry. The facial thirds were
about equal; however, the lower third appeared long because of the short upper lip, excessive
exposure of the upper teeth, and excessive interlabial distance. The alar base width was considered
somewhat narrow (Fig. &I).
In the profile a prominent nose, an obtuse nasolabial angle, and a severely recessive chin were
present (Fig. 8B).
184 Epker and Fish

Fig. 10D and E. Models before treatment.

Cephalometric evaluafion. Both the facial axis and the facial depth were dolichocephalic and
indicative of a recessive chin. The mandibular plane angle was normal. Convexity was high at + 7
mm., and the lower incisor was 2 mm. lingual to the A-PO line. Upper and lower lips were behind
the E line, mostly because of the extreme nasal prominence (Fig. 8C).
Occlusul unalysis. The patient had undergone 2% years of orthodontic treatment and had
well-coordinated arches. The Class II malocclusion had not been corrected, and an open-bite was
present (Fig. 80 and E).
Treatment planning decision: What to do wirh the mandible? There were several esthetic
concerns in planning treatment for this patient. The first, expressed by the patient, was that the
excessive upper front teeth were showing and an excessive interlabial gap existed. Thus the primary
procedure should be to reposition the maxilla superiorly, since other procedures might not improve
these relationships. Because the arches were well coordinated, the maxilla could be repositioned
superiorly in one piece, and the result would be a good occlusion. A prediction tracing was made,
and it was noted that, to correct the Class II occlusion, even with the mandibular autorotation, the
maxilla would have to be moved posteriorly about 5 mm. It was concluded that, with the already
prominent nose and obtuse nasolabial angle, this would significantly worsen the facial appearance.
In a second prediction tracing, the maxilla was moved upward and forward to improve the obtuse
nasolabial angle and the mandible was simultaneously advanced to produce a Class I occlusion
(Fig. 9). This greatly decreased the apparent nasal prominence and improved the chin-lip-nose
balance. Accordingly, the following treatment plan was adopted:
Surgery:
Superior repositioning of the maxilla, moving it up 7 mm. and forward 5 mm.
Mandibular advancement into a Class 1 occlusion
Suprahyoid myotomies
Postsurgical orthodontics:
Finish
Retain
The results of this treatment are seen in Fig. 8F to J. *

Case 5. The decision to perform reduction genioplasty

A 19-year-old female patient was referred with the chief complaint of exposing excessive upper
anterior teeth and showing too much gingiva when she smiled. Her gingiva was continuously
inflamed, despite excellent oral hygiene.
*Orthodontic treatment by Dr. Jerry Mills, Euless, Texas.
Volume 78
Number 2 Surgical superior repositioning of maxilla 185

E. M.

Fig. 1OF to H. F, Front face after treatment. G, Profile after treatment. H, Cephalometric tracings before
and after treatment.
Fig. 11. Cephalometric predictions of various options in a patient with a Class I occlusion and normal
chin projection who is to undergo SRM.

Esrhrric e~~r/uariotz. Frontally, the upper and middle thirds of the face were in good balance; yet
the alar bases of the nose were narrow. The lower third of the face was long relative to the middle
and upper thirds. The upper lip was short (16 mm. from subnasale to stomion). With the lips in
repose, the patient had 11 mm. of lip incompetence and exposed 10 mm. of maxillary incisor teeth
(Fig. 10.4).
In the profile, the upper and middle thirds of the face were in good balance, except for moderate
recessiveness in the paranasal area. The long lower third of the face and lip incompetence were
evident. The soft-tissue chin was essentially normal (Fig. IOB).
Cephdorn~tric anu~~sis. Both facial axis and facial depth were within normal limits. The
mandibular plane angle was normal. The convexity of 2 mm. indicated a recessive maxilla. Upper
and lower incisors were normally related to each other and to the A-PO line. The lower lip was
related well to the E line (Fig. IOC).
0~~Y~~rrl evuluution. The maxillary and mandibular arch forms were symmetrical. The patient
had undergone orthodontic treatment to establish a Class I molar and canine relationship. She had
been out of orthodontic treatment for more than 2 years (Fig. IOD and E).
T~rfarenf planning decision: What fo do with the mcrndible~~ With the patient’s chief complaint
of a “gummy” smile, the excessive exposure of the upper incisors, and the large interlabial gap, the
surgery must again be directed to superiorly repositioning the maxilla. The occlusion was good, and
no change in it was to be effected with surgery. A prediction tracing was made, keeping the
occlusion stable and rotating the maxilla superiorly 7 mm. The maxilla moved forward 3 mm. with
the superior movement and maintained a Class I occlusion. This change was considered desirable,
as it would help fill out the paranasal areas. However, the chin rotated forward more than the maxilla
and became too prominent. A second prediction tracing was done in which the maxilla was moved
up the long axis of the incisor teeth (upward and backward) and the mandible was simultaneously set
back. This, while producing an improved profile, involved a significant additional amount of
 J. B. 7.

3-16-78

Fig. 12A to C. A, Front face before treatment. 6, Profile before treatment. C, Cephalometric tracing
before treatment.
188 Epker und Fish

Fig. 12D. Pretreatment occlusion.

surgery. A third tracing was made with only autorotation of the mandible while reducing the chin in
both anteroposterior and vertical dimensions via genioplasty’ (Fig, 11). This produced a satisfactory
result and greatly decreased the amount of surgery and fixation necessary. With this procedure, the
paranasal areas were improved and the alar bases were widened, the occlusion remained unchanged,
the interlabial gap and tooth exposure were improved, and the chin was in a satisfactory relation to
the nose and lips. For the above reasons, the following plan was adopted:
Surgery:
Superior repositioning of the maxilla in one piece*
Reduction genioplasty (3 mm. anterior posteriorly and 8 mm. vertically)
The result of this treatment is seen in Fig. 10F to H.

Case 8. The decision to perform mandibular set-back

A 24-year-old woman was seen in consultation concerning her prominent upper teeth and
dimunitive chin.
Esthetic evaluation. Frontally, facial symmetry was good. Upper and middle thirds of the face
were in normal balance, while the lower third of the face was excessively long. There was excessive
upper tooth exposure, as well as lip incompetence (Fig. 12.4).
In the profile, again the upper two-thirds of the face were in normal balance. In the lower third
there was protrusion of the upper lip with an acute nasolabial angle. The lower lip was likewise
protrusive, and the chin was recessive (Fig. 12B).
Cephalometric evuluarion. The facial axis was dolichocephalic while the facial depth was
normal, leading to a long lower third of the face. The mandibular plane angle was steep. Convexity
was moderate at +4 mm. and would indicate that the maxilla was forward. Both upper and lower
teeth were protrusive, with the lower incisor being 8 mm. ahead of the A-PO plane. Upper and lower
lips were protrusive relative to the E line (Fig. 12C).
Occ/usul evaluation. There was a Class I occlusion with slight crowding. Function was good
(Fig. 120).
Treatment planning decision: What ro do with the mandible.~ Once again, to eliminate the
interlabial gap effectively and reduce the amount of upper incisor showing, the maxilla must be
moved superiorly. In addition, since an acute nasolabial angle existed in this patient, it would be
essential to move the maxilla and anterior teeth posteriorly simultaneously. The patient had a

*Surgical treatment by Larry M. Wolford, D.D.S.

Volume 78
Surgical superior repositioning of maxilla 189
Number 2

J. B. T.
Z-16-76
3-24-78 - - - - -

Fig. 12E to G. E, Front face after treatment. F, Profile after treatment. G, Cephalometric tracings before
and after treatment.
 Fig. 12H. Posttreatment occlusion

J. 8. T.

Fig. 13. Cephalometric prediction tracings of surgical options considered for the patient illustrated in
Fig. 12.

functional Class I occlusion and desired no orthodontic treatment. Thus, as part of the surgical
treatment, it would be necessary to move the upper incisors posteriorly to reduce the acuteness of the
nasolabial angle. Our first thought was to retract the lower incisors by a subapical procedure
removing premolars and then to reposition the maxilla superiorly in three pieces, removing upper
premolars. The prediction tracing with this done looked good. However, model surgery proved this
to be unworkable, as a satisfactory occlusion could not be attained. The only workable solution,
therefore, was to surgically reposition the maxilla superiorly and posteriorly and simultaneously set
the mandible back to maintain the original occlusion (Fig. 13). This would allow reduction of the
acute nasolabial angle, produce lip competence, and lessen the exposure of the upper incisor.
Performing this procedure would not produce a satisfactory result, however, as the chin would
become too recessive. Thus, a simultaneous augmentation genioplasty would be necessary to
complete the correction, producing good chin-lip-nose balance and increased support to the lower
lip.
With the above facts in mind, the following treatment plan was adopted:
Surgery:
I. Superior and posterior repositioning of the maxilla
2. Simultaneous mandibular set-back
3. Augmentation genioplasty
The result of this treatment is seen in Fig. 12F to H.

Conclusions
By careful correlation of clinical esthetic findings and the performance of cephalometric predic-
tion tracings, a deliberate, intelligent decision can be made concerning what to do with the mandible
when the maxilla is superiorly repositioned.

REFERENCES
1. West, R. A., and Epker, B. N.: Posterior maxillary surgery: Its place in the treatment of dentofacial
deformities, .I. Oral Surg. 30: 562-575, 1972.
2. Stoker, N. A., and Epker, B. N.: The posterior maxillary ostectomy: A retrospective study of treatment
results, Int. J. Oral Surg. 3: 153.157, 1974.
3. Wolford, L. M., and Epker, B. N.: The combined anterior and posterior maxillary ostectomy: A new
technique, J. Oral Surg. 33: 842.851, 1975.
4. Epker, B. N., and Fish, L. C.: Surgical-orthodontic correction of open-bite deformity, AM. J. ORTHOD.71:
278-299, 1977.
5. Fish, L. C., Wolford, L. M., and Epker, B. N.: Surgical-orthodontic correction of vertical maxillary excess,
AM. J. ORTHOD.73: 241-251, 1978.
6. Schendel, S. A., Eisenfeld, F. H., Bell, W. H., and Epker, B. N.: Superior repositioning of the maxilla:
Stability and soft tissue osseous relations, AM. J. ORTHOD. 70: 663-674, 1976.
7. Hohl. T., and Epker, B. N.: Macrogenia: A study of treatment results with surgical recommendations, J. Oral
Surg. 41: 545-567, 1976.
8. Epker, B. N., and Fish, L. C.: Surgical-orthodontic correction of Class 111 skeletal open-bite, AM. J.
ORTHOD.73: 601-18, 1978.
9. Fish, L. C., and Epker, B. N.: Surgical-orthodontic cephalometric prediction tracings, Clin. Orthod. 14:
36-50, 1980.

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