Surgical Orthodontic Treatment Planning: Profile Analysis and Mandibular Surgery Franx W. Worms, DDS. M.S.D. Roserr J. Isaacson, D.D.S., Ph.D. T. Micuacx Spewet, D.DS., MSD. The professional background and ex- perience of dentists and dental special- ists are focused almost exclusively on dental occlusion. All too often in a zeal to improve dental occlusion, clinicians plan a method of treatment based on inadequate or improper diagnostic cri- teria. When these treatment plans in- clude surgical procedures, dramatic changes of facial soft tissue contour can be produced. Sometimes these changes can be inappropriate. Substitution of one poor facial contour for another one is hardly in the patient’s best interest. The problem is well-illustrated by com- paring profiles of orthosurgically treat- ed patients in Figures 13-16. It is apparent that, even though identical mandibular surgical procedures were employed, other variables are present which need recognition to effect favor- able esthetic change. In the past the usual method of sur- gical treatment of interjaw malrelations was to surgically free one of the two malrelated jaws and reposition it in a more appropriate interjaw relationship. Based on the then existing limitations, this usually meant a surgical osteotomy in the ramus or the body of the man- dible to set back mandibular protru- sions. One of the limitations of this ap- proach was that the position of the teeth determined the relation and po- sition of the jaws at the time of sur- gery. This would not-be a limitation if, Read at the January, 1975 meeting of the Midwestern Component of the Angle Society. when the patient presented for treat- ment, the teeth were well-related to their individual jaws. A vast collection of clinical data has emerged in recent years to demonstrate that good tooth to Jaw relation is not the usual case. As deviations from harmonious skele- tal jaw base relations occur, teeth alter their normal vertical lengths and axial inclinations to maintain functional re- lations. When the mandible and max- illa have divergent growth patterns, open bites may result, However, if in- cisors increase their length by contin- ued eruption, satisfactory occlusion and function may be maintained. Also, if mandible and maxilla grow dispropor- tionately in anteroposterior directions, gross overjets or underjets may result. Alterations in normal axial inclinations of the incisors may overcome skeletal base disproportions and attempt to maintain functional occlusion. These alterations of vertical length and axial inclinations in response to deviate skel- etal growth are termed dental compen- sations. Jaw malrelations result from dispro- portional facial growth. As these dis- proportions progressively manifest, the teeth attempt to mask the dispropor- tional change and functional liability by compensating their positions through tooth movement.® In other instances the teeth are forced to migrate by per- verted muscular actions resulting from the jaw malrelations. In the case of mandibular prognathism the lower in- cisors are usually lingually inclined. The maxillary incisors are frequently\ Fig. 1 Angle Class III molar relatior ship with uncompensated incisor axial in- clination (white) and compensated in- cisor axial inclination (black). Compen- sated incisors (black) may mask or cen- fuse proper treatment planning. labially inclined. The amount of ante- rior dental crossbite is almost always less than the skeletal imbalance present (Fig. 1). In mandibular retrusion (Angle Class II) cases the malrelations of the incisors produce a different set of in- cisor deviations. In the case of Division 1 the overjet present frequently re- quires the lower lip to function in this space. This perverse lip function pro- duces forces that will tend to flare the maxillary incisors labially and tip the mandibular incisors lingually (Fig. 2). In other Angle Class IT cases, perverted lip activity may cause retroinclination FS a Fig. 2 Angle Class II, Division 1 molar relationships with uncompensated inci- sor axial inclination (white) and com- pensated incisor axial inclination. (black). Overjet often encourages per- verted lip function which displaces max- illary incisors labially (black) and man- dibular incisors lingually (black). Worms et al. January 1976 Fig. 8 Angle Class II, Division 2 molar relationship with uncompensated incisor axial inclination (white) and compen- sated incisor axial inclination (black). Teeth must be properly related to their respective basal bone structures to be considered uncompensated. of the upper incisors as in Division 2 types (Fig. 3). Teeth also compensate for jaw mal- relations in the vertical plane of space. In the case of a backward rotating mandible an open bite is usually an- ticipated. Buccal teeth move excessively in a vertical direction while incisors are required to erupt (compensate) even farther to maintain incisal over- bite. If the incisors do not fully com- pensate with vertical eruption, an open bite will exist (Fig. 4). In a forward rotating growth pattern, buccal teeth do not move as much in a vertical direction. Incisors also move less in a vertical direction, but still manifest deep overbite (Fig. 5). These disproportions of facial growth result in imbalanced facial profiles that present for treatment. If teeth alone are used for treatment planning cri- teria, surgical correction of the jaw will be determined by compensated tooth positions. The best profile is not likely to result (Fig. 6). In recent years it has become ap- parent that the best surgical reposition- ing of jaws is possible only when all dental compensations are removed. Therefore, it is necessary to properly relate teeth to their jaws prior to sur-Vol. 46, No. 1 Uy Fig. 4 Large vertical lower facial height with uncompensated incisors (white) and compensated incisors (black). An- terior open bite with a long lower face may be a sign of uncompensated vertical eruption. gery. Only in this manner will the full amount of surgical correction be rou- tinely achieved. Some variability is possible and consequently some deci- sions must be made prior to treatment. Compensations, whether exaggerat- ing or modifying dental malrelation- ships, prevent ideal relocation of basal skeletal areas if relocations are dictated by dental occlusion. The clinician must recognize the presence of dental com- pensation and determine the direction of necessary decompensating orthodon- tic tooth movement that will provide the most favorable facial change postsurgi- Surgical Treatment 3 cally. In some instances it may be pos- sible to increase dental compensations and provide a conclusive treatment by orthodontic means alone. Differential diagnosis depends upon proper analy- sis of skeletal, dental and soft tissue profile contours. When adequate arch length is pres- ent in each jaw, teeth need only be aligned on each jaw to project the ef- fect of surgery. The amount of surgery will result in an Angle Class I buccal segment when a full complement of teeth is present. In this instance the amount of anteroposterior surgical change is the difference between the existing buccal segment relationship after alignment and a Class I buccal segment. Co-existing vertical problems will be discussed later. If significant arch length discrepan- cies are present, teeth must be extract- ed. If one tooth is removed from each of four quadrants, the end result is still a Class I buccal segment. If two teeth are removed from the upper buccal arch, the end result will be Class II molars and Class I cuspids. Class I cuspids are mandatory in all combina- tions for proper incisal relations, This process often results in the retraction of anterior maxillary teeth and will in- crease the amount of surgical mandibu- lar reduction possible in a Class III problem (Fig. 7). Similarly, removal of Fig. 5 Removal of dental compensations in closed bite or reduced vertical dimen- sion requires extrusion mechanics of dental units (a) and (b). Incisors also need to be extruded and, hopefully, a clockwise rotation of the mandible Y occurs, This in- creases XXX, lower facial height, LFH, and reduces chin prominence, Z.