Int. J. Oral Maxillofac. Surg.

2014; 43: 40–45

http://dx.doi.org/10.1016/j.ijom.2013.07.738, available online at http://www.sciencedirect.com

Systematic Review Paper

Orthognathic Surgery

Aesthetic and functional C. L. Sonego1,2, Â. N. Bobrowski1,

O. L. Chagas Junior1, M. A. Torriani1
1
Bone Repair Research Group – Rigid

implications following rotation of Internal Fixation, Department of Oral and

Maxillofacial Surgery and Maxillofacial
Prosthodontics, School of Dentistry, Federal
University of Pelotas, Pelotas, RS, Brazil;

the maxillomandibular complex 2

Post Graduate Program in Dentistry, Master
Degree, School of Dentistry, Universidade
Luterana do Brasil, Canoas, RS, Brazil

in orthognathic surgery:
a systematic review
C.L. Sonego, Â.N. Bobrowski, O.L. Chagas Junior M.A. Torriani: Aesthetic and
functional implications following rotation of the maxillomandibular complex in
orthognathic surgery:
a systematic review. Int. J. Oral Maxillofac. Surg. 2014; 43: 40–45. # 2013
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. The manipulation of the maxillomandibular complex (MMC) in

orthognathic surgery has been used widely in the treatment of dentofacial
deformities so as to optimize aesthetic and functional results, making these more
stable in the long term. The aim of the present study was to perform a systematic
literature review of the aesthetic and functional implications following rotation of
the occlusal plane in orthognathic surgery, by evaluating skeletal stability, facial
harmony, respiratory function, and temporomandibular joint (TMJ) function after
clockwise or counterclockwise rotation of the MMC. A survey of Scopus, PubMed,
and Cochrane databases was performed through which 10 papers were selected for
the final review. From this review, it could be concluded that facial aesthetics, TMJ
function, and skeletal and occlusal stability in the orthosurgical treatment of
dentofacial deformities may be influenced by the surgical manipulation of the MMC
(clockwise or counterclockwise rotation). However, although this treatment
technique is used widely today, the results of the present study do not provide Accepted for publication 9 July 2013
sufficient scientific evidence with regard to the choice of this approach. Available online 14 August 2013

Orthosurgical treatment is recommended
for the correction of dentofacial deformi-
ties and often involves bimaxillary sur-
gery. This procedure can be performed by
altering the patient’s maxillomandibular
complex (MMC) in order to optimize final
functional (dental occlusion, respiration,
temporomandibular joint (TMJ) and long-
term stability) and aesthetic results.
Orthognathic surgery may be performed
by means of ‘conventional’ treatment,
or be complemented with clockwise or
counterclockwise MMC rotation. ‘Con-
ventional’ treatment is understood to be
that where the cephalometric prediction
tracing is able to correct antero-posterior
maxillomandibular discrepancies through
the pre-existing occlusal plane, and the

0901-5027/01040 + 06 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

final occlusal plane is determined by the
mandibular occlusal plane after its auto-
rotation, which occurs both clockwise and
counterclockwise at a superior–posterior
point to the condyle, depending, respec-
tively, on the inferior or superior reposi-
tioning of the maxilla. Surgical planning
that includes MMC occurs independently
of a pre-existing mandibular occlusal
plane.1,2
In bimaxillary surgery cases, the verti-
cal position of the upper incisors, the
antero-posterior position of the maxilla,
and the angulation of the occlusal plane
are taken into account. These factors dic-
tate the position of the mandible and affect
both functional and aesthetic results.3 The
impacts of these alterations have major
implications for surgical planning, and
long-term aesthetic stability and function
of the stomatognathic system are of the
utmost importance.
A specific treatment proposal is estab-
lished according to the type of dentofacial
deformity, by evaluating the surgical
movements to be performed as well as
aesthetic and functional effects on clinical
and cephalometric variables that occur
after orthognathic surgery.
The possibility of occlusal plane man-
agement in bimaxillary surgery was first
described in the literature in 1985.3 Never-
theless, Wolford and Hilliard4 had already
performed an occlusal plane alteration
through MMC counterclockwise rotation
as a differentiated surgical approach
applied to a Class II patient in 1979, but
this procedure was only publicized several
years later.
There must be a correlation between
clinical evaluation data (facial analysis)
and cephalometric analysis so as to aid in
the establishment of a surgical treatment
plan. However, these data do not always
correlate due to the abnormal orientation
of the Frankfort plane, which must be
corrected. The normal occlusal plane
angular relation must be 8  48 in relation
to the Frankfort plane.5,6
Autorotation of the mandible – follow-
ing either the superior or inferior reposi-
tioning of the maxilla where the mandible
can be repositioned without surgical
manipulation – is one of the most stable
long-term procedures in orthognathic sur-
gery. This treatment is recommended for
patients with excessive exposure of ante-
rior and superior teeth at rest or smiling, or
in large inter-labial distance cases, gener-
ating labial incompetence. These patients
usually present anterior open bite and
Angle’s Class II or I, where the superior
and anterior repositioning of the maxilla
with autorotation of the mandible will
Occlusal plane in orthognathic surgery 41
keep a Class I occlusion, only interfering Survey strategy
in aesthetic improvement.
An initial survey of PubMed, Scopus, and
In situations where there is a decrease in
Cochrane databases was done using the
the occlusal plane angulation (<48), the
following three search lines after a brief
gonial angle is very prominent, the chin
reading of the topics of interest: (1) ‘occlu-
very pronounced in relation to the alveolar
sal’, ‘plane’, ‘alteration’, ‘orthognathic’,
process, and in cases where there is
‘surgery’; (2) ‘occlusal’, ‘plane’, ‘rotation’,
Angle’s Class II division 2 malocclusion
‘orthognathic’, ‘surgery’; (3) ‘occlusal’,
(Class I or III may also occur) and deep
‘plane’, ‘autorotation’, ‘orthognathic’,
overbite, the most acceptable treatment
‘surgery’.
proposed is clockwise MMC rotation,
Titles and abstracts of all identified
i.e., an increase in the occlusal plane
articles were then analyzed by three inde-
inclination.
pendent reviewers (CLS, ANB, and
For patients with an increase in occlusal
OLCJr).
plane angulation (>128), mandibular defi-
The database survey was updated on
ciency, anterior vertical maxillary excess,
April 28, 2013, and resulted in 10 selected
and decreased chin projection, counter-
articles for the systematic review pre-
clockwise rotation is the most appropriate
sented in ‘Results’ section.
procedure, resulting in a decreased incli-
nation of the occlusal plane angle. This
technique limits the correction of Class III Data extraction
patients and is largely used in the treat-
The three reviewers (CLS, ANB, and
ment of patients suffering from obstruc-
OLCJr) collected the following data after
tive sleep apnoea/hypopnoea syndrome
a full reading of the articles included in the
(OSAHS).
sample: analysis of the type of study, type
Complementary genioplasty to MMC
of occlusal plane alteration (clockwise,
rotation allows optimization of the aes-
counterclockwise, and/or autorotation),
thetic results in both movements, and the
postoperative follow-up, as well as aes-
shape of the chin plays an important role in
thetic and functional results obtained. Any
the surgery decision-making process, pro-
disagreements between reviewers were
vided that this is more important than its
resolved through additional discussions.
antero-posterior positioning (horizontal
pogonion position).7
Based on these concepts, the aim of the Methodology
current study was to perform a systematic
A flowchart of the selection and evaluation
literature review of the functional and
procedure is given in Fig. 1.
aesthetic implications of MMC clockwise
Following the initial selection and amal-
or counterclockwise rotation in orthog-
gamation of the first two search topic lines
nathic surgery, including evaluation of
(‘alteration’  ‘rotation’) by the three
skeletal stability, aesthetics, and respira-
reviewers, a total of 16 potentially relevant
tory and TMJ function.
items were identified, among which six
were duplicates, i.e., these papers were
found in both the ‘alteration’ and ‘rotation’
Materials and methods
groups; so a shortlist of 10 relevant articles
Study selection criteria was reached. Two further articles found
through the ‘autorotation’ search item were
Article titles and/or abstracts were ana-
added, thus reaching a sample of 12 rele-
lyzed, delimiting for inclusion in this
vant articles; two of these were duplicates,
study the following: (1) specific studies
i.e., they were found in the ‘alteration’/
focusing on the alteration and/or manip-
’rotation’ and ‘autorotation’ groups. A final
ulation of the occlusal plane by means of
sample of 10 relevant articles was then
clockwise, counterclockwise, or autorota-
accessed fully and analyzed.
tion of the MMC; (2) studies in human
beings; (3) studies published in the Eng-
lish language; (4) no time limit; (5) type of
Quality evaluation
study: case report, case series, retrospec-
tive and/or prospective clinical study. An evaluation of methodological quality
Inclusion criteria were adopted so as to was done by combining PRISMA state-
obtain more general results in the review, ment8 criteria in order to verify the
without specifying cephalometric tracing strength of the scientific evidence avail-
type, surgical techniques used for articular able in the current literature for clinical
disc repositioning, postoperative neurosen- decision-making purposes.
sory evaluation, or surgical treatment of The classification of the potential risk of
temporomandibular dysfunction (TMD). bias for each study followed the criteria
42 Sonego et al.

Identification

‘occlusal’, ‘plane’, ‘alteration’, ‘occlusal’, ‘plane’, ‘rotation’, ‘occlusal’, plane’, ‘autorotation’,

‘orthognathic’, ‘surgery’ ‘orthognathic’, ‘surgery’ ‘orthognathic’, ‘surgery’

Electronic search Electronic search Electronic search

PubMed = 9 PubMed = 49 PubMed = 7

Scopus = 8 Scopus = 22 Scopus = 1
Cochrane = 0 Cochrane = 0 Cochrane = 0

Screening

By title or abstract By title or abstract By title or abstract

PubMed = 6 PubMed = 9 PubMed = 1

Scopus = 6 Scopus = 8 Scopus = 1
Cochrane = 0 Cochrane = 0 Cochrane = 0

Duplicate = 6 Duplicate = 7 Duplicate = 0

manuscripts manuscripts manuscripts

Potentially Potentially Potentially

relevant = 6 relevant = 10 relevant = 2
manuscripts manuscripts manuscripts

Eligibility

Potentially relevant =
Duplicate = 6
16 manuscripts
manuscripts

Potentially relevant = 12 Duplicate = 2

manuscripts (10+2) manuscripts

Included
Total of 10
manuscripts included
in the systematic
review

Fig. 1. Flow diagram of study selection; PRISMA.8

listed here, used by Clementini et al.9: (1)
random selection in (of) the population
(sample); (2) definition of inclusion/exclu-
sion criteria; (3) follow-up loss reported;
(4) validated measurements; (5) statistical
analysis. If the study included all these
criteria, it was classified as having a low
risk of bias; if one of the above criteria was
missing, it was classified as having a
moderate risk of bias; if two or more
criteria were missing, it was classified as
having a high risk of bias.
Results
The survey identified a total of 10 arti-
cles that met the study inclusion criteria;
details of these studies are shown in
Table 1. Of the 10 articles, seven were
 Occlusal plane in orthognathic surgery 43

Table 1. Study characteristics.

Postoperative
observation
Author, year, Ref.Type of study Occlusal plane movement period Results
Wolford et al.a Case series Group 1: 14 patients submitted to 21–23 monthsGood facial harmony, aesthetics, and facial
1993,5 19946 MMC clockwise rotation balance; stable and functional occlusal
relationship; asymptomatic postoperative
TMJ without detectable long-term alterations
Chemello Group 2: 27 patients submitted to
et al.a 199410 MMC counterclockwise rotation
Rosen 199314 Case series Group of 11 patients submitted to 9–24 months The author observed a few long-term
MMC counterclockwise rotation clinically significant alterations of immediate
postoperative values as compared to the final
value; however, these variations did not alter
the patients’ facial architecture as a whole
Reyneke Retrospective Group 1: 22 patients without MMCGroup 1: The long-term skeletal stability of the MMC
15
et al. 2007 study manipulation 14.1 months clockwise and counterclockwise rotations
could be compared favourably to the
postoperative skeletal stability of
conventional surgical treatment when MMC
rotation was located around the condylar point
Group 2: 25 patients submitted to Group 2:
MMC clockwise rotation 13.3 months
Group 3: 41 patients submitted to Group 3:
MMC counterclockwise rotation 13.9 months
Yosano Case series Sample of 16 patients submitted to12 months Rigid fixation of the mandible is one of the
et al. 200911 MMC clockwise rotation most important factors to obtain good occlusal
plane stability and preserve the aesthetic and
functional benefits obtained by altering the
MMC
Pinho and Case report Patient submitted to MMC 12 months After 1 year the patient did not report TMJ
Figueiredo counterclockwise rotation symptoms and/or signs and presented stable
201116 occlusion without relapses in this period of
time
Brevi et al. Case series Sample of 33 patients with OSAHS6 months Excellent functional results, such as a
12
2011 submitted to MMC significant improvement in respiratory
counterclockwise rotation function and absence of relapse at the 6-month
postoperative follow-up
Bang et al. Case series Sample of 31 Korean patients 6 months The maxilla and the mandible had a clinically
201213 submitted to MMC clockwise insignificant relapse during this period; for
rotation this reason, the MMC clockwise rotation can
be considered a predictable technique and a
relatively stable procedure that is without
clinical alterations or relapse
Tsai et al. 201217 Clinical case Patient submitted to MMC 10 months Facial–skeletal stable results during the 10-
clockwise rotation month postoperative period
MMC, maxillomandibular complex; TMJ, temporomandibular joint; OSAHS, obstructive sleep apnoea/hypopnoea syndrome.
a
Wolford et al. and Chemello et al. used the same sample.

case series reports,5,6,10–14 one was a
retrospective study,15 one included a
case report,16 and one was a clinical
report.17
Quality evaluation
One retrospective case series study15
showed a low risk of bias, whereas four
studies showed a moderate risk of
bias,10–13 and five showed a high risk
of bias,5,6,14,16,17 as shown in Table 2.
Discussion
The number of orthognathic surgeries
using the MMC manipulation technique
is on the increase. Based on this premise,
scientific support for this clinical approach
was sought by means of a systematic
literature review. Though PRISMA8 cri-
teria propose that, ideally, random clinical
prospective and retrospective studies
should be included, only one article—that
of Reyneke et al.15—fitted into this clas-
sification in our review.
Aesthetic and functional results follow-
ing MMC rotation in orthognathic surgery
are related to several factors, such as the
type of fixation, surgical technique, mus-
cle physiology of the condyle, direction of
the surgical procedure, and pre- and post-
operative orthodontics.
Surgical clockwise rotation has been
used widely and is supported by the
authors of this review, especially in open
bite cases, due to the greater skeletal and
functional stability it provides in the
long-term follow-up. The articles
reviewed here report that, in addition
to an increase in the occlusal plane angle,
this procedure results in the posterior
rotation of the mentum, making it less
prominent by reducing the posterior
facial height and the advancement of
paranasal structures. Clockwise rotation
shows predictable and stable results, pro-
vided that the mastication muscles basi-
cally maintain the same length or at most
there is a slight reduction without TMJ
postoperative symptomatology.
Clockwise rotation for the treatment of
Class III skeletal malocclusion has been
observed to bring about, as a positive
44 Sonego et al.
Table 2. Assessment of the quality of included studies.
Random
selection in
Author, year, Ref. population
Wolford et al. 19935 No
Rosen 199314 No
Wolford et al. 19946 No
Chemello et al. 199410 No
Reyneke et al. 200715 Yes
Yosano et al. 200911 No
Pinho and Figueiredo 201116 No
Brevi et al. 201112 No
Bang et al. 201213 No
Tsai et al. 201217 No
aesthetic result, the normalization of the
nasolabial angle reduction in mentum pro-
minence, alteration of the occlusal plane,
and an increased smile angle curvature;
however, as a disadvantage, there is an
increase in nasal width, which must be
taken into account so that necessary cor-
rections can be made during the surgical
procedure.17 This method of occlusal
plane rotation is a quite stable skeletal
and aesthetic technique due to the fact
that the pterygo-masseteric muscular
function remains unchanged or shortened,
without TMJ alterations in the long-term
follow-up.13
Generally, MMC clockwise rotation,
implying an increase in the occlusal plane
angle, is a technique that produces pre-
dictable and long-term stable results when
osteotomy, adequate fixation, and TMJ
pre-evaluation are performed.
The maxillary surgical procedure,
together with the autorotation of the
mandible, corrects labial incompetence
and establishes Class I occlusion, reducing
mandibular retrognathism. The TMJ func-
tion is usually normal in this kind of
surgery, without meaningful joint altera-
tions.5,15
In cases of MMC counterclockwise
rotation, i.e., a decrease in the occlusal
plane angle, studies have described the
restoration of facial harmony, skeletal sta-
bility, and occlusal stability in the long-
term follow-up when the correct surgical
technique and adequate fixation are used.
Anatomic alterations include a reduction
in the occlusal plane angle and an increase
in mentum projection, oropharyngeal
space, and upper incisor inclination, thus
leading to a decrease in the lower incisor
inclination. The literature consulted
agrees5,6,10–17 that the greatest problem
posed by this type of surgical rotation is
stability and its effect on the TMJ, as
this is thought to be an unstable procedure
due to the decrease in joint spaces, which
may cause postoperative pain, functional
impairment, condylar resorption, anterior
Defined inclusion/ Reported loss Validated
exclusion criteria to follow-up measurements
No Yes
Yes Yes
No Yes
Yes Yes
Yes Yes
Yes Yes
No Yes
Yes Yes
Yes Yes
No Yes
open bite, malocclusion, and mandibular
retrusion in the long-term follow-up.
Hence, a careful pre-evaluation of the joint
condition so as to predict the degree of
adjustment that the TMJ can withstand,
and in this way choosing the best surgical
procedure, is of great importance. In addi-
tion, there may be a pre-existing idiopathic
condylar resorption, which can be mana-
ged safely by removing the hyperplastic
synovial and bilaminar tissues, reposition-
ing the articular disc, and repairing the
articular ligament, followed by orthog-
nathic surgery with MMC counterclock-
wise manipulation; this resorption often
affects Class II patients.18 Gonçalves
et al.19 argue that the MMC counterclock-
wise rotation is stable for both patients
with healthy TMJs and those who need
articular disc repositioning during the
same procedure. Even in patients who
need a total TMJ reconstruction with the
use of joint prostheses, MMC counter-
clockwise rotation is stable in the long-
term follow-up.20
The use of counterclockwise maxillo-
mandibular rotation is increasing, and it
has proven to produce better aesthetic/
functional results and a greater stability
in the long-term follow-up, mainly due to
improvements in surgical techniques and
rigid fixation.5
Some authors have reported stable
results for both clockwise and counter-
clockwise rotations owing to adequate
preoperative orthodontic treatment, suc-
cessful surgical techniques, and healthy
TMJs.5,6,10 They have also pointed to the
importance of the degree of counterclock-
wise rotation of the MMC, as this can lead
to an increase in joint pressure due to
muscular forces and a greater lever arm.
Rosen14 also reported similar results by
following some specific surgical recom-
mendations to improve the final result. In
his case series study, he concluded that,
despite the fact that the use of rigid inter-
nal fixation provided an increase in post-
operative stability, in cases of MMC
Statistical Estimated potential
analysis risk of bias
Yes No High
Yes No High
Yes No High
Yes Yes Moderate
Yes Yes Low
Yes Yes Moderate
Yes No High
Yes Yes Moderate
Yes Yes Moderate
Yes No High
advancement and extensive counter-
clockwise rotation, there is a clinically
significant recurrence of immediate post-
operative values as compared to the final
value up to 2 years following surgery
because of bone remodelling and/or con-
dylar resorption. In order to reduce this
alteration, the author suggests the use of
2.7-mm bicortical screws in the mandib-
ular area (three on each side); these pro-
vide better stiffness as compared to the
use of 2-mm screws, which generate a
greater pressure between bone ends, pre-
dicting a higher friction coefficient and
guaranteeing skeletal stability secondary
to bone movement. The use of Class II
elastic rubber bands for a 4- to 6-week
postoperative period decreases the load
potential, allowing soft tissue relaxation.
According to the literature,1 there are
three factors that may influence stability
after orthognathic surgical procedures:
stretching of soft tissues, neuromuscular
adaptation, and muscle orientation.
For the treatment of OSAHS, the
MMC counterclockwise rotation techni-
que results in an improvement in airway
function.6 Changes in the pharyngeal air-
way space are important for stomatog-
nathic system function. Accordingly,
counterclockwise rotation with MMC
advancement has proved to improve the
oropharyngeal airway dimensions, with
stability in the long-term follow-up.21
Mehra et al.,22 upon evaluating the effect
of bimaxillary surgery with counter-
clockwise MMC rotation on the pharyn-
geal airway space and the velopharyngeal
anatomy in patients showing high occlu-
sal plane morphology, concluded that
these areas are significantly affected in
both mandibular advancement and set-
back. These authors stated that this is the
preferred approach in patients with
OSAHS; in addition, it allows a predict-
able correction with aesthetic and func-
tional results. However, the pharyngeal
airway space may be significantly
reduced in mandibular setback without

MMC rotation. Thus, the same authors
recommend a careful evaluation of the
pharyngeal airway space for this defor-
mity pattern in order to avoid an eventual
development of OSAHS after the surgi-
cal procedure. In their case series study,
Brevi et al.12 state that counterclockwise
rotation of the occlusal plane resulted in
resolution of OSAHS in 93.9% of the
patients, who were satisfied with their
new appearance.
The present study shows that aesthetic
and functional implications following
occlusal plane clockwise or counterclock-
wise rotation in orthognathic surgery,
such as mandible autorotation, bring about
facial harmony as well as skeletal and
occlusal stability when adequate osteotomy
and functionally stable fixation techniques
are used. The MMC counterclockwise
rotation technique is highly recommended
for OSAHS patients, improving the condi-
tion of the upper airway. Clinical studies
(Randomized Clinical Trials (RCTs))
should be performed within CONSORT23
parameters so that results can be used as
scientific evidence of the quality of clinical
decision-making. The greatest difficulty
faced in this study was the scarcity of
literature on the topic addressed.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
Acknowledgements. The authors are grate-
ful to Maximiliano Cenci, PhD, Adjunct
Professor of Cariology, School of Dentis-
try, Federal University of Pelotas, Brazil,
and to Paulo Eduardo Kreisner, PhD,
OMFS, Porto Alegre, Brazil, for their help
in drafting the manuscript.
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Address:
Camila Leal Sonego
Bone Repair Research Group – Rigid Internal
Fixation
Department of Oral and Maxillofacial
Surgery and Maxillofacial Prosthodontics
Dentistry School
Federal University of Pelotas
Rua Gonçalves Chaves 457 – 38 andar
Centro
Pelotas
RS 96015-560
Brazil
Tel: +55 53 81330375
E-mail: camilasonego@gmail.com