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The aim of this work is to review the relationship between the function of the masseter muscle and the occurrence of malocclusions. An analysis was made of the masseter muscle samples from subjects who underwent mandibular osteotomies. The size and proportion of type-II fibers (fast) decreases as facial height increases. Patients with mandibular asymmetry have more type-II fibers on the side of their deviation. The insulin-like growth factor and myostatin are expressed differently depending on the sex and fiber diameter. These differences in the distribution of fiber types and gene expression of this growth factor may be involved in long-term postoperative stability and require additional investigations. Muscle strength and bone length are two genetically determined factors in facial growth. Myosin 1H (MYOH1) is associated with prognathia in Caucasians. As future objectives, we propose to characterize genetic variations using "Genome Wide Association Studies" data and their relationships with malocclusions., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

LeFort I osteotomy, anterior segmental osteotomy, bilateral sagittal split ramus osteotomy, and genioplasty are frequently used methods for correcting facial deformities. However, in patients with an abnormally shaped maxilla or mandible, more complex surgical techniques or multiple combinations must be considered for improved esthetic results. This article presents a patient with bialveolar protrusion, mandibular prognathism, chin retrusion, a long face, and severe facial asymmetry. A combination of LeFort I asymmetric impaction, anterior segmental osteotomy, and 3-piece segmentation of the maxilla, and bilateral sagittal split ramus osteotomy, anterior segmental osteotomy, genioplasty advancement, and angle shaving in the mandible were conducted simultaneously. In patients with complicated deformities that cannot be classified by simple conventional classification methods, multisegmental osteotomy can be an option for improved esthetic results., (Copyright © 2013 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.)

Objective: The objective of this study was to evaluate the radiological and functional results of unilateral sagittal split osteotomy (USSO) of the mandible., Study Design: Between January 2001 and December 2008, 26 patients underwent USSO to correct laterognathia (isolated USSO in 3 patients and Le Fort I osteotomies in combination with USSO in 23 patients). Radiographs of 23 patients were evaluated for signs of condylar resorption or loss of ramus height; 16 patients were clinically examined and the movement of both condyles was measured with a nontouch device., Results: Unilateral condylar resorption was observed in 1 patient and bilateral signs of resorption with loss of ramus height were observed in a further patient. Mouth opening and protrusion were significantly reduced after surgery (6.06 ± 6.91 mm, P = .005/0.63 ± 0.89 mm, P = .020). The selected surgical site, whether left or right, had no influence on laterotrusion or retrusion (P > .05), but patients operated on the right side showed higher values of protrusion on the left side than patients who were operated on the left (mean difference: 3.13 ± 1.24 mm; P = .038)., Conclusions: USSO appears to be a procedure that can be used in orthognathic surgery, if applied to a certain extent. In this study, there was no evidence of adverse results in terms of condylar resorption or functional outcome when compared with the results of regular bilateral sagittal split osteotomy (BSSO) reported in the literature. To our best knowledge this is the first study in the literature investigating the impact of USSO in orthognathic surgery., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Even if the relationship between condylar position and/or temporomandibular disorders (TMDs) and dentofacial deformity is controversial in literature, several patients presenting malocclusion refer to pain and TMDs as the main trouble. There are also various opinions concerning the alterations or improvements of temporomandibular joint symptoms after orthognathic surgery. In agreement with the experience of Universität Würzburg, the purpose of this study was to evaluate the validity of splint technique to reproduce centric condyle positioning in bimaxillary osteotomy surgeries for the patients with skeletal-facial disorders and coexisting TMDs. The present study is based on a sample of patients with maxillomandibular malocclusion and coexisting TMDs who underwent bimaxillary osteotomy surgeries with splint technique. All patients underwent a protocol consisting of various steps: Pretreatment evaluation consisted of a questionnaire on subjective symptoms, clinical examinations, photographs of the occlusion, plaster casts, bite registrations, examination of the posture; instrumental examinations; panoramic, teleradiography, and cephalometric analysis; stratigraphy of TMD; and electromyography. Presurgical treatment consisted of therapy by modified Farrar splint associated with a pharmacologic therapy for the acute symptoms; orthodontic treatment associated with a global reeducation of the posture and a pompage of the masticatory muscles; and manufacturing of an occlusal splint in the most posterior asymptomatic position. Surgical treatment consisted of bimaxillary osteotomies performed after registering condyle position by a "repositioning" plate. The condyle position is guided by the intermaxillary fixation with the interposition of the occlusal splint. Surgery on maxillary is performed through Le Fort I osteotomy and fixation. Later, sagittal splint osteotomy of mandible is performed. Position of ramus and TMD complex is guided by the positioning of the plates modeled previously and fixed to maxillary and ramus in the same relationship registered with the splint. Finally, fixation of mandibular osteotomies is performed. Postsurgically patients underwent orthodontic treatment (to stabilize occlusal and articular changes) and physical therapy. After the end of treatment, stability of results was investigated with clinical, radiologic, and electromyographic valuations. The authors' experience suggests that, as in orthognathic surgery, identification of a correct condyle-fossa relationship (achieved by splint and repositioning plate) is essential to guide osteosynthesis after sagittal split osteotomy in patients affected by TMDs and ultimately affects the stability of the procedure.

This article presents a survey of characteristic features of Williams-Beuren syndrome (WBS) as reported in the literature and the interdisciplinary treatment of a subject with WBS with special regard to morphological and functional disorders. Typical features of a patient with WBS and his dental development in a follow-up from 8 to 25 years of age are shown. Early orthodontic treatment approaches, later combined orthodontic-orthognathic surgical procedures, and the status 5 years after surgery are presented.

Background: This article aims to present and discuss 53 patients who received a new identity because of major changes to the face after treatment with bimaxillary osteotomy, concomitant maxillomalar augmentation, genioplasty, and rhinoplastic procedures for their complex dentofacial skeletal deformity and class 3 malocclusion., Methods: During a 12-year period (January 1993 to April 2005), more than 500 patients with dentofacial deformities and malocclusions have undergone orthognathic surgery performed by a team consisting of the same plastic surgeons and orthodontists. Among this group, 53 patients (30 women and 23 men) underwent surgery for both aesthetic and functional concerns. The mean patient age was 20.4 years (range, 17-28 years). All the patients were treated with bimaxillary osteotomy, concomitant maxillomalar augmentation, osseous genioplasty, and rhinoplastic procedures in the same session. The patients were followed 12 to 44 months by the plastic surgeon, and at least 1 year by the orthodontist., Results: There was no orthognathic relapse or other major complications requiring reoperation. There was prolonged nerve anesthesia or hypoesthesia that resolved within 6 months for 4 patients (7.5%), a short period of anesthesia or hypoesthesia that resolved within 4 weeks for 11 patients (20.7%), a wide alar base in 3 patients, and a slight deviation of the cartilage septum in 2 patients., Conclusion: In one session, five different procedures can be performed without any problem, each of which can produce major changes to the face while maintaining the whole facial harmony. The authors determined that these dramatic positive outcomes for the combined procedure can easily be tolerated and accepted by all their patients. However, the patients have had difficulty with their family or friends accepting their new appearance, and even have had to change their photos on identification cards. This is encouraging for the management of new patients in the future.

For more than one decade the extremity surgery already used distraction osteogenesis. This new therapy in the region of the maxillofacial surgery (in the case of malformation of the maxilla and mandible) was adapted from the extremity surgeons. The authors summarized and classified the methods and history of the osteodistraction surgery based on literature. The indication fields, the used protocols and the most common distractor types are listed. The authors emphasized the multidisciplinary feature of the therapies, underlined the leading role of the orthodontist. With presenting their own two mandible distraction case reports they introduced the practical use of the distractors while using intra- and extraoral devices. They also emphasized the difficulties and failure opportunities. Their aim was to make suggestions for the further development of this method in our country.

Background: Nasalance represents a measure of the relative amount of oral and nasal acoustic energy produced by a speaker. Literature shows changes in nasalance after surgery of the oropharynx. The aim of this prospective study was to evaluate the outcome of speech and nasalance scores after Le-Fort-I-Osteotomy., Patients and Methods: A total of 20 individuals with normal speech development were examined preoperatively and 6 weeks postoperatively with the Nasometer 6200 (Kay-Elemetrics, USA) after bimaxillary surgery. The tone materials used comprised the standardized text passage: "Ein Kindergeburtstag", the vowels: /a/, /e/, /i/, /o/, /u/ and a syllable repetition subtest., Results: All patients showed changes in nasalance scores 6 weeks postoperatively. There were no significant changes reading the standard text. The syllable repetition test showed significant changes for repetition of "ma ma ma" and "na na na" (p=0,003, respectively p=0,033). Intonation of the vowel /a/1 also revealed significant changes regarding the pre- and postoperative values (p=0,006). However, the obtained values had no significant impact on the nasality characteristics of speech., Conclusion: This study confirms that maxillary osteotomies can result in significant changes of nasalance scores. However these changes do not have any impact on normal speech and voice.

Nemaline myopathy is a rare congenital muscle disease, which is clinically and genetically heterogeneous. Both neonatal and adult onset can occur; in those with neonatal onset, the resulting muscle weakness can also afflict the facial musculature and hence influence facial growth and development. This article reports on a case in which no orthodontic intervention was undertaken during childhood and adolescence. An early decision was made to treat the facial dysmorphogenesis surgically once skeletal maturity had been reached. The authors discuss and illustrate the untreated facial growth in this condition and the surgical outcome following orthodontic treatment and orthognathic surgery.

Corrective jaw (orthognathic) surgery is indicated for patients with a malocclusion caused by a skeletal deformity. This paper will discuss current concepts in patient evaluation and review contemporary surgical treatment.

The aim of this study was to review the reported psychosocial benefits of orthognathic surgery. A systematic review of the literature was conducted using MEDLINE (1966 to December 2000), Web of Science (1981 to December 2000), and reference sections of identified articles. We also hand searched key orthodontic, oral surgery, and psychology journals. No language limitations were imposed. Randomized controlled trials, other controlled clinical trials, prospective studies (with or without controls), and retrospective studies (with or without controls) were considered for inclusion. Two reviewers extracted the data and independently assessed the quality of the studies. In all, 29 studies, including a number of prospective and retrospective studies, were identified as relevant. The results of the review indicated that orthognathic patients experience psychosocial benefits as a result of orthognathic surgery, including improved self-confidence, body and facial image, and social adjustment. However, there were wide variations in the study designs and a lack of uniformity in measuring the psychosocial constructs. This made it difficult to quantify the extent and the duration of the psychosocial benefits.

Sz. S. a 39-years-old patient was referred to our department in 1968. Patient's masticatory dysfunction, orofacial pain syndrome and substantial weight loss was due to a combined genuine and acquired deep vertical overbite aggravated by a marked difference between the size of the lower and upper jaw bones. The premolars and molars had already been extracted. The lower incisors bit onto the palatal gingiva in centric occlusion causing direct mechanical irritation on the palate. Consequently the centric occlusion position of the mandible was only defined by the contact between the lower central incisors and the palatal soft tissue. According to the literature this kind of defect can only be corrected by a combined surgical prosthodontic therapy (increasing the mandibular arch by vertical osteotomy combined with bone grafting followed by complex prosthodontic reconstruction). Because patient refused any kind of surgical treatment a special upper full arch bridge was constructed with an extended occlusal surface on the palatal surfaces of the front crowns to provide full occlusal contact for the mandibular anterior teeth. The OVD was raised by 11 mm. The present paper reports the history of a 31 years long prosthodontic treatment and patient's follow up. It is shown how the correct centric occlusion, the masticatory functions, the phonetics and also the esthetics could have been maintained by a series of gradually changing fixed restorations meeting the demands imposed by the continuing tooth loss.

Objective: To investigate the kind and degree of deformtive and the charactertics and effects of prosthetic treatment in patients with secondary maxillofacial deformities after cleft lip and palate operation at early age., Methods: Clinical examinations and cephalometric analysis were performed in 30 patients., Results: The results showed that prosthetic treatment can improve facial form and oral functions a great deal but with limitations., Conclusion: Prosthetic treatment should be considered as an essential part in serial therapy of cleft lip and palate.

Combining large-segment orthognathic surgery and unitooth or small-segment surgery is an effective approach to deal with a wide range of dentofacial deformities that have minor to severe occlusal problems. The indications for combining single- or double-tooth osteotomies with traditional orthognathic surgery were patients with dentofacial deformities and malocclusion requiring stable correction within a short overall treatment period. From 1991 to 1998, a total of 36 patients underwent combination single- or double-tooth-segment osteotomy with traditional orthognathic procedures performed at Chang Gung Memorial Hospital. The indications for surgery were maxillary protrusion (N = 5), bimaxillary protrusion (N = 19), mandibular prognathism with maxillary protrusion (N = 11), and noncleft maxillary retrusion (N = 1). The types of osteotomies performed were the Le Fort I, the anterior segmental osteotomies of the maxilla or the mandible, the palatal split, and the posterior segment in combination with single-tooth or double-tooth segments. Follow-up ranged from 12 months to 6 years and showed stability in the movements with no complications. There was no loss of any "osteotomized" segment. The average overall treatment time was approximately 18 months--5 months preoperative and 13 months postoperative orthodontic treatment. This was at least 6 months shorter in duration compared with traditional orthognathic surgery. Combining traditional orthognathic surgery with single- or double-tooth segments allows us to treat complex dentofacial deformities in the vertical, transverse, and sagittal dimensions with differential repositioning of all segments, either major or minor, simultaneously. The authors' experience with 36 consecutive patients evidence good results and demonstrate the procedure to be safe with minimal complications.

Although there is little solid evidence that dental malocclusion directly results in significant TMJ problems, there appears to be strong correlation with malocclusions resulting from skeletal deformities. The highest correlation is generally noted in the patient with a deep bite or with asymmetry. Significant improvement can be anticipated with surgical correction of these deformities, but great care must be taken to properly diagnose the source of the deformity, and to use the correct technique, applied as atraumatically as possible.

Rotation of the maxillomandibular complex and the consequent alteration of the occlusal plane angulation to improve functional and esthetic results have been well documented. The decision to change the occlusal plane angulation cannot be arbitrary and is made only when desired results cannot be obtained by conventional treatment planning. The geometry of rotation should be accurately planned by establishing a specific point around which the maxillomandibular complex should be rotated to achieve specific esthetic results. Treatment planning using anterior nasal spine and maxillary incisor tip as rotation points has been described and results demonstrated. This article will introduce additional points of rotation that may be considered based on a triangle constructed during treatment planning. Two clinical examples are presented in which these types of rotation were implemented.

We reviewed the complications and long-term results of a consecutive series of adolescents (67 males, 49 females; age range 15 to 25 years; mean 18 years) born with a cleft who underwent primary repair in childhood and later developed a jaw deformity and malocclusion that required orthognathic surgery. Between 1986 and 1992, 116 adolescents with either unilateral cleft lip and palate (n = 66), bilateral cleft lip and palate (n = 33), or isolated cleft palate (n = 17) underwent an orthognathic procedure that included a Le Fort I osteotomy; 32 also underwent simultaneous sagittal split osteotomies of the mandible; and 87 underwent osteoplastic genioplasty. Clinical follow-up ranged from 1 to 7 years (mean 40 months) at the close of the study. The preoperative clinical examination varied according to cleft type and individual variation, but all patients had maxillary hypoplasia. Additional cleft-related deformities included residual oronasal fistula and bony defects, clefted alveolar ridges that retained dental gaps, and mobile premaxilla that lacked union to the lateral segments. Overall, 89 percent of residual fistulas underwent successful closure as part of the orthognathic procedure. Surgical cleft dental gap closure was achieved and maintained to the extent planned at 92 percent of the cleft sites. A fixed (prosthetic) bridge was used successfully for dental rehabilitation to close the gap in all other patients at each cleft site (n = 9). All patients with alveolar clefts (n = 99) maintained keratinized mucosa along the labial surface of the cleft-adjacent teeth (n = 264 teeth). Complications were few and generally not serious. There was no segmental bone loss of teeth because of aseptic necrosis or infection. Only 5 percent of cleft adjacent teeth underwent a degree of gingival recession and root exposure as a result of the maxillary osteotomy procedure; all were retained long term. The long-term maintenance of overjet and overbite measured directly from the late (> 1 year) postoperative lateral cephalometric radiograph indicated that 97 percent of patients maintained a positive overjet and 89 percent maintained a positive overbite; 5 percent shifted to a neutral overbite. The methods used to manage jaw deformity, malocclusion, residual oronasal fistula, and bony defects in adolescents born with a cleft are safe and reliable and offer the patient an enhanced quality of life. They also provide a stable foundation in which final soft-tissue lip and nose revisions may be carried out.

Purpose: Individuals with developmental deformities of the jaws may be less efficient at chewing food. Previous studies have reported masticatory deficiency in patients with such deformities. This study was designed to detect any changes in masticatory performance that accompany orthognathic surgery., Materials and Methods: Masticatory performance was tested in 18 patients with various jaw deformities before application of orthodontic appliances and 2 to 3 years after surgical correction of their malocclusion. A control group was tested at three 6-month intervals. The subjects chewed carrots and masticatory performance was measured using a standard sieve technique. The Rosin-Rammler equation was used to calculate the median particle size and broadness index of each set of carrots. The number of chewing cycles required for each subject to swallow one piece of carrot was also recorded., Results: A statistically significant difference in median particle size between patients and controls was found both preoperatively and postoperatively (P < .05), but no difference in median particle size or broadness index was seen between trials for controls or patients (P > .05)., Conclusion: It was concluded that before surgery patients have a lower level of performance than controls and surgical correction of the malocclusion does not significantly enhance performance.

In general, orthognathic surgery is a reliable, appropriate and prudent treatment option to correct maxillofacial deformities that cannot be managed by nonsurgical means alone. Unfavorable outcomes are relatively rare, but the statistical frequency of these complications loses its meaning in those cases where they occur. If a complication happens to an individual patient, it represents a one-hundred per cent incidence for that individual. For this reason, prior to the provision of treatment it is vitally important to obtain informed consent, ideally by establishing the widest possible information base on which meaningful communication can be built for the patient, the orthodontist, the surgeon, and the family dentist.

The purpose of this study was to document the prevalence of disk displacement and temporomandibular joint symptoms in orthognathic surgery patients. Fifty-three consecutive patients with different types of dentofacial anomalies were examined clinically and with bilateral arthrography. Disk displacement unilaterally or bilaterally was found in 57% of the patients or 46% of the joints. Displacement with reduction was seen in 38 joints, and displacement without reduction was seen in 11 joints. Fifty-three percent of the patients had pain in the temporomandibular joint or masticatory muscles, 30% of the joints demonstrated clicking, and 4% had crepitation. No association was found between disk displacement and clinical symptoms except for an association between clicking and anterior disk displacement with reduction. Neither could an association between disk displacement and the type of dentofacial anomaly be appreciated. It was concluded that disk displacement was frequent in patients with dentofacial anomalies, but no relationship to temporomandibular joint symptoms and the type of dentofacial anomaly could be clearly demonstrated.

A review of the literature clearly shows that dental and facial disfigurements have significant effects and can be an important social disadvantage. The motivational patterns of patients requesting orthognathic surgery are many and varied, but a desire for improvement in esthetics and alleviation of functional problems are the two most commonly cited reasons. The careful assessment of patients requesting orthognathic surgery is imperative, because the success of surgery may well depend on careful patient selection. Care must be taken with those patients suspected of exhibiting dysmorphophobic tendencies and, if there is any doubt, psychiatric referral should be undertaken. Patient satisfaction following orthognathic surgery has been reported as high overall, as has been the number of patients who have said they would re-elect to have surgery. Many of the studies found that patients had improved self-confidence and social skills after treatment.

A concensus conference on the timing of facial osteotomies was held in Jönköping, Sweden. Seven teams consisting of a maxillofacial surgeon and an orthodontist representing five countries discussed treatment planning for young patients with maxillomandibular deformities with special emphasis on timing. Patients with severe syndromic facial deformities were not considered. Consensus was reached that for most deformities it is best advised to wait until growth has ceased, as determined by longitudinal cephalometric data. This rule is less tight for Angle Class II than for Class III cases. For asymmetries often there is still not enough scientific evidence to obtain well-founded uniform agreement.

The angular relationship of the occlusal plane and Frankfort horizontal (occlusal plane angle, normal value 8 degrees +/- 4 degrees) is very important, in both diagnosis and treatment planning, but is usually ignored. Surgical alteration of the occlusal plane may influence presurgical orthodontic mechanics and surgical technique and design, but may offer significant benefits relative to the patient's functional and esthetic results. Candidates for surgical alteration of the occlusal plane angulation include the low occlusal plane (LOP) facial type and the high occlusal plane (HOP) facial type. Correction of the LOP facial type by downward and backward (clockwise) rotation of the maxillomandibular complex has been a well accepted technique. Upward and forward (counter-clockwise) rotations of the maxillomandibular complex for correction of the HOP facial type has not been supported as an acceptable treatment modality. However, we have demonstrated that upward and forward rotations are stable with proper treatment planning, appropriate presurgical orthodontics, proper execution of the surgery, and in the presence of healthy and stable temporomandibular joints. This article will discuss the clinical characteristics of the LOP and HOP facial types, the specific anatomic changes with alteration of the occlusal plane, the presurgical orthodontic goals, and the surgical techniques for downward and backward and upward and forward repositioning of the maxillomandibular complex. Cases are presented to demonstrate the application of this treatment approach.

A group of 20 patients (12 females and 8 males) who underwent orthognathic surgery during the previous three years were surveyed. The reasons which determined the decision to undergo surgery are discussed. Patient satisfaction and the effect of surgery on psychological and social attitudes are explored.

Patients requiring surgical correction of skeletal dysplasia and malocclusion often present with a co-existing function and/or aesthetic nasal deformity. This article reviews the techniques of nasal surgery, rationale for combined nasal and orthognathic surgery, and timing of corrective nasal and jaw surgery.

The complexities introduced into the practice of orthodontics with the advent of the newer orthognathic surgery procedures are now being better understood. Widespread discovery of temporomandibular disorders further complicates this situation. Lack of understanding about dental problems and practice by some physicians may result in less than satisfactory patient care. Two case reports are presented that illustrate these problems.

This article discusses correction of functional and esthetic deformities by surgically increasing or decreasing the occlusal plane angulation. Clockwise rotation, or increase of the occlusal plane angulation, is a well-accepted technique in orthognathic surgery. However, counterclockwise rotation (decrease of the occlusal plane angulation), has not been a well-accepted treatment approach. The functional and esthetic characteristics of the low occlusal plane and the high occlusal plane facial types are presented, specific surgical approaches to alteration of the occlusal plane are described, and the long-term stability of results with both clockwise and counterclockwise rotations of the occlusal plane are discussed. Cases illustrating the application of these surgical approaches are presented.

Computerized video imaging is a valuable adjunct for communication with patients and planning orthognathic surgical treatment. The incorporation of adjunctive soft tissue procedures to enhance the final aesthetic result of orthognathic surgery is a valuable addition to the orthodontic and orthognathic treatment plan. This paper presents the use of video imaging techniques in the planning and execution of comprehensive functional and aesthetically orientated orthodontic and surgical treatment.

The field of orthognathic surgery offers ever-improving technology to better rehabilitate patients with dentofacial deformities. Hospital stays have been reduced due to improved surgery and anesthesia. Rigid internal fixation has increased comfort for many patients by eliminating the inconvenience of having the jaws wired together. Most important has been the realization that teamwork between the general dentist and the various specialty disciplines is indispensable for good patient care and the attainment of the very best results.

A new computerized, cephalometric, orthognathic surgical program (TIOPS) has been evaluated in surgical simulation, prediction and postoperative assessment of precision. Records of 10 consecutive patients admitted for orthognathic surgical treatment were analysed and prediction plans produced by computerized surgical simulation. Predicted and postoperative positions of maxilla and mandible were compared with linear and angular measurements. No statistically significant differences between predicted and postoperative positions could be demonstrated (p greater than 0.05).

Even if the functional factors are the most important in the decision, we have always to remember the need of our patient concerning aesthetic improvement. At this moment, the traditional approach based upon morphologic cephalometric analysis (which are frequently discordant) must be substituted by an aesthetic approach. The goal is to obtain a realistic 3D-imaging of the face as it will be after surgery. But it cannot really be achieved yet and we are obliged to work on lateral X-ray cephalograms. The most important at this stage of the decision is not to make a static aesthetic evaluation. It is on the contrary to perform a prospective simulation of the new profile line, as accurate as possible, based upon statistical correlations between soft- and hard-tissues changes. Even if there are some technical problems, even if the results are not currently good enough, the aesthetic prospective analysis allows validation or modulation of the initial functional surgical indication. We can compare for instance the aesthetic results of different amounts of displacements in bimaxillary surgery. Meanwhile, it is sure that the result depends also on the precision of the surgical procedure and on the good functional re-equilibration which is essential for the stability.

Most of the scientific papers concerning facial osteotomies are focused on the surgical procedures. However, the most important thing to consider is how to go to the right indication and not how to do it. By an only morphological approach, as we can do with dental casts and cephalometric studies, it is obvious that we forget the functional factors. They nevertheless are essential to consider. Their knowledge permits understanding the physiopathology of the deformity and avoiding the postsurgical relapses. The main five factors concern: the dentoalveolar corridor, between tongue and orbicularis oris muscle, the facial bone growth modeling by functional matrix, the relations between upper incisors, lower incisors and lips, the posterior airway and the rest position of the tongue, the vertical muscular balance. Surgery has to normalize the abnormal function which is at the origin of the abnormal morphology. For this reason, maxillary surgery is better than mandibular surgery for the correction of a Class III deformity. Moreover, the transversal and vertical dimensions are always to be considered at the light of the functional parameters. Most of cases of dentofacial deformities are to be treated by bimaxillary osteotomies, including often transversal and/or vertical modifications. When the anatomical sites of these surgical procedures are determined, then we have to make an aesthetic facial profile simulation to validate the total amount of the bone displacements (cf. Part 2).

27 patients subjected to various orthognathic surgery procedures were studied preoperatively and during a period of 18 months postoperatively by a team of psychologists to evaluate the patients' own opinions concerning the indication for surgery, information about the surgical procedure, the postoperative period and the long-term aesthetic and functional results. The patients were interviewed 5 times: 2 days before surgery, 2 days after surgery and 2, 6 and 18 months after surgery. The decision to undergo surgery was taken after a long period of time, 4 years on average, and half of the patients were influenced by their family or dentist before they made their decision. 60% gave three or more reasons for surgery, 85% mentioned functional problems, 74% facial appearance and 59% craniomandibular symptoms. 63% indicated that the facial appearance problems had negatively influenced their personal life and 44% their social life. Women experienced this problem more often than men. The results showed that the overall majority of patients were relieved of their presurgical problems. The aesthetic improvement was better than expected. It was found that improvements in facial features had a beneficial influence on the patients as individuals and also on their social life situation.

In this clinical study the position of the mandibular condyles of 40 patients treated for malocclusion by surgical splitting of the mandibular ramus alone or combined with Le Fort I osteotomies was studied on lateral linear TMJ tomograms. Linear tomograms of the right and left TMJ with the mandible closed were taken from each patient prior to surgery and 6 months postoperatively. The postoperative changes in condylar position wee assessed in terms of direction and amount. Condylar displacements were found in 89% of the examined joints, most of them were less than 2mm. All types and combinations of displacement occurred, however, general trends in direction depending on the type of treatment could not be established with statistical significance. The type of surgical correction, its direction and amount did not seem to have an effect on the direction and amount of condylar displacement resulting. A comparison of the measured values with data in the literature showed that the amount of condylar displacement was markedly less--this seemed to be attributable to our precise evaluation method and a more sophisticated surgical technique.

As a followup to a longitudinal study of orthognathic surgery patients who had participated in a study of alternative approaches to surgical preparation, 27 patients were administered questionnaires regarding postsurgical changes in their oral, general, and psychological well-being. Age and sex had minimal effect on the patients' responses. Diagnosis, surgery type, and complications did not influence postoperative patient reports. Esthetic improvement was most often cited as a motive for surgery and most likely to be achieved. Fewer postoperative problems were experienced than expected, although interpersonal problems increased for some patients. Oral and general health problems declined significantly after surgery; the greatest improvements were found in occlusion and appearance of teeth and facial profile. Satisfaction with outcomes reflected these improvements in patient well-being. Exceptions to these generally favorable outcomes and the implications for patient preparation for orthognathic surgery are discussed.

The following case report is an example of a team of dentists correcting a pronounced occlusal and facial anomaly. A primary care dentist, endodontist, orthodontist, and oral/maxillofacial surgeon all contributed to the successful outcome. As the technological resources available to dentists increase, teamwork between generalists and specialists will become essential for comprehensive restoration to excellent health, function, and esthetics.

This article deals with orthodontics and maxillofacial surgery as an integrated treatment. During the last fifteen years orthognathic surgery has made extensive progress, and almost all great malocclusions combined with facial anomalies can be treated with good and stable results. Because the surgical methods are more refined and sophisticated, greater demands have been put on the planning of the treatment making this a team effort between the orthodontist and the surgeon. Treatment of anterior crossbite, extreme overjet and open bite are shown as examples of what can be achieved by this team approach. The outlines of the treatment are given and it is stressed that the orthodontic treatment must be done with fixed appliances. The complications are few, and the results are usually stable. This integrated treatment can therefore be recommended to those patients who are motivated for it and really need it.

Anterior openbite (AOB) malocclusion is considered one of the most demanding challenges for the orthodontist, as occlusal correction is difficult, facial aesthetics may be unsatisfactory and the incidence of relapse is high. A retrospective cephalometric study of 19 consecutively treated AOB patients is presented. The follow-up ranged from 12 to 48 months. Several case reports are included to demonstrate a contemporary approach combining orthodontic treatment and orthognathic surgery. The results indicate that overbite was maintained with good vertical skeletal stability. Anteroposterior position was less stable. Posterior facial height was maintained or decreased, and there was no evidence of postsurgical maxillary incisor movement. It is concluded that occlusal stability and clinical success may be anticipated when certain criteria are adhered to in all phases of treatment, and that a coordinated surgical-orthodontic treatment approach currently offers the best chance of attaining occlusal stability, improved function and satisfactory aesthetics.

The indication for surgical-orthodontic treatment is a skeletal or dentoalveolar deformity so severe that the magnitude of the problem lies outside the envelope of possible correction by orthodontics alone. For adults, this means that satisfactory correction by tooth movement is not possible; for children, it means that the problem cannot be corrected satisfactorily by a combination of tooth movement and growth modification. Correction of the dental occlusion is not an adequate description of successful treatment; satisfactory facial esthetics must also result. Extrapolation from existing data for malocclusion in the United States suggests that there are a total of 1.2 million individuals in the present population with problems severe enough to require surgical-orthodontic treatment for satisfactory correction. Of these, 700,000 have Class II malocclusions and 300,000 have Class III malocclusions. Approximately 220,000 individuals have long-face problems and another 220,000 have other problems, but these groups have about a 60% overlap with the Class II and Class III groups.

The psychologic and behavioral changes that may occur with the impact of orthognathic surgery on the physical appearance of an identical twin set have been addressed. This unique situation has not been discussed in the literature with respect to reconstructive or cosmetic facial surgery. A report on elective orthognathic surgery performed on identical twins and the subsequent impact on the twin relationship due to alterations of "self-image phenomenon" is given. Such an impact was a consideration in this case. Further collective study in this area is needed but is difficult to obtain because of the rarity of occurrence of this type of case.